Date of Award

January 2026

Document Type

Open Access Thesis

Degree Name

Doctor of Nursing Practice (DNP)

Department

Yale University School of Nursing

First Advisor

Lindsay Powell

Abstract

Major depressive disorder (MDD) is a prevalent psychiatric condition that significantlyimpairs daily functioning, cognitive performance, and overall quality of life. Evidence-based interventions, including pharmacotherapy and psychotherapy, are effective in managing MDD, with cognitive behavioral therapy (CBT) recognized as one of the most empirically supported treatments (Cuijpers et al., 2016). Interventions are needed to improve adherence to CBT to reduce relapse rates by addressing barriers to engagement and supporting sustained participation in treatment. This project developed and implemented a standardized protocol to improve CBT adherence among patients with MDD newly referred for combined CBT and medication management. A new ‘barriers form’ was introduced along with a revised front desk workflow. The intervention targeted transportation challenges, scheduling conflicts, limited access to telehealth services, and personal psychodynamic issues. Over a 12-week implementation period, 20 patients diagnosed with MDD and referred for CBT with medication management participated. Psychiatric mental health nurse practitioners (PMHNPs) reviewed completed barriers forms and individualized care plans to address additional complex psychological adherence-related factors. Pre- and post-implementation adherence rates were compared to evaluate the impact of the protocol. Results demonstrated a statistically significant 12.1% increase in CBT adherence following implementation. In addition, depressive symptoms improved significantly, with mean PHQ-9 scores decreasing from 16.58 to 11.47 (p < .001). The most frequently reported barriers were transportation difficulties and scheduling conflicts, highlighting the importance of addressing practical access issues. These findings suggest that structured and barrier-focused interventions can enhance CBT adherence and improve clinical outcomes in individuals with MDD.

Comments

This is an Open Access Thesis.

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