[Solved] NUR 670

Assignment Prompt & Instructions

**files (1)**

– ## NUR670responsewk4.pdf

**## NUR670responsewk4.pdf**

1. Response for Libia

Abstract

Perimenopausal women frequently experience anxiety and
depressive symptoms associated with fluctuating hormone levels and
neurotransmitter disruptions. The purpose of this literature review was to
evaluate the evidence supporting the use of hormone replacement
therapy (HRT) combined with psychiatric treatment compared with
psychiatric treatment alone for reducing anxiety and depressive
symptoms over six months in perimenopausal women. An evidence
pyramid was used to assess the reliability of available research, and a
systematic literature search was conducted across multiple databases.
The findings demonstrate that higher levels of evidence, including
systematic reviews, meta-analyses, and randomized controlled trials,
provide the strongest support for clinical decision-making, while lower
levels of evidence offer valuable contextual information but are more
susceptible to bias (Vatkar et al., 2025).

Comparison of Evidence Using the Evidence Pyramid

An evidence pyramid ranks study designs based on their potential
for bias and overall data reliability (Vatkar et al., 2025). When
evaluating how combined HRT and psychiatric
care affects perimenopausal mood disorders, different layers of the
pyramid yield varying degrees of scientific authority. At the highest level
of the pyramid are systematic reviews and meta-analyses, which provide
the most reliable evidence for clinical decision-making. They are the
most dependable because they synthesize findings from multiple high-
quality studies and reduce the influence of single-study bias (Blunt,
2026). According to Li et al. (2026), a recent comprehensive meta-
analysis verified that estrogen-based therapies actively reduce depressive
symptom severity during perimenopause.

Below systematic reviews are randomized controlled trials (RCTs),
which are considered the gold standard for evaluating treatment
effectiveness (Vatkar et al., 2025). Their reliability level is high since

randomization prevents selection bias, but strict inclusion criteria
sometimes make it hard to generalize results to everyday patients with
complex comorbidities, and their findings may be limited by sample
size, study duration, and participant characteristics. Several RCTs
investigating estrogen therapy and depressive symptoms in
perimenopausal women demonstrate improvements in mood and anxiety
symptoms, particularly among women experiencing hormonally related
mood disturbances (Sharma et al., 2023).

Observational studies, including cohort and case-control studies,
occupy the middle of the evidence pyramid (Blunt, 2026). These studies
contribute valuable information regarding associations between
hormonal changes during perimenopause and the development of mood
symptoms; however, they cannot establish causality due to the potential
influence of confounding variables. At the lower levels of the pyramid
are expert opinions, narrative reviews, and clinical experience. While
these sources may provide useful clinical insight, they are more
vulnerable to bias and should not be used independently to guide
treatment decisions (Vatkar et al., 2025). Therefore, the highest level of
reliability for this PICO question comes from systematic reviews, meta-
analyses, and RCTs evaluating hormone therapy and psychiatric
interventions.

Literature Review Search Strategy

For this literature review, the search was deployed across PubMed/
MEDLINE, CINAHL, PsycINFO, Cochrane Library, and Google
Scholar, capturing peer-reviewed, English-language literature. These
databases were selected because they provide extensive coverage of
nursing, psychiatric, psychological, and medical research relevant to
perimenopausal mental health. The search strategy was built by
systematically translating each component of the PICO question into a
combination of controlled vocabulary, specifically Medical Subject
Headings (MeSH), and highly targeted keywords (Hosseini et al., 2024).
To capture the precise population, keywords
like "climacteric", "menopause transition", and "midlife women" were
paired alongside the core MeSH term "perimenopause". The

intervention layer was constructed using terms such
as "hormone replacement therapy", "estrogen", "estradiol", and
the abbreviation "HRT". To address the comparative psychiatric arm, the
search incorporated the MeSH term "antidepressive agents" alongside
keywords like "SSRIs", "SNRIs", "psychotherapy", and "psychiatric
treatment". Finally, the clinical outcomes were targeted using the
terms "depression", "anxiety", "mood swings", and "symptom
reduction".

These distinct conceptual blocks were bridged using Boolean
operators. Within each individual category, terms were expanded using
the "OR" operator to capture every possible linguistic variation (Dekkers
et al., 2022). The broad categories were then locked together using the
"AND" operator to ensure that every retrieved article explicitly featured
all components of the clinical inquiry. The resulting master string—
(Perimenopause OR "Menopause transition" OR "Climacteric") AND
(Hormone Replacement Therapy OR Estrogen OR Estradiol OR HRT)
AND (Antidepressants OR SSRI OR Psychotherapy OR "Psychiatric
treatment") AND (Depression OR Anxiety OR "Symptom
reduction") — served as the filter to isolate relevant research.

Inclusion criteria consisted of peer-reviewed studies published in
English, studies involving perimenopausal women, research evaluating
hormone therapy and mental health outcomes, and studies published
within the previous five years. Exclusion criteria included studies
focused exclusively on postmenopausal women, articles examining only
vasomotor symptoms without psychological outcomes, non-peer-
reviewed publications, editorials, opinion papers, and studies unrelated
to anxiety or depression.

The search initially identified 86 records. After removal of
duplicates and application of inclusion and exclusion criteria, 62 studies
underwent title and abstract screening. Twenty-five full-text articles
were assessed for eligibility, and 10 studies met all criteria for inclusion
in the final review. A PRISMA-style literature flow diagram was
developed to illustrate the identification, screening, eligibility, and
inclusion process. This systematic approach enhanced the transparency,

reproducibility, and credibility of the literature review while ensuring
that the highest-quality evidence available was used to answer the
clinical question.

2. Response for Leydiana

Creating a Search Strategy.

Abstract.

Evidence-based practice allows psychiatric-mental health nurses to
make clinical decisions using timely research evidence. This literature
review aimed to rank sources based on reliability using the evidence
pyramid and explain our search strategy to complete a literature review
on continuity of psychiatric care with barriers to transportation and
caregiver support for older adults. The evidence pyramid was utilized to
understand how strong of evidence there was for our research question.
Systematic reviews and meta-analysis proved to provide the highest
level of evidence. A literature search was completed on PubMed,
CINAHAL Complete, PsycINFO, Cochrane Library, and Google
Scholar. Keywords consisted of older adults, geriatric mental health,
transportation barriers, caregiver support, continuity of care, social
isolation, mental health services utilization. Articles were included if
they were peer-reviewed and published from 20 21-20 26 and included
adults ages 65 years or older. After title and abstract screening with
assessment of eligibility, 20 articles were included in our final review.
Our results showed that transportation barriers, caregiver burden, social
isolation, and decreased access to health care have negative effects on
continuity of psychiatric care and mental health outcomes in older
adults. Our thorough search allowed us to find current and high-quality
evidence that could be used in psychiatric nursing practice.

Key words: evidence-base practice, older adult, continuity of care,
transportation barriers, caregiver support, psychiatric mental health
nursing.

Compare the reliability of evidence-based research using and
evidence pyramid.

Evidence-based practice is essential to psychiatric-mental health
nursing because it allows providers to make clinical decisions based on
the best available evidence. The evidence pyramid is one strategy
utilized to grade research evidence (Melnyk & Fineout-Overholt, 2023).
Studies that rank high on the pyramid provide stronger evidence than
those on lower levels.

Systematic reviews sit at the top of the pyramid and synthesize
research studies to provide large overviews of evidence about certain
topics. In addition to proving stronger evidence for decision-making,
these studies attempt to remove bias (Melnyk & Fineout-Overholt,
2023). Randomized trials are placed beneath systematic reviews and are
highly effective forms of research because people are assigned to
intervention and control groups.

Studies that provide moderate evidence include cohort studies, case
control studies, and qualitative studies. Cohort and case-control studies
are utilized when randomized trials are not ethical or possible.
Qualitative studies can highlight patient perceptions about certain
barriers to care but are limited by lack of generalizability. Expert opinion
and background information provide the least amount of evidence
because they do not typically provide scientific data. However, they can
be helpful when making clinical decisions.

Systematic reviews, cohort studies, and peer-reviewed research
about healthcare access, continuity of care, caregiver support,
transportation barriers, and mental health outcomes among older adults
were used. These studies were utilized because they provided the highest
level of evidence available regarding the selected topic. Social isolation,
transportation barriers, caregiver burden, and poor healthcare access

among older adults lead to poor mental health outcomes and lack of
continuity in care (Choi et al., 2022; Yang et al., 2023).

Describe the search strategy used to conduct the literatures
review for your PICO question.

Multiple databases were utilized to identify evidence about
continuity of psychiatric care among older adults: PubMed, CINAHL
Complete, PsycINFO, Cochrane Library, and Google Scholar. These
databases were specifically chosen because they allow users to search
through nursing, psychiatric, medical, and behavioral health literature
that has been peer-reviewed.

Search terms included older adults, geriatric mental health,
transportation barriers, caregiver support, continuity of care, psychiatric
appointment adherence, social isolation, care coordination, and mental
health service utilization. Keywords were paired using Boolean
operators (AND, OR) to increase relevancy. (“older adults” AND
“mental health access”), (“transportation barriers” AND “psychiatric
care”), and (“caregiver support” AND “continuity of care”).

Certain inclusion and exclusion criteria were used to increase the
quality of literature found. Articles had to be peer reviewed and
published between 2021 and 2026, written in English, and involve
participants who were aged 65 years and older. Studies had to examine
one or more of the following topics: mental health service utilization,
barriers to healthcare access, transportation barriers, informal caregiver
support and involvement, social support, care coordination, and
continuity of care.

Exclusion criteria included articles published before 2021, research
involving pediatric populations, articles not written in English,
editorials/opinion pieces, and articles that did not focus on healthcare
access or continuation of psychiatric care. Studies were also excluded if
they were only conducted in inpatient settings. Research studies were
excluded if they focused solely on inpatient settings because the

literature search was meant to identify studies related to outpatient
psychiatric care.

To illustrate the search and screening process, a literature flow
diagram was generated. The search resulted in 145 articles across all
databases. Duplicate records were removed, leaving 120 articles
screened by title and abstract. Abstracts were screened based on
inclusion criteria and 80 articles were excluded. Forty articles were
assessed by full text review and 20 articles were excluded after further
evaluation. 20 studies were included in our final literature review. We
believe our systematic search provided evidence that is up-to-date,
relevant and can be applied to psychiatric nursing practice with older
adults facing barriers accessing mental health care.

**## NUR670responsewk4.pdf**

1. Response for Libia

Abstract

Perimenopausal women frequently experience anxiety and
depressive symptoms associated with fluctuating hormone levels and
neurotransmitter disruptions. The purpose of this literature review was to
evaluate the evidence supporting the use of hormone replacement
therapy (HRT) combined with psychiatric treatment compared with
psychiatric treatment alone for reducing anxiety and depressive
symptoms over six months in perimenopausal women. An evidence
pyramid was used to assess the reliability of available research, and a
systematic literature search was conducted across multiple databases.
The findings demonstrate that higher levels of evidence, including
systematic reviews, meta-analyses, and randomized controlled trials,
provide the strongest support for clinical decision-making, while lower
levels of evidence offer valuable contextual information but are more
susceptible to bias (Vatkar et al., 2025).

Comparison of Evidence Using the Evidence Pyramid

An evidence pyramid ranks study designs based on their potential
for bias and overall data reliability (Vatkar et al., 2025). When
evaluating how combined HRT and psychiatric
care affects perimenopausal mood disorders, different layers of the
pyramid yield varying degrees of scientific authority. At the highest level
of the pyramid are systematic reviews and meta-analyses, which provide
the most reliable evidence for clinical decision-making. They are the
most dependable because they synthesize findings from multiple high-
quality studies and reduce the influence of single-study bias (Blunt,
2026). According to Li et al. (2026), a recent comprehensive meta-
analysis verified that estrogen-based therapies actively reduce depressive
symptom severity during perimenopause.

Below systematic reviews are randomized controlled trials (RCTs),
which are considered the gold standard for evaluating treatment
effectiveness (Vatkar et al., 2025). Their reliability level is high since

randomization prevents selection bias, but strict inclusion criteria
sometimes make it hard to generalize results to everyday patients with
complex comorbidities, and their findings may be limited by sample
size, study duration, and participant characteristics. Several RCTs
investigating estrogen therapy and depressive symptoms in
perimenopausal women demonstrate improvements in mood and anxiety
symptoms, particularly among women experiencing hormonally related
mood disturbances (Sharma et al., 2023).

Observational studies, including cohort and case-control studies,
occupy the middle of the evidence pyramid (Blunt, 2026). These studies
contribute valuable information regarding associations between
hormonal changes during perimenopause and the development of mood
symptoms; however, they cannot establish causality due to the potential
influence of confounding variables. At the lower levels of the pyramid
are expert opinions, narrative reviews, and clinical experience. While
these sources may provide useful clinical insight, they are more
vulnerable to bias and should not be used independently to guide
treatment decisions (Vatkar et al., 2025). Therefore, the highest level of
reliability for this PICO question comes from systematic reviews, meta-
analyses, and RCTs evaluating hormone therapy and psychiatric
interventions.

Literature Review Search Strategy

For this literature review, the search was deployed across PubMed/
MEDLINE, CINAHL, PsycINFO, Cochrane Library, and Google
Scholar, capturing peer-reviewed, English-language literature. These
databases were selected because they provide extensive coverage of
nursing, psychiatric, psychological, and medical research relevant to
perimenopausal mental health. The search strategy was built by
systematically translating each component of the PICO question into a
combination of controlled vocabulary, specifically Medical Subject
Headings (MeSH), and highly targeted keywords (Hosseini et al., 2024).
To capture the precise population, keywords
like "climacteric", "menopause transition", and "midlife women" were
paired alongside the core MeSH term "perimenopause". The

intervention layer was constructed using terms such
as "hormone replacement therapy", "estrogen", "estradiol", and
the abbreviation "HRT". To address the comparative psychiatric arm, the
search incorporated the MeSH term "antidepressive agents" alongside
keywords like "SSRIs", "SNRIs", "psychotherapy", and "psychiatric
treatment". Finally, the clinical outcomes were targeted using the
terms "depression", "anxiety", "mood swings", and "symptom
reduction".

These distinct conceptual blocks were bridged using Boolean
operators. Within each individual category, terms were expanded using
the "OR" operator to capture every possible linguistic variation (Dekkers
et al., 2022). The broad categories were then locked together using the
"AND" operator to ensure that every retrieved article explicitly featured
all components of the clinical inquiry. The resulting master string—
(Perimenopause OR "Menopause transition" OR "Climacteric") AND
(Hormone Replacement Therapy OR Estrogen OR Estradiol OR HRT)
AND (Antidepressants OR SSRI OR Psychotherapy OR "Psychiatric
treatment") AND (Depression OR Anxiety OR "Symptom
reduction") — served as the filter to isolate relevant research.

Inclusion criteria consisted of peer-reviewed studies published in
English, studies involving perimenopausal women, research evaluating
hormone therapy and mental health outcomes, and studies published
within the previous five years. Exclusion criteria included studies
focused exclusively on postmenopausal women, articles examining only
vasomotor symptoms without psychological outcomes, non-peer-
reviewed publications, editorials, opinion papers, and studies unrelated
to anxiety or depression.

The search initially identified 86 records. After removal of
duplicates and application of inclusion and exclusion criteria, 62 studies
underwent title and abstract screening. Twenty-five full-text articles
were assessed for eligibility, and 10 studies met all criteria for inclusion
in the final review. A PRISMA-style literature flow diagram was
developed to illustrate the identification, screening, eligibility, and
inclusion process. This systematic approach enhanced the transparency,

reproducibility, and credibility of the literature review while ensuring
that the highest-quality evidence available was used to answer the
clinical question.

2. Response for Leydiana

Creating a Search Strategy.

Abstract.

Evidence-based practice allows psychiatric-mental health nurses to
make clinical decisions using timely research evidence. This literature
review aimed to rank sources based on reliability using the evidence
pyramid and explain our search strategy to complete a literature review
on continuity of psychiatric care with barriers to transportation and
caregiver support for older adults. The evidence pyramid was utilized to
understand how strong of evidence there was for our research question.
Systematic reviews and meta-analysis proved to provide the highest
level of evidence. A literature search was completed on PubMed,
CINAHAL Complete, PsycINFO, Cochrane Library, and Google
Scholar. Keywords consisted of older adults, geriatric mental health,
transportation barriers, caregiver support, continuity of care, social
isolation, mental health services utilization. Articles were included if
they were peer-reviewed and published from 20 21-20 26 and included
adults ages 65 years or older. After title and abstract screening with
assessment of eligibility, 20 articles were included in our final review.
Our results showed that transportation barriers, caregiver burden, social
isolation, and decreased access to health care have negative effects on
continuity of psychiatric care and mental health outcomes in older
adults. Our thorough search allowed us to find current and high-quality
evidence that could be used in psychiatric nursing practice.

Key words: evidence-base practice, older adult, continuity of care,
transportation barriers, caregiver support, psychiatric mental health
nursing.

Compare the reliability of evidence-based research using and
evidence pyramid.

Evidence-based practice is essential to psychiatric-mental health
nursing because it allows providers to make clinical decisions based on
the best available evidence. The evidence pyramid is one strategy
utilized to grade research evidence (Melnyk & Fineout-Overholt, 2023).
Studies that rank high on the pyramid provide stronger evidence than
those on lower levels.

Systematic reviews sit at the top of the pyramid and synthesize
research studies to provide large overviews of evidence about certain
topics. In addition to proving stronger evidence for decision-making,
these studies attempt to remove bias (Melnyk & Fineout-Overholt,
2023). Randomized trials are placed beneath systematic reviews and are
highly effective forms of research because people are assigned to
intervention and control groups.

Studies that provide moderate evidence include cohort studies, case
control studies, and qualitative studies. Cohort and case-control studies
are utilized when randomized trials are not ethical or possible.
Qualitative studies can highlight patient perceptions about certain
barriers to care but are limited by lack of generalizability. Expert opinion
and background information provide the least amount of evidence
because they do not typically provide scientific data. However, they can
be helpful when making clinical decisions.

Systematic reviews, cohort studies, and peer-reviewed research
about healthcare access, continuity of care, caregiver support,
transportation barriers, and mental health outcomes among older adults
were used. These studies were utilized because they provided the highest
level of evidence available regarding the selected topic. Social isolation,
transportation barriers, caregiver burden, and poor healthcare access

among older adults lead to poor mental health outcomes and lack of
continuity in care (Choi et al., 2022; Yang et al., 2023).

Describe the search strategy used to conduct the literatures
review for your PICO question.

Multiple databases were utilized to identify evidence about
continuity of psychiatric care among older adults: PubMed, CINAHL
Complete, PsycINFO, Cochrane Library, and Google Scholar. These
databases were specifically chosen because they allow users to search
through nursing, psychiatric, medical, and behavioral health literature
that has been peer-reviewed.

Search terms included older adults, geriatric mental health,
transportation barriers, caregiver support, continuity of care, psychiatric
appointment adherence, social isolation, care coordination, and mental
health service utilization. Keywords were paired using Boolean
operators (AND, OR) to increase relevancy. (“older adults” AND
“mental health access”), (“transportation barriers” AND “psychiatric
care”), and (“caregiver support” AND “continuity of care”).

Certain inclusion and exclusion criteria were used to increase the
quality of literature found. Articles had to be peer reviewed and
published between 2021 and 2026, written in English, and involve
participants who were aged 65 years and older. Studies had to examine
one or more of the following topics: mental health service utilization,
barriers to healthcare access, transportation barriers, informal caregiver
support and involvement, social support, care coordination, and
continuity of care.

Exclusion criteria included articles published before 2021, research
involving pediatric populations, articles not written in English,
editorials/opinion pieces, and articles that did not focus on healthcare
access or continuation of psychiatric care. Studies were also excluded if
they were only conducted in inpatient settings. Research studies were
excluded if they focused solely on inpatient settings because the

literature search was meant to identify studies related to outpatient
psychiatric care.

To illustrate the search and screening process, a literature flow
diagram was generated. The search resulted in 145 articles across all
databases. Duplicate records were removed, leaving 120 articles
screened by title and abstract. Abstracts were screened based on
inclusion criteria and 80 articles were excluded. Forty articles were
assessed by full text review and 20 articles were excluded after further
evaluation. 20 studies were included in our final literature review. We
believe our systematic search provided evidence that is up-to-date,
relevant and can be applied to psychiatric nursing practice with older
adults facing barriers accessing mental health care.