SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION

Screening for Vitamin D Deficiency in Adults with Depression

Evangelina (Angel) Miller
Edson College of Nursing and Health Innovation, Arizona State University

Author Note
Evangelina Miller is a Family Nurse Practitioner at the Veterans Affairs Texas Valley
Coastal Bend Health Care System in Tele-Pain Medicine.
She has no known conflict of interest to disclose.
Correspondence concerning this article should be addressed to Evangelina Miller,
Arizona State University, 975 South Myrtle Avenue, Tempe AZ 85281. Email:
epmille3@asu.edu

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Abstract
Purpose & Background: This project evaluates the impact of education on a provider’s intent to
screen for vitamin D deficiency in adults with depression. An internal Quality Improvement (QI)
study at a local mental health primary care clinic revealed that only 1 in 3 patients with
depression were routinely screened for vitamin D deficiency. Vitamin D is a crucial component
of numerous systemic functions, including mental health, specifically depression.
Methods: This QI project used the Rosswurm and Larrabee Model implementation framework.
Institution Review Board (IRB) expedited review approval was received. This project was
conducted at 10 Veteran’s Affairs (VA) primary care clinics in Arizona. An initial email with a
recruitment flyer was sent to providers to launch the project. A second email was sent to
participants who volunteered to participate in the project, with instructions and links to the
asynchronous pre-survey, recorded education PowerPoint, and post-survey. Responses were
analyzed using Intellectus Statistics software.
Results: Provider knowledge of impact and intent to screen for vitamin D deficiency increased
after viewing a brief education video (n=30). Frequency distribution analyses revealed a 23%
average increase in agreement to screen for vitamin D deficiency at annual visits, “at-risk”
individuals, knowledge of the association, and intent to screen regularly in depression.
Conclusion: The education intervention was found to positively impact the provider’s intent and
demonstrate the importance of screening for vitamin D deficiency in adults with depression.

Keywords: vitamin D, vitamin d deficiency, adults with depression, screening

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Screening for Vitamin D Deficiency in Adults with Depression
According to the National Institutes of Health (2021), over 42% of adults in the United
States have low vitamin D levels. Adequate vitamin D levels are essential to overall adult health.
Vitamin D is a crucial component of calcium absorption for bone strength, decreases insulin
resistance, impacts cardiovascular health, promotes healthy immune system function, and
impacts mental health, including depression. Cuomo et al. (2019) studied patients with bipolar
depression disorder and found that 94% had inadequate vitamin D levels. An internal QI study at
a local mental health primary care clinic revealed that only 1 in 3 patients with depression were
routinely screened for vitamin D deficiency. Further, an extensive literature review revealed the
clinically significant impact of evaluating and addressing vitamin D deficiency in depression
(Briggs et al., 2019; Cuomo et al., 2019; Darnton-Hill, 2019; Erensoy, 2019; Gugger et al., 2019;
Kaviani et al., 2020). The project aimed to evaluate the impact of education on the provider’s
intent to screen for vitamin D deficiency in adults with depression.
Problem Statement
In the last decade, tremendous progress has been made in developing evidence-based
vitamin D guidelines and policies (Sempos & Binkley, 2020). However, despite this progress,
vitamin D screening and management are not consistently utilized in adults with depression.
Purpose and Rationale
Vitamin D is a unique neurosteroid hormone that has a vital role in depression. Vitamin
D receptors are present in neurons in the brain, contributing to the pathophysiology of depression
(Anglin et al., 2013). Many research studies have shown an association between vitamin D
deficiency and increased depression symptoms (Briggs et al., 2019; Cuomo et al., 2019;
Darnton-Hill, 2019; Erensoy, 2019; Gugger et al., 2019; Kaviani et al., 2020). The project was

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designed to assess the effect of education on the provider’s intent to screen for vitamin D
deficiency in adults with depression.
Many factors contribute to vitamin D deficiency, especially in individuals with
depression. It is difficult to obtain adequate vitamin D from diet alone, as many foods lack
enough to maintain appropriate levels. The typical protected indoor environment limits exposure
to UV, causing a lack of vitamin D exposure. An individual experiencing symptoms of
depression such as lack of appetite and motivation to leave home also contributes to decreased
vitamin D levels, typically obtained by exposure to UV sunlight and consuming vitamin D in the
diet. As a result, vitamin D supplementation is often the recommended treatment or standard of
care (SOC).
Background and Significance
In 1920, Vitamin D's influential discovery led to curing a painful childhood bone
disease, known as rickets. Vitamin D is endogenously produced when the skin is exposed to
ultraviolet (UV) rays, which triggers vitamin D synthesis, but can require supplementation
(Anglin et al., 2013). Vitamin D is converted in the liver and kidneys to its active form, known as
calcitriol (National Institutes of Health, n. d.). Vitamin D is a fat-soluble vitamin that is absorbed
in the small intestine. Vitamin D deficiency is associated with numerous medical conditions such
as osteoporosis, hypertension, cardiovascular disease, diabetes, obesity, and depression.
Vitamin D deficiency is associated with poor outcomes of numerous inflammatory
problems. Mediated by elements of the inflammatory cascade, vitamin D deficiency predisposes
a patient to certain degrees of pathologic central nervous system (CNS) induced sleepiness, a
depression symptom (McCarty, 2010). Depression is associated with inflammation in the body,
as evidenced by an elevated C-Reactive Protein (CRP) and there appears to be relationship

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between elevated CRP and decreased vitamin D levels (Puglisi, 2014). Many studies indicate
that nutritional intake, including lack of vitamin D, is part of the underlying causes of depression
symptoms (Alavi et al., 2019, Alghamdi et al., 2020, Anglin et al., 2013, Irandoust and Taheri,
2017, Gugger et al., 2019; Kaviani et al., 2020, Krysiak et al., 2018, Vaziri et al., 2016, Zheng et
al., 2019).
Adults with Depression
Depression is a serious mental health condition that can be devastating for people if left
untreated. Symptoms of depression can vary in presentation, are evident for over two weeks, and
affect daily functioning (National Alliance on Mental Illness (NAMI), 2017). Common
symptoms include fatigue, insomnia, lack of appetite, lack of interest in activities, physical aches
and pains, hopelessness, or suicidal thoughts (National Alliance on Mental Illness (NAMI),
2017). Over 18 percent of adults over age 18 have regular feelings of depression (Centers for
Disease Control and Prevention (CDC), 2021). Numerous studies associate a significant risk of
depression symptoms with vitamin D deficiency (Alghamdi et al., 2020, Anglin et al., 2013,
Briggs et al., 2019; Cuomo et al., 2019; Darnton-Hill, 2019; Erensoy, 2019; Gugger et al., 2019;
Kaviani et al., 2020).
Screening for Vitamin D Deficiency in General Population
Vitamin D levels are typically used to screen for bone disorders. However, vitamin D
levels are also checked in people with chronic medical problems such as diabetes, cardiovascular
disorders, inflammation, and depression. The Vitamin D Standardization Program (VDSP)
established protocols to standardize vitamin D measurement procedures (Sempos & Binkley,
2020). The VDSP, in collaboration with the Institute of Medicine (IOM) and the American
Association of Clinical Endocrinology (AACE), determined the appropriate serum vitamin D

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levels and the Recommended Daily Allowance (RDA) for adults (Ross et al., 2011). Vitamin D
status is measured by serum levels of a total 25-hydroxyvitamin D [25(OH)] concentration
(National Institutes of Health, n. d.). A normal level or adequate for healthy adults is 20
nanograms/milliliter (ng/ml) to 50 ng/ml, and a level of less than 20 ng/ml is considered vitamin
D deficiency (Bikle, 2014). The SOC, as recommended by VDSP, IOM, and AACE, is to
monitor Vitamin D levels at intervals of three months, six months, or annually depending on
levels and treatment or deficiency management.
Standard treatment with supplementation for vitamin D deficiency varies depending on
the level of deficiency. Supplementation with vitamin D3 or ergocalciferol can range from 1,000
to 2,000 international units (IU) daily to 50,000 IU weekly or even 50,000 IU monthly (Pepper et
al., 2009). As vitamin D is fat-soluble, it is recommended that vitamin D supplements be taken
with food for optimal absorption.
Screening for Vitamin D Deficiency in Mental Health
Evaluation and management of vitamin D deficiency in adults with mental health
diseases are inconsistent. Data is limited regarding the standardization or consistent use of
screening and treatment for low vitamin D in patients with depression, and the research field of
vitamin D remains controversial. Ethical considerations must be given high priority in study
design, given the risk of any severe or irreversible damage caused by insufficiency of vitamin D
(Frame et al., 2018). While the science continues to emerge, a relationship between vitamin D
deficiency and symptoms of depression are apparent in many observational studies (Anglin et al.,
2013, Briggs et al., 2019; Cuomo et al., 2019; Darnton-Hill, 2019; Erensoy, 2019; Gugger et al.,
2019; Kaviani et al., 2020). Alghamdi et al. (2020) demonstrated that after three months of
vitamin D supplementation, baseline Beck Depression Inventory (BDI) scores decreased

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significantly, and vitamin D levels increased. Many other studies had similar results of reduced
depression scores and increased vitamin D levels, see Table 1. Studies suggest that adding
vitamin D supplementation as a SOC in conjunction with depression treatment should be a gold
standard (Alghamdi et al., 2020).
Internal Evidence/Setting Generated Data
Routine vitamin D screening is not being performed in patients with depression in the
primary care setting. Upon reviewing 100 charts at a Veteran's Affairs (VA) medical center in
the Southwest United States, only one in three patients with depression were screened for
vitamin D deficiency. The VA serves approximately 1700 patients in the mental health primary
care and homeless primary care clinics, mainly cared for by Nurse Practitioners and Medical
Doctors. The VA medical center provider's treatment guidelines are derived from the Veterans
Health Administration (VHA) Pharmacy Benefits Management Services (PBM), Medical
Advisory Panel (MAP), and Center for Medication Safety (VA MEDSAFE) (National PBM
Bulletin, 2009). The VDSP, in collaboration with IOM, determines the national SOC guidelines
for evaluating and managing vitamin D deficiency and AACE and aligns with the VA guidelines.
PICOT Question
This inquiry has led to the development of the following PICOT question: In adults with
depression, does screening for vitamin D deficiency, compared to not being screened, have an
impact on depression symptoms?
Search Strategy
An exhaustive search was performed in the electronic databases PubMed, PsychInfo, and
the Cumulative Index to Nursing and Allied Health Literature (CINAHL). These databases were
selected for components encompassing symptoms of depression, vitamin D deficiency, and

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supplemental management and relevance to the PICOT question. All three databases generated
pertinent and related articles. The search method for each database has been explained below.
Inclusion Criteria, Exclusion Criteria, and Limitations
The inclusion criteria focused on studies published in English and ranged from 2015 to
the present. Articles greater than five years were excluded, except for landmark studies. Criteria
for inclusion consisted of adults and primary care, and the terms treatment and management were
used synonymously. Studies from several countries were included unless they were not available
in English. Most studies examined European and American regions. Opinion articles, studies
lacking evidence to support, non-peer-reviewed, and non-primary research studies were
excluded, except for landmark meta-analysis or systemic reviews. In all databases, inclusion and
exclusion criteria were the same.
Keyword Selection
Keywords were carefully considered based on the PICOT question, and relevant
information was generated with each search. The following keywords were utilized in the initial
search: Depression and vitamin D. This search produced numerous articles related to depression
and vitamin D; however, not all results met the inclusion criteria. A second search was
completed with more specific choice of words: vitamin D or ergocalciferol, depression or
depressive disorder, vitamin D insufficiency or deficiency, screening, and supplementation. This
refined search generated a more concise selection of literature to use.

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Search Yield
An initial search of CINAHL using vitamin D, depression, and fatigue yielded 39 results;
a subsequent search that included vitamin D, depression, fatigue, and supplementation produced
6 results. A database search of PsychInfo using key terms vitamin D, depression, and
supplements yielded 84 results. A search in PubMed generated 9 results using the terms vitamin
D, depression, fatigue, and supplement. Critical appraisal was performed on 12 citations, and
with careful consideration, 10 have been chosen to use in this review. The chosen studies
addressed the PICOT question appropriately and evaluated if screening and treatment with
supplementation for vitamin D deficiency impacts adults with depression.
Critical Appraisal and Synthesis of Evidence
Ten studies were saved for this review, including 9 RCTs, one longitudinal study, and one
retrospective study. The studies were similar across many components. Detailed measures were
taken to ensure blinded methods and randomization were clearly explained. Five out of the ten
studies did not compare placebo to the intervention of vitamin D supplementation. However, all
ten studies evaluated and described a notable reduction in depression scores and increased serum
25(OH) levels (Appendix A).
The studies reveal various demographic information (Appendix A). The age range was
from 18 to over 65 years old. Three out of the ten studies included female participants only; the
other seven included both male and female participants. Most studies reported the Beck
Depression Inventory (BDI) scale of depression symptoms. The settings designated in the studies
were primarily outpatient-based (Appendix A).
Assessment of primary interventions showed that most studies included interventions such
as vitamin D supplementation versus placebo. All studies exhibited some degree of regular

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monitoring of depression and vitamin D levels throughout and after the study. One study
included additional interventions such as physical activity and UV sunlight exposure, and
another study evaluated the impact of vitamin D plus calcium supplementation on depression.
Most studies assessed vitamin D supplementation from 2,000 international units (IU) daily to
50,000 IU monthly. The length of the studies were mixed, ranging from 2 months to 24 months.
Key outcomes of interest mainly focused on reducing depression scores and increasing
serum vitamin D levels (Appendix A). Five of the studies measured and reported BDI scores for
depression symptoms and serum vitamin D levels; four of the studies utilized Geriatric
Depression Scale (GDS), Hamilton D-17 Depression Score (HAM-D17), or Patient Health
Questionnaire (PHQ-9). The remaining study used Edinburgh Postnatal Depression Scale
(EPDS). All studies utilized standardized serum 25(OH) assay levels (Appendix A).
Measurement instruments were similar and included self-completion of depression
questionnaires, interviews, and blood draws. A variety of reliable instruments were used to
measure the effect of vitamin D supplementation on depression, showing an affect on reducing
depression symptoms. The BDI was used in several studies. This questionnaire is a commonly
used, reliable instrument to quantify levels of depression. The BDI has a reported coefficient
alpha rating of 0.92 for outpatients (Sepehrmanesh et al., 2016). The BDI and HAM-D1
positively correlate and have test-retest reliability of r = 0.93 and confidence interval (CI) a=
0.91 (Sepehrmanesh et al., 2016). Most of the studies used analysis of variance (ANOVA),
independent t-test, chi-square, regression analysis, and level of significance (p) to test
heterogeneity. The overall significance of the effect consistently indicated a significant degree of
certainty that vitamin D supplementation on depression positively affects depression symptoms
and vitamin D levels.

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Theoretical Framework
While only one study mentioned an applied theoretical framework, this project used
Bandura's Self-Efficacy Theory. Bandura suggests that following self-efficacy-based
interventions, particularly performance of the behavior of interest, increases outcome
probabilities and self-efficacy (Smith & Liehr, 2018). Life as a busy primary care provider is
demanding and stressful, which requires higher levels of independence, initiative, and selfregulation. This applies to the project's purpose to evaluate the impact of education on the
provider's intent to screen for vitamin D deficiency in adults with depression. Virtual learning, as
noted in this project, creates a flexible environment that combines structure, freedom and ease of
access to the most recent EBP which enables providers to learn when it works best for them; thus
promoting self-efficacy and the ability to leverage the most recent evidence to ensure optimal
care for their patients.
Integrating evidence-based information on benefits and harms, can potentially lead to
improved screening and decision-making for vitamin D deficiency (Rodrigues et al., 2019).
There is an inadequate promotion of vitamin D education, including the benefits of routine
screening and supplementation as needed. Many healthcare providers, public health
professionals, and the public are deficient in information and awareness about the value of
vitamin D, protecting against many chronic diseases, and its potential to reduce health disparities
(American Public Health Association (APHA), 2008). Consistent screening may improve health
outcomes for patients with vitamin D deficiency and depression, affect patient quality of life, and
improve holistic care and treatment of individuals (Rodrigues et al., 2019). Self-efficacy is
essential to support virtual learning activities. The Self-Efficacy Theory guided and evaluated
factors that affect provider self-efficacy to make the project's education intervention successful.

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Implementation Framework
The Rosswurm and Larrabee Model, which focuses on utilizing evidence-based practice,
supported this project's development (Rosswurm & Larrabee, 1999). This model consists of 6
stages: Assess the need for change, link the problem and interventions and outcomes, synthesize
best evidence, design practice change, implement and evaluate change in practice and integrate
and maintain change in practice (see Appendix A). In the first stage: Assessing the need for
change, internal and external evidence suggests that vitamin D deficiency in depressed adults is a
significant problem. In the second stage, link the problem and interventions and outcomes, the
lack of screening for vitamin D deficiency in depressed adults suggests a potential knowledge
deficit or lack of adherence to established protocols of primary care providers (PCPs). PCPs are
inundated with patient care and often cannot stay updated on the most recent evidence-based
guidelines. Providing an efficient, condensed education method for primary care providers may
increase screening for vitamin D deficiency in depressed adults, optimizing patient health
outcomes. The third stage of synthesizing the best evidence revealed several studies that found
that many adults with depression had vitamin D deficiency. Designing a practice change's fourth
stage includes providing providers with the best evidence by an educational presentation via an
asynchronous PowerPoint video. The fifth stage of implementing and evaluating a practice
change includes sending a pre-and post-survey with the asynchronous education video to primary
care providers. In this stage, data is collected to determine the effectiveness of the education
video on a provider's intent to screen for vitamin D deficiency in depression. The last stage of
integrating and maintaining a change practice may include regular promotion of the educational
video to primary care providers and assess if screening and treating vitamin D deficiency
becomes a standard of care.

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Project Method
Institutional Review Board (IRB) expedited review approval was received from Arizona
State University (ASU) and the Veterans Affairs Health Care System (VAHCS) prior to the
commencement of this project. All efforts were made through secure links to preserve the
participant's privacy. The review of the education video and completion of the surveys were
considered the participant's consent to participate in the project. The data was reviewed in
aggregate only. The collection consisted of evaluating the impact of the educational intervention
on the provider's intent to screen for vitamin D deficiency in adults with depression. The
collection of email addresses and personally identifiable information (PII) was for recruitment
purposes only, and the study did not identify PII in the data collection process. There was no
apparent risk to the participants.
Participants and Recruitment
The co-investigator recruited and educated the project participants. A week before the
project launch date, a recruitment email was sent to primary care clinics at the VAHCS via
global network addresses titled "xx Agave" and "xx CBOC All." Week -1: The recruitment email
included an embedded recruitment flyer and consent form. The flyer and consent form described
the project to the potential participants in the primary care clinics. The initial project launch
email was sent to 5 primary care clinics with approximately 60 providers. However, the initial
response only yielded 10 completed responses. The co-investigator collaborated with site
stakeholders, and the decision was made to send the invitation email to 5 additional primary care
clinics, with approximately 130 providers. In the initial pre-survey, the response was 49
providers. However, only 30 completed responses were used in the final data analysis, a 23%
response rate.

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Intervention
The participant's total involvement in the project did not exceed 10 minutes. The
education video took approximately 7 minutes to view, while each 5-item Likert-type survey
took approximately 1 minute to complete. The expected education review and completed survey
responses were within one week of email receipt. The total project occurred within an eightweek timeframe. The estimated study completion date, including primary analysis, was
approximately March 1, 2022. During week 1, participants across the selected VA clinics
received an email that consisted of 3 parts: A link to the pre-survey, the education video, and the
post-survey. All three steps needed to be completed in sequential order to complete the project.
The pre-survey collected deidentified demographics, including gender, role (i.e., physician, nurse
practitioner, physician's assistant,) years of practice, and primary area(s) of practice, such as
outpatient primary care and inpatient or internal medicine. The recorded education PowerPoint
covered the history of vitamin D, prevalence, the association between vitamin D deficiency and
depression, and the benefits of screening and treating vitamin D deficiency. During week 8, the
co-investigator sent a final thank you email to providers for participation in the project.
Incomplete participant responses were not used in the final data analysis.
Project Results
Data Analysis Procedure
Intellectus Statistics software was used to complete the data analysis, and
descriptive statistics and frequency distribution examined the outcome variables. Standard
frequency analysis was performed to describe and compare the PCP demographics who
completed the surveys. The outcomes measured included knowledge of the impact of vitamin D
deficiency on depression and the PCP’s intent to screen for vitamin D deficiency in depression.

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The data was converted to percentage values from Survey Monkey into Intellectus Statistics.
Long-term data was not collected. No cost was associated with the project, and participants were
not responsible for any costs related to participation in the project.
Demographic Data
The first four pre-survey questions were demographic inquiries, followed by five preeducation questions. The recruitment email was sent to approximately 60 providers. Forty-nine
providers completed the pre-survey. However, thirty providers (n=30) fully completed both preand post-surveys, making them eligible for the project. The 19 incomplete survey responses were
removed and were not used in the final data analysis. Of the remaining participants, 2 were male
(6.7%), and 28 (93.3%) were female. All 30 (100%) providers were Nurse Practitioners, and
worked in Primary Care (43%), Outpatient (23%), Internal Medicine (10%), inpatient providers
(3.3%), Neurology/Headache (3.3%), Nurse Leadership (3.3%), Psychiatry (3.3%) and
Education (3.3%). Most of the providers were in practice an average of 10-20 years (30%),
followed by 5-9 years (27%), 21+ years (23%) , and 1-4 years (20%) in practice.

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Figure 1
Distribution of Years in Practice

Years in Practice

10-20 years

30%

5-9 years

27%

21+ years

23%

1-4 years

20%
1

5

10

15

20

25

30

35

Percentage
n = 30

Outcome Data
The co-investigators developed the pre-and post-surveys. Each survey contained 5 Likerttype scaled questions, ranging from 1-strongly disagree to 6-strongly agree. The co-investigators
were unable to find an applicable instrument or survey of interest, therefore created these short
surveys for the sake of this project. The pre-and post-survey demonstrate face validity having
been reviewed by various content experts to assess provider knowledge and intent to screen for
vitamin D deficiency. The surveys took 2 minutes to administer with clear directions, and they
were easy to score. The comparison of all pre-and post-survey responses revealed a 23% average
increase in agreement to screen for vitamin D deficiency at annual visits, "at-risk" individuals,
knowledge of the association, and intent to screen regularly in depression. The corresponding
level of disagreement decreased by an average of 19% comparing the pre-and post-survey
responses.

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Figure 2

Percentage

Comparison of Pre- & Post Education Responses
n=30
93%
100%
90%
80%
63%
70%
60%
50%
36%
40%
30%
20%
7%
10%
0%
disagree agree

93%

93%

80%

20%

80%

disagree agree

Screen at annual visitsScreen “at risk”

73%

27%

20%
7%

93%

7%
disagree agree

7%
disagree agree

KnowledgeRegularly screen in depression

blue: pre & post-survey disagree
green: pre & post-survey agree

The first pre-survey question was, "I screen all my patients for vitamin D deficiency
during my annual office visits." The disagree response percentage was 36%, and the agree
response percentage was 63%. The post-survey question was, "I will screen all my patients for
vitamin D deficiency during my annual office visits." The disagree response percentage
decreased to 7%, and the agree response percentage increased to 93%. The post-education
intervention revealed an increase in providers' intent to screen for vitamin D deficiency during
annual office visits.
The second pre-survey question was, "I screen for vitamin D deficiency in "at-risk"
individuals such as those with osteoporosis and cardiovascular disease." The disagree response
percentage was 20%, and the agree response was 80%. The question on the post-survey was, "I
will screen for vitamin D deficiency in "at-risk" individuals such as those with osteoporosis and
cardiovascular disease. The disagree response percentage decreased to 7%, and the agree

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response increased to 93%. The post-education intervention revealed a 13% increase in
providers' intent to screen for vitamin D deficiency in "at-risk" individuals such as those with
osteoporosis and cardiovascular disease.
The pre-and post-survey questions were "I (will) screen for vitamin D deficiency in
adults with depression. The disagree response percentage was 20%, and the agree response was
80%. The percentage of the post-survey disagree response decreased to 7%, and the agree
response increased to 93%. This information revealed an increased knowledge of the association
vitamin D deficiency and depression.
A question on the pre-and post-survey was, "I am knowledgeable about the impact of
vitamin D deficiency in adults with depression. The pre-survey disagree response percentage was
27%, and the agree response was 73%. The percentage of the post-survey disagree response
decreased to 7%, and the agreed response increased to 93%. This information reveals a 20%
increase in providers' knowledge of the impact of vitamin D deficiency on depression.
The last pre-survey statement was, "I routinely access information about current
evidence-based practice guidelines." Nine out of 10 respondents agree with this statement. All 30
respondents agreed to the post-survey question, "The education format was an effective method
to convey information about current evidence-based practice guidelines." This data comparison
pre-and post-education intervention demonstrates the increased likelihood of providers to seek a
concise, practical, and convenient delivery method such as demonstrated by this project
Discussion
The progression through this DNP project has evolved and revealed exciting outcomes.
All providers that completed the project were Nurse Practitioners, the majority of whom have

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been in practice for 10 to 20 years. Continuing education and staying up to date on the latest
evidence-based information is critical to support better patient outcomes.
Studies are sparse or outdated regarding Nurse Practitioners continuing education.
However, according to Smith et al. (2021), providing continuing education training via a
distance-accessible education model for Nurse Practitioners in rural areas without traveling was
beneficial. This example exemplifies the need to provide providers with alternative means, such
as asynchronous, virtual, or online formats, to promote continuing education and provide the
most recent evidence. Nurse Practitioners are busy, and providing an education format such as
this project has great potential. Studies on virtual provider learning or continuing education are
emerging and warrants dissemination of this project's outcomes and pursuance of further
investigation. Organizations should consider using credible, in-house experts to present the most
recent EBP guidelines. Providers may be more inclined to participate in educational forums
presented by a credible peer or individual that they recognize and are comfortable with. Another
future recommendation is to perform a follow-up chart audit to determine if the intent to screen
for vitamin D deficiency in depression was performed.
Strengths and Limitations
There were several notable strengths and limitations of this project. The facilitators of the
project implementation were very helpful. Barriers were also faced during and contributed to the
project journey, although they were learning experiences. The widespread information
technology usage has increased the convenience of accessing information and knowledge sharing
for medical providers. Providers are subjected to numerous educational methods, especially
virtual learning, and are often inundated with too much information. This project demonstrated
that a compressed, asynchronous education delivery method was effective.

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Many strengths arose during the progression of the project. The education intervention
enhanced the provider’s intent to screen for vitamin D deficiency in adults with depression. The
intervention was short and practical for PCPs and they were able to participate at their
convenience. The site mentor was instrumental in facilitating the project and providing guidance
throughout the process.
The project site encouraged the success of the project. Many VA facilities are
academically affiliated and encourage research promotion. The site mentors and key stakeholders
were well prepared to guide the project. The site mentors were also doctoral-prepared nurses. As
a result of this, the facilitation of the project was well executed.
The feasibility of the project is considerable. This strength was revealed by the
participants' increased percentage of the agreement responses. The use of evolving information
technology potentially increases a busy provider's satisfaction by promoting quality of care
through enhanced access to and adherence to the latest evidence-based guidelines. Virtual
learning such as this project creates a flexible environment that combines structure and freedom.
A few limitations occurred through the progression of this project. The sample size was
small; therefore, the findings are not generalizable. The pre-survey was completed by 49
providers (38%), whereas 30 (23%) providers only completed the entire project protocol. A few
providers commented that they had technical difficulties listening to the recorded PowerPoint.
The providers’ responses were soley from Nurse Practitioners. The respondent roles were not
diverse enough to draw substantive conclusions about providers overall. No physicians
participated in the project, possibly due to higher workloads than their NP colleagues, or perhaps
they were less inclined to receive education from an NP. All providers, including NPs, should be

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION

21

equally supportive of another’s professional development. Interdisciplinary education and
perspectives on issues that primary care providers commonly confront are important.
Another limitation is that the project was implemented during the holidays from
December 2021 to January 2022. Responses were initially limited, as many providers were out of
the office. The project was also performed amidst the COVID-19 pandemic. Although this was
considered a barrier, it was also a strength due to the nature of the delivery method. The COVID19 pandemic spring-boarded numerous virtual delivery methods like this project protocol.
Implications for Practice Change
As this project demonstrated, the evidence regarding the evaluation and management of
vitamin D deficiency in adults with depression is underutilized. Internal and external evidence
suggests a lack of consistency in evaluating and managing vitamin D deficiency in adults with
depression. For potential data collection, research studies recommend the usage of depression
questionnaires such as BDI and PHQ-9 and measurement of serum 25(OH) levels to evaluate the
association between low vitamin D levels and depression. A clinical decision-making tool or
protocol for primary care providers to consistently screen for vitamin D deficiency could be
helpful. Appropriate use of professional knowledge and skills is a controlled personal activity of
a self-system such as Self-Efficacy (Smith & Liehr, 2018). Life as a primary care provider can be
demanding and stressful, which requires higher levels of independence, initiative, and selfregulation.
Another fundamental provider implication is the effectiveness of presenting the most
recent evidence in a condensed, efficient manner. The convenience, brevity, and timeliness of the
education delivery method increased a provider’s knowledge of the impact of vitamin D
deficiency in depression. The way in which the content was delivered potentially increases a

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION

22

provider’s intent to implement a practice change. This project demonstrates that providers may
be more inclined to seek out short yet effective education offerings.
Sustainability
The impact of the project on the provider and patient was studied. The intent was to raise
awareness about vitamin D deficiency and depression and craft an intervention to be mindful of a
provider's time and busy schedule. The total project intervention time was less than 10 minutes.
The short education intervention notably affected the provider's knowledge and the impact of
vitamin D deficiency on depression. It increased the likelihood of the provider to screen for
vitamin D deficiency in at-risk individuals. The impact on patients is also insightful. The
literature evaluation revealed a noteworthy impact of screening and treatment for vitamin D
deficiency in depression. Consideration for evaluation and treatment has shown to decrease
depression symptoms. Access to timely evidence-based information and guidelines potentially
enhances a patient's overall health; and can increase the provider's confidence in applying the
most recent evidence to ensure optimal care for their patient.
Numerous hours went into the project’s progression, preparing the relatively simple
intervention. This project can easily be resumed, extended, and further developed. The use of
VA’s information technology, such as Microsoft Outlook and Teams, are easy to use and is
conducive to future education presentations.
The project intervention is sustainable for several reasons. The data demonstrates
effectiveness in provider education via an asynchronous mechanism. The evaluation and
treatment of vitamin D deficiency are also cost-effective. The research on vitamin D deficiency
is evolving, and the education delivery method is concise and practical. Vitamin D has numerous
health implications brought to light with this project’s development. Providers responded that

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION

23

they are more inclined to regularly screen for vitamin D deficiency not only in depression but
also in at-risk individuals. A project goal of developing and delivering the most recent evidencebased information and guidelines was proven successful and demonstrated effectiveness in the
delivery. The format is usable and sustainable for further use.
Future Recommendations
The project aimed to evaluate the impact of education on the provider’s intent to screen
for vitamin D deficiency in adults with depression. Other on-line delivery forums should be
examined to promote provider self-efficacy. Additional evaluation is also necessary to determne
if this form of education delivery actually changed provider practice, versus “intent” to change
practice. Future recommendations include consistent vitamin D screening and treatment; and to
further explore the education protocol with a larger and more diverse sample size.
Conclusions
The evidence suggests that evaluation and management for vitamin D deficiency
conducted primarily in the outpatient or primary care setting can reduce depression symptoms
and increase vitamin D levels. The evidence also suggests that screening for vitamin D
deficiency in adults with depression is inconsistent. This project’s education intervention
positively impacts a provider’s intent to screen for vitamin D deficiency in adults with
depression and consistently during annual visits and “at-risk” individuals such as those with
osteoporosis, diabetes, cardiovascular disease, autoimmune disorders, and numerous other health
issues. This project demonstrates that providers may be more motivated to pursue brief, efficient
education offerings. Therefore providing similar educational formats and delivering the most
recent evidence-based guidelines potentially optimizes patient health outcomes and primary care
provider satisfaction.

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION

24

Appendix A
Evaluation Tables
Table 1
Evaluation Table for Quantitative Studies
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

(Alghamdi et
al., 2020)
Vit D
supplement
ameliorates
severity of
MDD.

Self-Efficacy
Theory

Design: RCT 2
randomized
treatment
groups.

N=1
n=62

IV : Vit D suppl
50,000IU/wk x
3 mo.

DV1: BDI.

T-test, One-way
ANOVA,
Tukey’s
multiple
comparison test.

DV1:
-Females severe
depression,
improved from
36 ± 0.9 to
27 ± 3.6
(p < 0.05)
-Males: decrease
in their BDI
scores after
vitamin D
supplementation
(p < 0.05).

Country: Saudi
Arabia.
Funding:
Deanship of
scientific
research (DSR),
King Abdulaziz
University,
Saudi Arabia
under Grant.
Bias: None
stated or noted.

Purpose:
Evaluate adding
vit D
supplement to
existing MDD
treatment such
as SSRI’s.

Demographics:
Adults 18-65 yo
Inclusion
criteria:
Dx w/ MDD.
Exclusion
criteria:
Abn PTH levels,
renal and
hepatic
impairment.

DV1 : BD1
depression
symptoms.
DV2: 25 (OH)
& serotonin
levels.

DV2: serum
25(OH).

DV2: levels rose
significantly at
3 months in
male and female
subjects in
comparison to
the baseline
levels

Level/
Quality of
Evidence;
Decision for
practice/Applica
tion to Practice
LOE: 1
Strengths:
RTC.
Limitations:
Lacks placebo
tx.
Sample size may
be too small.
Some pts had
disclosed
adjunct tx with
SSRI’s for
depression;
some already on
Vit D
supplementation
.
Feasibility:
Adds additional

Key: Abn-abnormal; add’l-additional; ANOVA-analysis of variance; BDI-Beck Depression Inventory; BPAD-Bipolar affective disorder; Ca-calcium; CBC-complete blood
count; CES-D-Center for Epidemiologic Studies Depression; Cont-continue; CRF-chronic renal failure; CRP-C-reactive protein; DSM-IV- Diagnostic and Statistical Manual of
Mental Disorders; d/t-due to; DV-dependent variable; Dx-diagnosis; EPDS-Edinburgh Postnatal Depression Scale; Eval-evaluate; FSFL-female sexual function levels; GDSGeriatric Depression Scale; HAM-D17-Hamilton D-17 depression score; Hx-history; ID-identify; IPA-indoor physical activity; IV-independent variable; LFT-liver function test;
LOE-level of evidence; MCS-Mental Component Summary; MDD-major depressive disorder; MH-mental health; MMSE-Mini-Mental State Exam; mo-month; MSKmusculoskeletal; N-number of studies; n-number of participants; NNT-number needed to treat; OA-osteoarthritis; OPA-outdoor physical activity; PHQ-9-Patient Health
Questionnaire; PTH-parathyroid hormone; Pts-patients; Psych-Psychiatric; P-value probability; RCT-randomized control trial; Rx-prescription; S/E-side effects; SOC-standard
of care; SSRI-Selective serotonin reuptake inhibitor; suppl-supplement; sx-symptoms; TB-Tuberculosis; TSH-thyroid stimulating hormone; Tx-therapy; IU-international units;
Vit D-Vitamin D; Wk-week; wt-weight; 25(OH)-Vitamin D; YO-year old; yr-year.

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION

(Alavi et al.,
2019)
Effect of vit D
suppl on
depression in
elderly pts.
Country: Iran
Funding: Grant
(no. 93160)
from Kashan
University of
Medical
Sciences.
Bias: None
stated or noted.

Self-Efficacy
Theory

Design: RCT
Purpose: Eval
effect of Vit D
supplement and
placebo of
depression in
psych clinics.

N=1
n=78
Demographics:
Adults over 60
yo w/ mod to
severe
depression.
Inclusion
criteria: Iranian
citizenship,
speak Farsi, no
hx mental illness
except
depression, no
physical
disability and
GDS score >5.
Exclusion
criteria:
Uncooperative
and refused to
cont tx and
those with
severe stress
such as
hospitalization
or death of
relatives.

IV: Vit D suppl
50,000U vit D3
pearl/wk vs
placebo x 8 wks
vs placebo.

DV1:
Depression
symptoms.
DV2: 25(OH)
level.

25

DV1: GDS-15.
DV2: Serum
25(OH).

GDS-15
questionnaire,
25(OH) serum
levels, MannWhitney U Test,
Wilcoxon
signed rank test,
chi-square and
multiple
regression
analysis.

DV1: Scores
decreased from
9.25 to 7.48 in
vitamin D group
(p = 0.0001)
DV2: Vit D
increased from
baseline
(22.57 ± 6.2 ng/
ml in vitamin D
group.

support to prior
data suggesting
a relationship
between mood
regulation,
depressive
symptoms, and
vitamin D level.
LOE: 1
Strengths:
RCT, placebo tx
included.
Weekly Rx of
supplements
increased
compliance.
Only 1 pt
declined in each
group to
participate in
study, 78
completed trial,
100% adherence
in both groups.
Vit D and
placebo groups
has mostly equal
sex, age, and
severity in
depression.
No adverse

Key: Abn-abnormal; add’l-additional; ANOVA-analysis of variance; BDI-Beck Depression Inventory; BPAD-Bipolar affective disorder; Ca-calcium; CBC-complete blood
count; CES-D-Center for Epidemiologic Studies Depression; Cont-continue; CRF-chronic renal failure; CRP-C-reactive protein; DSM-IV- Diagnostic and Statistical Manual of
Mental Disorders; d/t-due to; DV-dependent variable; Dx-diagnosis; EPDS-Edinburgh Postnatal Depression Scale; Eval-evaluate; FSFL-female sexual function levels; GDSGeriatric Depression Scale; HAM-D17-Hamilton D-17 depression score; Hx-history; ID-identify; IPA-indoor physical activity; IV-independent variable; LFT-liver function test;
LOE-level of evidence; MCS-Mental Component Summary; MDD-major depressive disorder; MH-mental health; MMSE-Mini-Mental State Exam; mo-month; MSKmusculoskeletal; N-number of studies; n-number of participants; NNT-number needed to treat; OA-osteoarthritis; OPA-outdoor physical activity; PHQ-9-Patient Health
Questionnaire; PTH-parathyroid hormone; Pts-patients; Psych-Psychiatric; P-value probability; RCT-randomized control trial; Rx-prescription; S/E-side effects; SOC-standard
of care; SSRI-Selective serotonin reuptake inhibitor; suppl-supplement; sx-symptoms; TB-Tuberculosis; TSH-thyroid stimulating hormone; Tx-therapy; IU-international units;
Vit D-Vitamin D; Wk-week; wt-weight; 25(OH)-Vitamin D; YO-year old; yr-year.

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION

26
effects reported
during trial.
Limitations:
Some
uncontrolled
variables such as
severity of
depression,
depression tx,
sun exposure, hx
of depression,
possible cross
contamination
between groups.
Feasibility
(relevance): Vit
D
supplementation
can safely
improve
depression score
in adults >60 yo.

Key: Abn-abnormal; add’l-additional; ANOVA-analysis of variance; BDI-Beck Depression Inventory; BPAD-Bipolar affective disorder; Ca-calcium; CBC-complete blood
count; CES-D-Center for Epidemiologic Studies Depression; Cont-continue; CRF-chronic renal failure; CRP-C-reactive protein; DSM-IV- Diagnostic and Statistical Manual of
Mental Disorders; d/t-due to; DV-dependent variable; Dx-diagnosis; EPDS-Edinburgh Postnatal Depression Scale; Eval-evaluate; FSFL-female sexual function levels; GDSGeriatric Depression Scale; HAM-D17-Hamilton D-17 depression score; Hx-history; ID-identify; IPA-indoor physical activity; IV-independent variable; LFT-liver function test;
LOE-level of evidence; MCS-Mental Component Summary; MDD-major depressive disorder; MH-mental health; MMSE-Mini-Mental State Exam; mo-month; MSKmusculoskeletal; N-number of studies; n-number of participants; NNT-number needed to treat; OA-osteoarthritis; OPA-outdoor physical activity; PHQ-9-Patient Health
Questionnaire; PTH-parathyroid hormone; Pts-patients; Psych-Psychiatric; P-value probability; RCT-randomized control trial; Rx-prescription; S/E-side effects; SOC-standard
of care; SSRI-Selective serotonin reuptake inhibitor; suppl-supplement; sx-symptoms; TB-Tuberculosis; TSH-thyroid stimulating hormone; Tx-therapy; IU-international units;
Vit D-Vitamin D; Wk-week; wt-weight; 25(OH)-Vitamin D; YO-year old; yr-year.

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION
(Briggs et al.,
2019)
Country:
Ireland
Funding: None
Bias: Self report
to define CV
and chronic dx
cases, may be
subject to report
bias.

Self-Efficacy
Theory

Design:
Longitudinal
study

N=1
n=400
Demographics:
> 50 years old
Inclusion
criteria:
Communitydwelling people
with depression
dx
Exclusion
critieria: < 50
yo
noncommunity
dwelling people.

IV : vit D levels
DV1 :
depression
symptoms
DV2: vit D
levels

27
DV1: CES-D
scale

Logistic
regression, t-test
with adjusted
Wald test.

DV: 95%
confidence
interval (CI)
15.1–24.7] vs
[12.4 (95% CI
11.1–14.0);
Z = 3.93; P < .0
01]
Logistic
regression
models
demonstrated
that participants
with vitamin D
deficiency had a
significantly
higher
likelihood of
incident
depression (odds
ratio 1.75, 95%
CI 1.24–2.46;
t = 3.21; P = .00
1)

LOE: 1
Strengths:
Statistical
significance of
increased risk
for vit D
deficiency in
depressed
adults.
Limitations:
CES-D is valid
for older
population, but
clinical
interview is gold
standard for
depression dx.
Feasibility:
Supplementation
has low risk of
toxicity or side
effects for older
adults,
depression has
significant
adverse effect
on functional
status later in
life.

Key: Abn-abnormal; add’l-additional; ANOVA-analysis of variance; BDI-Beck Depression Inventory; BPAD-Bipolar affective disorder; Ca-calcium; CBC-complete blood
count; CES-D-Center for Epidemiologic Studies Depression; Cont-continue; CRF-chronic renal failure; CRP-C-reactive protein; DSM-IV- Diagnostic and Statistical Manual of
Mental Disorders; d/t-due to; DV-dependent variable; Dx-diagnosis; EPDS-Edinburgh Postnatal Depression Scale; Eval-evaluate; FSFL-female sexual function levels; GDSGeriatric Depression Scale; HAM-D17-Hamilton D-17 depression score; Hx-history; ID-identify; IPA-indoor physical activity; IV-independent variable; LFT-liver function test;
LOE-level of evidence; MCS-Mental Component Summary; MDD-major depressive disorder; MH-mental health; MMSE-Mini-Mental State Exam; mo-month; MSKmusculoskeletal; N-number of studies; n-number of participants; NNT-number needed to treat; OA-osteoarthritis; OPA-outdoor physical activity; PHQ-9-Patient Health
Questionnaire; PTH-parathyroid hormone; Pts-patients; Psych-Psychiatric; P-value probability; RCT-randomized control trial; Rx-prescription; S/E-side effects; SOC-standard
of care; SSRI-Selective serotonin reuptake inhibitor; suppl-supplement; sx-symptoms; TB-Tuberculosis; TSH-thyroid stimulating hormone; Tx-therapy; IU-international units;
Vit D-Vitamin D; Wk-week; wt-weight; 25(OH)-Vitamin D; YO-year old; yr-year.

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION
(Cuomo et al.,
2019)
Prevalence,
correlation of
Vit D deficiency
in pts with
mental illness

Self-Efficacy
Theory

Design:
Retrospective
study

Demographics :
Inpatient
psychiatric unit
adults

IV: vit D levels
DV: also vit D
levels

DV: serum vit D
level

Descriptive
statistics,
logistic
regression
model

Inclusion
criteria :
diagnosis of
depression

Country: Italy
Funding: None

Exclusion
critieria :
Malnutrition
syndromes,
malabsorption,
metabolic bone
diseases,
hyperprolactine
mia, CRF,
dialysis

Bias: None

(Gugger et al.,
2019)

N=1
n=290

28

Self-Efficacy
Theory

Design: Double
blind
randomized

N=1
n=200

IV : D3
suppl/mo

DV: Depression
score

GDS, MCS
mixed model
linear
regresssion

DV: 94% (n =
272) of the 290
study subjects
showed vit D
levels below the
normal range
(vit D ≥30
ng/ml).
Specifically,
31% met criteria
for vit D
deficiency (vit D
levels <10
ng/ml), and 63%
had vit D
insufficiency
(vit D levels =
10−30 ng/ml)

DV: participants
achieving the
highest
25(OH)D
quartile (Q) at
12 months
(44.7-98.9

LOE: 1
Strengths:
Significant
statistical
significance
Limitations:
retrospective
design of the
study, the
evaluation of vit
D levels via
blood samples
collected in
different seasons
of the year
Feasibility:
Findings
highlight a
higher degree of
concern for vit
D def in mental
illness, need for
routine
screening of vit
D, supplement
may improve
outcomes of
depression.
LOE: 1

Strengths:
Statistically
significant. No
difference in
scores with
Key: Abn-abnormal; add’l-additional; ANOVA-analysis of variance; BDI-Beck Depression Inventory; BPAD-Bipolar affective disorder; Ca-calcium; CBC-complete blood
count; CES-D-Center for Epidemiologic Studies Depression; Cont-continue; CRF-chronic renal failure; CRP-C-reactive protein; DSM-IV- Diagnostic and Statistical Manual of
Mental Disorders; d/t-due to; DV-dependent variable; Dx-diagnosis; EPDS-Edinburgh Postnatal Depression Scale; Eval-evaluate; FSFL-female sexual function levels; GDSGeriatric Depression Scale; HAM-D17-Hamilton D-17 depression score; Hx-history; ID-identify; IPA-indoor physical activity; IV-independent variable; LFT-liver function test;
LOE-level of evidence; MCS-Mental Component Summary; MDD-major depressive disorder; MH-mental health; MMSE-Mini-Mental State Exam; mo-month; MSKmusculoskeletal; N-number of studies; n-number of participants; NNT-number needed to treat; OA-osteoarthritis; OPA-outdoor physical activity; PHQ-9-Patient Health
Questionnaire; PTH-parathyroid hormone; Pts-patients; Psych-Psychiatric; P-value probability; RCT-randomized control trial; Rx-prescription; S/E-side effects; SOC-standard
of care; SSRI-Selective serotonin reuptake inhibitor; suppl-supplement; sx-symptoms; TB-Tuberculosis; TSH-thyroid stimulating hormone; Tx-therapy; IU-international units;
Vit D-Vitamin D; Wk-week; wt-weight; 25(OH)-Vitamin D; YO-year old; yr-year.
Country:
Switzerland

Demographics:
adults > 70 yrs

DV : depression
symptoms

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION
Funding: None

29

Inclusion
criteria:
Community
dwelling adults,
MMSE >27, hx
of falls.

Bias: None

ng/mL) had the
greatest
improvements in
MCS (Q4 = 0.79
vs
Q1 = −2.9; p = .
03) and MH
scales
(Q4 = 2.54 vs
Q1 = −3.07; p =
.03)

Exclusion
critieria: Vit D
supplementation
, insufficient
mobility to go to
study center.

(Irandoust &
Taheri, 2017)
Effect of vit D
supplement &
indoor vs
outdoor physical
activity on
depression of
obese depressed
women.
Country: Iran

Self-Efficacy
Theory

Design:
Prospective
cohort study
using purposeful
sampling
method.
Purpose:
1. Whether vit D
can improve
depression.

N=1
n=75
Demographics:
Women, ages
35-50yrs
Inclusion
criteria:
Severely
depressed and
vit D deficiency,

IV1: 25(OH)
suppl. 2000 IU
vit D daily x12
wks.
IV2: Indoor vs
outdoor PA.
DV1: 25(OH)
level.

DV1: Serum
25(OH).
DV2: BDI.

BDI score,
25(OH) serum
total assay,
coefficient alpha
rating, One-way
ANOVA, Tukey
post hoc
analysis,
independent ttest.

DV1: OPA +
VD and IPA +
VD groups were
no more
deficient
(respectively,
38.99 and 31.47
ng/mL; P <
0.05)
DV2: Decreased
rate of
depression in

varied
supplement
dose, but there
was an
improvement in
depression
scores with
supplementation
Limitations:
Lack of true
placebo group.
Feasibility:
Supplementation
has low risk of
toxicity or side
effects for older
adults,
depression has
significant
adverse effect
on functional
status later in
life.
LOE: I
Strengths:
Purposeful
sampling
method used.
NNT adequate.
Limitations:
Only studied
women.

DV2: depression
symptoms.
Lacks placebo
Key: Abn-abnormal; add’l-additional; ANOVA-analysis of variance; BDI-Beck Depression Inventory; BPAD-Bipolar affective disorder; Ca-calcium; CBC-complete blood
count; CES-D-Center for Epidemiologic Studies Depression; Cont-continue; CRF-chronic renal failure; CRP-C-reactive protein; DSM-IV- Diagnostic and Statistical Manual of
Mental Disorders; d/t-due to; DV-dependent variable; Dx-diagnosis; EPDS-Edinburgh Postnatal Depression Scale; Eval-evaluate; FSFL-female sexual function levels; GDSGeriatric Depression Scale; HAM-D17-Hamilton D-17 depression score; Hx-history; ID-identify; IPA-indoor physical activity; IV-independent variable; LFT-liver function test;
LOE-level of evidence; MCS-Mental Component Summary; MDD-major depressive disorder; MH-mental health; MMSE-Mini-Mental State Exam; mo-month; MSKmusculoskeletal; N-number of studies; n-number of participants; NNT-number needed to treat; OA-osteoarthritis; OPA-outdoor physical activity; PHQ-9-Patient Health
Questionnaire; PTH-parathyroid hormone; Pts-patients; Psych-Psychiatric; P-value probability; RCT-randomized control trial; Rx-prescription; S/E-side effects; SOC-standard
of care; SSRI-Selective serotonin reuptake inhibitor; suppl-supplement; sx-symptoms; TB-Tuberculosis; TSH-thyroid stimulating hormone; Tx-therapy; IU-international units;
Vit D-Vitamin D; Wk-week; wt-weight; 25(OH)-Vitamin D; YO-year old; yr-year.
2. Whether

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION
Funding: Imam
Khomeini
International
University grant.

outdoor PA
elicits greater
effective
benefits that
indoor PA.

Bias: None
stated or noted.

(Kaviani et al.,
2020)
Effects of vit D
supplementation
on depression &
some involved
neurotransmitter
s.
Country: Iran

Self-Efficacy
Theory

Design: Double
blind
randomized
clinical trial.
Purpose: To
evaluate the
effects of vit D
supplementation
on depression
severity

30

BMI >40%,
scored >30 BDI
Exclusion
criteria:
Physical
limitation to
exercise, no
prior vit D
suppl, estrogens,
calcium, steroids
or other that
would inhibit vit
D metabolism,
significant MSK
disease,
atherosclerosis,
renal and liver
function
impairment,
current
psychotherapy
or antidepressant use,
participated in
exercise during
past 6mo.
N=1
n=56
Demographics:
18-60 yo
Inclusion
criteria: age 1860 yo, mild to
moderate
depression.

OPA+VD,
IPA+VD, OPA,
and IPA groups
than the control
groups [P =
0.001].

tx.
Results might be
d/t wt loss or
other
confounding
factors.
Smaller sample
size, lack of a
more controlled
environment.
Feasibility:
Incorporating
OPA + vit D
suppl is
instrumental in
any aspect of
MH.

IV-Vitamin D
suppl
50,000IU/2 wks,
vs placebo.
DV1-BD1
depression
symptoms.
DV2- 25(OH)
levels.

DV1: BDI.
DV2: serum
25(OH).

Shapiro-Wilks
test, Chi-square,
paired-sample ttest or Wilcoxon
test, independent
sample t-test or
Mann-Whitney
test

DV1: Decreased
(-11.75±6.40 vs.
3.61±10.40, P =
0.003).
DV2: 25(OH)D
concentrations
increased
(+40.83±28.57 v
s.
+5.14±23.44 nm

LOE: 1
Strengths:
RCT.
Limitations:
Study duration
may not reflect
long term effects
of vit D
supplement on
depression.

Key: Abn-abnormal; add’l-additional; ANOVA-analysis of variance; BDI-Beck Depression Inventory; BPAD-Bipolar affective disorder; Ca-calcium; CBC-complete blood
count; CES-D-Center for Epidemiologic Studies Depression; Cont-continue; CRF-chronic renal failure; CRP-C-reactive protein; DSM-IV- Diagnostic and Statistical Manual of
Mental Disorders; d/t-due to; DV-dependent variable; Dx-diagnosis; EPDS-Edinburgh Postnatal Depression Scale; Eval-evaluate; FSFL-female sexual function levels; GDSGeriatric Depression Scale; HAM-D17-Hamilton D-17 depression score; Hx-history; ID-identify; IPA-indoor physical activity; IV-independent variable; LFT-liver function test;
LOE-level of evidence; MCS-Mental Component Summary; MDD-major depressive disorder; MH-mental health; MMSE-Mini-Mental State Exam; mo-month; MSKmusculoskeletal; N-number of studies; n-number of participants; NNT-number needed to treat; OA-osteoarthritis; OPA-outdoor physical activity; PHQ-9-Patient Health
Questionnaire; PTH-parathyroid hormone; Pts-patients; Psych-Psychiatric; P-value probability; RCT-randomized control trial; Rx-prescription; S/E-side effects; SOC-standard
of care; SSRI-Selective serotonin reuptake inhibitor; suppl-supplement; sx-symptoms; TB-Tuberculosis; TSH-thyroid stimulating hormone; Tx-therapy; IU-international units;
Vit D-Vitamin D; Wk-week; wt-weight; 25(OH)-Vitamin D; YO-year old; yr-year.

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION
Funding:
National
Nutrition and
Food
Technology
Research
Institute
(NNFTRI).

ol/L, P <0.001)
Exclusion
criteria: other
psychiatric
disease., h/o MI,
angina, CVA,
kidney stones,
HTN, liver
disease,
hyperparathyroi
dism, pregnancy
or lactation,
reproductiveaged women not
receiving
contraception,
consumption of
supplements
with vit D prior
to intervention,
lack of
willingness to
continue study
and failure to
follow

Bias: None
stated or noted.

(Krysiak et al.,
2018)
Effect of vit D
supplementation
on sexual
functioning &

31

Self-Efficacy
Theory

Design: RCT
Purpose: Assess
if vit D suppl
affects sexual

N=1
n=47
Demographics:
Women 20-40yo

IV: vit D suppl

DV1: FSFI.

Deficiency:
4000IU daily x6
mo.

DV2: BDI.

FSFI score, BDI
score,
KolmogrorovSmirnov test,
analysis of
covariance,

DV1: Decreased
to 14% in vit D
treated pts.
DV2: Down to
9.1 from 13.4 in

At the beginning
of the study,
most subjects
had optimal
levels of serum
25 (OH),
potentially
hindering true
effects of vit D
supplementation
.
Difference in
dosing and types
of vitamin D
supplement,
duration,
method, age of
target group and
additional
simultaneous
interventions.
Feasibility:
Great need for
further clinical
trials with
longer durations
on depressive
patients with vit
D deficiency to
determine exact
effects and
follow up
LOE: 2
Strengths:
RCT. Different
doses for
insufficiency vs

Key: Abn-abnormal; add’l-additional; ANOVA-analysis of variance; BDI-Beck Depression Inventory; BPAD-Bipolar affective disorder; Ca-calcium; CBC-complete blood
count; CES-D-Center for Epidemiologic Studies Depression; Cont-continue; CRF-chronic renal failure; CRP-C-reactive protein; DSM-IV- Diagnostic and Statistical Manual of
Mental Disorders; d/t-due to; DV-dependent variable; Dx-diagnosis; EPDS-Edinburgh Postnatal Depression Scale; Eval-evaluate; FSFL-female sexual function levels; GDSGeriatric Depression Scale; HAM-D17-Hamilton D-17 depression score; Hx-history; ID-identify; IPA-indoor physical activity; IV-independent variable; LFT-liver function test;
LOE-level of evidence; MCS-Mental Component Summary; MDD-major depressive disorder; MH-mental health; MMSE-Mini-Mental State Exam; mo-month; MSKmusculoskeletal; N-number of studies; n-number of participants; NNT-number needed to treat; OA-osteoarthritis; OPA-outdoor physical activity; PHQ-9-Patient Health
Questionnaire; PTH-parathyroid hormone; Pts-patients; Psych-Psychiatric; P-value probability; RCT-randomized control trial; Rx-prescription; S/E-side effects; SOC-standard
of care; SSRI-Selective serotonin reuptake inhibitor; suppl-supplement; sx-symptoms; TB-Tuberculosis; TSH-thyroid stimulating hormone; Tx-therapy; IU-international units;
Vit D-Vitamin D; Wk-week; wt-weight; 25(OH)-Vitamin D; YO-year old; yr-year.

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION
depressive sx in
young women
with low vit D
status.
Country:
Poland.
Funding: None
Bias: None
stated or noted.

functioning and
depressive sx.

Inclusion
criteria: vit D
insufficiency or
deficiency.
Insufficiency:
25(OH)
<20ng/ml
Deficiency:
25(OH)
20-30ng/ml
Exclusion
criteria: Any
acute/chronic
do, sexual
inactivity,
pregnant or
lactating, hx of
urogynaecologic
al operation that
might affect
sexual function,
any
pharmacotherap
y, poor patient
compliance.

Insuffiency:
2000IU daily
x6mo.
DV1: 25(OH)
levels
DV2: Female
sexual function
(FSFI)
symptoms.
DV3: BDI
depressive
symptoms.

32
Bonferroni posthoc tests, paired
t-test, Pearson’s
correlation
coefficient.

vit D tx w/
deficiency.
P<0.05.
- Down to 8.1
from 10.2 in vit
D tx with
insufficiency.
P<0.05.

deficiency.
Length of trial
(6mo).
Limitations:
Lack of placebo
group. Small #
participants.
Self-report
inventories like
FSFI and BDI
scales.
Seasonal
variations can
affect 25(OH)
concentrations.
Effect of vit D
suppl may be
different in
women
suffering from
other disorders
or taking other
Rx.
Feasibility:
Effect on vit D
suppl is positive
on women with
sexual
dysfunction and
low vit D levels,
however, not
enough info
based on this
study thus far.

Key: Abn-abnormal; add’l-additional; ANOVA-analysis of variance; BDI-Beck Depression Inventory; BPAD-Bipolar affective disorder; Ca-calcium; CBC-complete blood
count; CES-D-Center for Epidemiologic Studies Depression; Cont-continue; CRF-chronic renal failure; CRP-C-reactive protein; DSM-IV- Diagnostic and Statistical Manual of
Mental Disorders; d/t-due to; DV-dependent variable; Dx-diagnosis; EPDS-Edinburgh Postnatal Depression Scale; Eval-evaluate; FSFL-female sexual function levels; GDSGeriatric Depression Scale; HAM-D17-Hamilton D-17 depression score; Hx-history; ID-identify; IPA-indoor physical activity; IV-independent variable; LFT-liver function test;
LOE-level of evidence; MCS-Mental Component Summary; MDD-major depressive disorder; MH-mental health; MMSE-Mini-Mental State Exam; mo-month; MSKmusculoskeletal; N-number of studies; n-number of participants; NNT-number needed to treat; OA-osteoarthritis; OPA-outdoor physical activity; PHQ-9-Patient Health
Questionnaire; PTH-parathyroid hormone; Pts-patients; Psych-Psychiatric; P-value probability; RCT-randomized control trial; Rx-prescription; S/E-side effects; SOC-standard
of care; SSRI-Selective serotonin reuptake inhibitor; suppl-supplement; sx-symptoms; TB-Tuberculosis; TSH-thyroid stimulating hormone; Tx-therapy; IU-international units;
Vit D-Vitamin D; Wk-week; wt-weight; 25(OH)-Vitamin D; YO-year old; yr-year.

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION
(Vaziri et al.,
2016)
Vit D
supplementation
on perinatal
depression in
Iranian pregnant
mothers.
Country: Iran
Funding:
Research Vicechancellor of
Shiraz
University of
Medical
Sciences. Bias:
Note stated or
noted.

Self-Efficacy
Theory

Design: RCT,
single blind
study.
Purpose: Study
relationship
between low vit
D and perinatal
depression.

N=1
n=169
Demographics:
>18 yo women,
mean age 26,
max age 39.
Inclusion
criteria: No hx
of mental illness
& internal dx,
have a single
live fetus, no
pregnancy
complications,
gestational age
26-28 wks,
depression score
0-13.
Exclusion
criteria: EPDS
baseline >13,
not providing
blood sample at
start of study,
<8wks vit D
suppl.

IV: Vit D suppl.
2000IU D3
daily.
DV1: 25(OH)
levels.
DV2: depression
symptoms.

33
DV1: Serum
25(OH).
DV2: EPDS.

EPDS,
Chemiluninesce
nce
immunoassay
(CLIA) to eval
vit D level,
stratified
random
sampling, block
randomization
strategy,
Pearson’s
correlation
coefficient;
Fisher’s exact
test,
KolmogrorovSmirnov test, ttest and paired ttest parametric
tests, MannWhitney U test.

DV1:
-Nulliparous
18.40 at delivery
[13.13 at
baseline] p=
0.01.
-Multiparous
16.58 [12.49 at
baseline]
p=0.02.

LOE: 1

DV2: Lower in
the vitamin D
group than the
control one at
38–40 weeks of
gestation
(p = 0.01) also,
at 4 and 8 weeks
after birth
(p > 0.001).

Limitations:
Participant’s
honesty.
Selected from 1
prenatal clinic.
Population may
be too small.
Statistical
authority to ID
differences in
depressive sx vs
dx MDD.

Strengths:
RCT, 1st study
to eval vit D
suppl
consumption
during antenatal
and postnatal
depressive dx.

Feasibility: Vit
D deficiency &
depression
higher
prevalence in
pregnant
women. Vit D
suppl is
imperative in tx
more than just
depression in
this population,
esp in
decreasing risk

Key: Abn-abnormal; add’l-additional; ANOVA-analysis of variance; BDI-Beck Depression Inventory; BPAD-Bipolar affective disorder; Ca-calcium; CBC-complete blood
count; CES-D-Center for Epidemiologic Studies Depression; Cont-continue; CRF-chronic renal failure; CRP-C-reactive protein; DSM-IV- Diagnostic and Statistical Manual of
Mental Disorders; d/t-due to; DV-dependent variable; Dx-diagnosis; EPDS-Edinburgh Postnatal Depression Scale; Eval-evaluate; FSFL-female sexual function levels; GDSGeriatric Depression Scale; HAM-D17-Hamilton D-17 depression score; Hx-history; ID-identify; IPA-indoor physical activity; IV-independent variable; LFT-liver function test;
LOE-level of evidence; MCS-Mental Component Summary; MDD-major depressive disorder; MH-mental health; MMSE-Mini-Mental State Exam; mo-month; MSKmusculoskeletal; N-number of studies; n-number of participants; NNT-number needed to treat; OA-osteoarthritis; OPA-outdoor physical activity; PHQ-9-Patient Health
Questionnaire; PTH-parathyroid hormone; Pts-patients; Psych-Psychiatric; P-value probability; RCT-randomized control trial; Rx-prescription; S/E-side effects; SOC-standard
of care; SSRI-Selective serotonin reuptake inhibitor; suppl-supplement; sx-symptoms; TB-Tuberculosis; TSH-thyroid stimulating hormone; Tx-therapy; IU-international units;
Vit D-Vitamin D; Wk-week; wt-weight; 25(OH)-Vitamin D; YO-year old; yr-year.

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION

(Zheng et al.,
2019)
Effects of vit D
supplementation
on depressive sx
in pts w/ knee
oa.
Country:
Australia
Funding:
Australian
National Health
and Medical
Research
Council Grant.
Bias: Potential
selection bias,
baseline PHQ-9
was higher in
group
maintaining vit
D sufficiency.

Multilevel
mixed-effect
model

Design: RCT
double blind
study.

Purpose:
Determine effect
of vit D suppl
and maintaining
sufficient vit D
levels on
depressive sx in
pts w/ OA and
vit D deficiency.

N=1
n=340
Demographics:
Mean age 63 yo
Inclusion
criteria:
PHQ-9 score >5
Exclusion
criteria: Taking
vit D suppl,
exclusionary
comorbidities,
surgery
scheduled,
withdrew
consent, severe
radiographic
OA, ineligible
pain, declined
participation,
physically
unwell,
contraindication
to MRI,
ineligible age.

IV : vit D suppl
50,000IU/mo
x24 mo
DV1 : 25(OH)
concentration.
DV2 :
depression
symptoms.

34

DV1: Serum
25(OH).
DV2: PHQ-9.

25(OH)
concentration,
PHQ-9 scores,
independent ttest, chi-square

DV1: Increased
from
43.7 ± 11.8 nmo
l/L to
84.5 ± 17.3 nmo
l/L in the
vitamin D
group.
DV2: Improved
more in the
vitamin D
supplementation
group compared
to the placebo
group [β: −0.66,
95% confidence
interval
(CI): −1.22
to −0.11].

of rickets in the
fetus.
LOE: 1
Strengths:
Double blind
RCT, length of
trial 24 mo,
large sample
size.
Limitations:
This was a
secondary
analysis of an
RCT.
Adjustments
needed for
confounders
including use of
anti-depressants.

Feasibility: In
adults w/ OA,
maintaining vit
D sufficiency
with suppl may
be beneficial.

Key: Abn-abnormal; add’l-additional; ANOVA-analysis of variance; BDI-Beck Depression Inventory; BPAD-Bipolar affective disorder; Ca-calcium; CBC-complete blood
count; CES-D-Center for Epidemiologic Studies Depression; Cont-continue; CRF-chronic renal failure; CRP-C-reactive protein; DSM-IV- Diagnostic and Statistical Manual of
Mental Disorders; d/t-due to; DV-dependent variable; Dx-diagnosis; EPDS-Edinburgh Postnatal Depression Scale; Eval-evaluate; FSFL-female sexual function levels; GDSGeriatric Depression Scale; HAM-D17-Hamilton D-17 depression score; Hx-history; ID-identify; IPA-indoor physical activity; IV-independent variable; LFT-liver function test;
LOE-level of evidence; MCS-Mental Component Summary; MDD-major depressive disorder; MH-mental health; MMSE-Mini-Mental State Exam; mo-month; MSKmusculoskeletal; N-number of studies; n-number of participants; NNT-number needed to treat; OA-osteoarthritis; OPA-outdoor physical activity; PHQ-9-Patient Health
Questionnaire; PTH-parathyroid hormone; Pts-patients; Psych-Psychiatric; P-value probability; RCT-randomized control trial; Rx-prescription; S/E-side effects; SOC-standard
of care; SSRI-Selective serotonin reuptake inhibitor; suppl-supplement; sx-symptoms; TB-Tuberculosis; TSH-thyroid stimulating hormone; Tx-therapy; IU-international units;
Vit D-Vitamin D; Wk-week; wt-weight; 25(OH)-Vitamin D; YO-year old; yr-year.

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION

35
Appendix B

Synthesis Table
Table 2
Synthesis Table for Quantitative Studies
Author

Alghamdi

Alavi

Briggs

Cuomo

Gugger

Irandoust

Kaviani

Krysiak

Vaziri

Zheng

Year

2020

2019

2019

2019

2019

2017

2020

2018

2016

2019

Design

RCT

RCT

Cohort

RCT

RCT

RCT

RCT

Saudi Arabia

Iran

Retrospectiv
e study
Italy

RCT

Country

Longitudinal
study
Ireland

Switzerland

Iran

Iran

Poland

Iran

Australia

Number of subjects

62

78

400

290

200

75

56

47

169

340

Demographics

Adults 18-65
yo

Adults over
60 yo

Adults >
50yo

Inpt psych
adults

adults > 70
yrs

Women 3550 yo

Adults 1860 yo

Women 2040 yo

Women 1839 yo

Length of study

3 mo.

2 mo

12 mo

3 yrs

12 mo

3 mo.

2 mo.

6 mo.

3 mo.

Adults
mean age
63 yo
24 mo.

Vit D supplementation

50,000IU/wk

50,000IU/wk

No

No

Yes

2000IU/day

50,000IU/2
wks

2000IU4000IU/day

2000IU/day

50,000IU/
mo

Placebo

No

Yes

No

No

Yes

No

Yes

No

Yes

Yes

Depression scale

BDI

GDS-15

CES-D

GDS, MCS

BDI

BDI

BDI, FSFI

EPDS

PHQ-9

25(OH) serum level

Yes

Yes

Yes

NA, dx of
depression
Yes

Yes

Yes

Yes

Yes

Yes

Yes

Reduced depression
scores

Yes

Yes

No, high
scores

No, dx of
depression

Yes

Yes

Yes

Yes

Yes

Yes

Increased 25(OH) levels

Yes

Yes

No, low vit
D levels.

No, low vit
D levels.

Yes

No

Yes

NA

Yes

Yes

Independent variables

Dependent variables

Results

Key: BDI-Beck Depression Inventory; Ca-calcium; EPDS-Edinburgh Postnatal Depression Scale; FSFI-Female Sexual Function Index; GDS-Geriatric Depression Scale; HAM-D17-Hamilton D-17
depression score; IU-international units; mo-month; NA-not available; PHQ-9-Patient Health Questionnaire; RCT-randomized control trial; vit D-vitamin D; wk-week; yo-year old.

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION

36
Appendix C

Implementation Framework Diagram
Rosswurm & Larrabee Model

(Rosswurm & Larrabee, 1999)

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION

37

Appendix D
Theoretical Framework Diagram
Bandura’s Self-Efficacy Theoretical Model

(Smith & Liehr, 2018)

SCREENING FOR VITAMIN D DEFICIENCY IN DEPRESSION

38

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