No comfort in the rural South: women living depressed

Building interventions when distress is under debate: a case study from Appalachia

Scholarship on idioms of distress has emphasized cross-cultural variation, but devoted less attention to intra-cultural variation-specifically, how the legitimacy of distress may vary according to the context in which it is expressed, social position, and interaction with medical categories of distress. This variation can pose challenges for interventionists seeking to establish culturally acceptable ways of identifying distress and creating relevant resources for recovery. We describe efforts over three years (2014-2016) to identify and adapt a culturally appropriate evidence-based intervention for depressed rural Appalachian women. Though the prevalence of depression among rural women is high, limited services and social barriers restrict treatment access. Formative research revealed varied understandings of distress. Depression was (a) medicalized as a treatable condition, (b) stigmatized as mental illness, (c) accepted as a non-pathological reaction to regional poverty and gendered caregiving responsibilities, (d) rejected as a worthy justification for seeking individual care, and (e) less represented in comparison to other competing forms of distress (i.e., multiple morbidities, family members' distress). In a small pilot trial, we applied an implementation science perspective to identify and implement appropriate evidence-based programming for the context. We outline how we reached Appalachian women despite these diverse understandings of depression and established a flexible medicalization of depression that enabled us to legitimize care-seeking, work with varied rural healthcare professionals, and engender culturally relevant support. Our adaptation and implementation of the concept of "mental health recovery" enabled the development of programming that furthered non-pathological communicative distress while resisting the normalization that silences women in the context of deep health disparities.

Engaging rural young mothers in a technology-based intervention for depression

Peripartum depression is prevalent among young mothers (ages 25 and younger), and low family support can exacerbate depressive symptoms. The current study explores an innovative method for engaging young mothers in a family-based intervention to help reduce peripartum depressive symptoms. This descriptive study includes details on the baseline characteristics of participants, integrative support teams, and a service delivery method to engage families living rural communities. In conclusion, engaging depressed young mothers living in rural communities requires a multifaceted approach. Our approach has demonstrated promise in engaging this hard-to-reach population. Implications for clinical practice and future research are addressed.

What Role Can Community Health Workers Play in Connecting Rural Women with Depression to the "De Facto" Mental Health Care System?

The prevalence of depression among rural women is nearly twice the national average, yet limited mental health services and extensive social barriers restrict access to needed treatment. We conducted key informant interviews with community health workers (CHWs) and diverse health care professionals who provide care to Appalachian women with depression to better understand the potential roles that CHWs may play to improve women's treatment engagement. In the gap created by service disparities and social barriers, CHWs can offer a substantial contribution through improving recognition of depression; deepening rural women's engagement within existing services; and offering sustained, culturally appropriate support.

Modeling Health Disparities and Outcomes in Disenfranchised Populations

The Health Disparities and Outcomes (HDO) model originally created to explain the complexity of obtaining healthcare in rural settings has been revised and updated using emerging theoretical models of adversity and inequity and two decades of empirical work by the authors. With a strong orientation to explaining population-based health inequities, the HDO is applied to individuals with Serious Mental Illness (SMI), to explain their high rates of morbidity and mortality compared to the general population. Individual-, community-, and system-level factors that reflect an understanding of life-long risk, accrued hazards associated with multiple and intersecting disadvantages, and difficulty obtaining healthcare that meets accepted standards are described. The revised HDO can be applied to populations with disproportionate health challenges to identify multi-level factors that affect illness trajectory and overall health outcomes.

Depression, Smoking, and Ego-Centric Social Network Characteristics in Ohio Appalachian Women

Depression is a serious, costly, and debilitating disorder that is understudied in rural women. Studies show that depression is associated with low social integration and support, but few studies investigate the relationship between depression and social network characteristics. This study examined the associations among women from three Ohio Appalachian counties enrolled in a health study, which aimed to collect information for a future social network smoking cessation intervention. An address-based sampling method was used to randomly select and recruit 404 women. A cross-sectional survey and interview were used to collect information about demographic, psychosocial, behavioral factors, and ego-centric social network characteristics, which are variables derived from an individual (ego) and her first degree contacts (alters). The CES-D scale assessed depressive symptoms. A multivariable logistic regression analysis described the association between these factors and participants with depression (defined as CES-D≥16). Higher network density, or greater number of relationships among alters divided by the total amount of alters, reduced the risk for depression (OR = 0.84, 95% confidence interval [CI] 0.73-0.95). Additionally, women with a high percentage of smoking alters were at greater risk for depression (OR = 1.19, 95% CI 1.02-1.39). Other factors associated with risk for depression included perceived stress score (OR = 1.34, 95% CI 1.24-1.45), loneliness score (OR = 1.37, 95% CI 1.05-1.80), and days with poor physical health (OR = 1.06, 95% CI 1.02-1.11). Findings suggest that psychosocial factors and social networks should be considered when addressing depression in clinical practice.

Mental health treatment seeking patterns and preferences of Appalachian women with depression

This qualitative study explored social-cultural factors that shape treatment seeking behaviors among depressed rural, low-income women in Appalachia-a region with high rates of depression and a shortage of mental health services. Recent research shows that increasingly rural women are receiving some form of treatment and identifying their symptoms as depression. Using purposive sampling, investigators recruited 28 depressed low-income women living in Appalachian Kentucky and conducted semistructured interviews on participants' perceptions of depression and treatment seeking. Even in this sample of women with diverse treatment behaviors (half reported current treatment), participants expressed ambivalence about treatment and its potential to promote recovery. Participants stressed that poor treatment quality-not merely access-limited their engagement in treatment and at times reinforced their depression. While women acknowledged the stigma of depression, they indicated that their resistance to seek help for their depression was influenced by the expectation of women's self-reliance in the rural setting and the gendered taboo against negative thinking. Ambivalence and stigma led women to try to cope independently, resulting in further isolation. This study's findings reiterate the need for improved quality and increased availability of depression treatment in rural areas. In addition, culturally appropriate depression interventions must acknowledge rural cultural values of self-reliance and barriers to obtaining social support that lead many women to endure depression in isolation. (PsycINFO Database Record

Depression in rural women: implications for nurse practitioners in primary care settings

PURPOSE

The purpose of this study was threefold: (a) to determine what percent of rural women self-report as currently depressed when asked; (b) to explore the congruence between self-report of depression and Center for Epidemiologic Studies-Depression Scale (CES-D) score; and (c) to identify factors associated with congruence between self-report of depression and CES-D score.

DATA SOURCE

Self-report data were collected from 140 women who lived in a rural community in the Midwest. The convenience sample was recruited at a Federally Qualified Health Center.

CONCLUSIONS

The percent of rural women who self-reported as currently depressed was 36.4%. Congruence between self-report of depression and CES-D score was 76.8%, indicating the majority of women were able to identify if they were depressed or not. Women in the incongruent group were significantly more likely to be diagnosed with diabetes, reported more headaches, and received treatment for depression in the past.

IMPLICATIONS FOR PRACTICE

Dependence on primary care providers to identify and treat depression is the current standard of care for the vast majority of rural women. As more advanced practice registered nurses work in rural areas, they need to be cognizant of the high rates of depression in women and the most effective strategies for identifying and treating.

An exploration of perceptions of possible depression prevention services for caregivers of elderly or chronically ill adults in rural Georgia

Caregiving for elderly or chronically ill adults can be stressful, contributing to a high rate of depression in caregivers. Rural caregivers are at particularly high risk due to reduced access to mental health care services. This study explored the acceptability among rural caregivers of introducing a program to prevent or alleviate depression. Focus groups with caregivers and community members were conducted in four rural counties of Georgia. Caregivers reported high levels of stress and depression and recommended the following interventions: support groups, respite care, a centralized source of information, training for caregivers and other community members, financial support, and a telephone hotline. There were more commonalities than differences across the locations, but some programmatic preferences and acceptability varied.

An ethnic/racial comparison of causal beliefs and treatment preferences for the symptoms of depression among patients with diabetes

PURPOSE

The purpose of the study was to explore African American, Latino, and Non-Hispanic White adult patients with type 2 diabetes cultural perceptions of symptoms of depression and factors that predict depression care treatment preferences between these groups.

METHODS

A community sample of African Americans, Latinos, and White diabetic adults receiving services in 1 of 2 central Austin, Texas facilities participated in the study. Each participant was given a survey, which consisted of the following 5 components: (1) illness screener questions, (2) demographic questions, (3) Patient Health Questionnaire, (4) Depression Treatment Questionnaire, and (5) Illness Perception Questionnaire. A binary logistic regression was used to examine the relationship between cultural perceptions of symptoms and the predictor variables. A multinomial logistic regression analyses was used to examine the relationship between treatment and provider preferences for the symptoms of depression and ethnicity.

RESULTS

The first research question addressed whether there were differences across ethnicity in how symptoms of depression are attributed among patients with diabetes. There were 7 causal beliefs that were associated with differences in cultural endorsements of the causes of depressive symptoms. In addition, culture was associated with treatment preferences but not with provider preferences.

CONCLUSIONS

The utility of assessing a patient's understanding of symptoms of depression to determine how personal illness models impact treatment preferences and clinical implications of how knowledge of patient's causal attributions can aid medical and behavioral health providers working in collaborative management of diabetes and depression are discussed.

A pilot study to reduce risk for antepartum depression among women in a public health prenatal clinic

This pilot study evaluated the feasibility, effectiveness, and helpfulness of Insight-Plus, a brief culturally-tailored cognitive behavioral intervention for African-American and Caucasian rural low-income women at risk for APD [Edinburgh Postnatal Depression Scale (EPDS) > or = 10]. Forty two percent (63/149) of women in this non-randomized study were at risk for APD and 41% (26/63) of women, who met all eligibility criteria, initially agreed to participate. Seventeen participants completed all six intervention sessions. Ninety-four percent (16/17) who completed their one-month post-intervention interviews had an antepartum recovery rate of 81% (13/16, EPDS < or = 10). Participants reported that many aspects of the program were helpful and they continued to use the intervention exercises after the sessions ended.

Rural African American clergy: an exploration of their attitudes and knowledge of Alzheimer's disease

Rural African American clergy's ability to recognize Alzheimer's Disease (AD) and their capacity to provide support to elders with this illness has been neglected in the literature. Using a mental health literacy framework, the purpose of this research was to explore rural African American clergy knowledge and beliefs of AD. In-depth interviews were conducted with 9 African American clergy who oversaw churches in central Kentucky. Although few had direct experience with providing pastoral care to elders with AD, all clergy were literate and aware of the need for additional training. This study seeks to further clarify the role of African American clergy and their understanding of AD to inform the future development of appropriate interventions and establish better collaborative community treatment relationships.

Spirituality and Its Relationships With the Health and Illness of Appalachian People

This article explores the ways spirituality intertwines with the health and culture of those living in the Appalachian region. Nursing has long considered the value of spirituality and faith, noting its complex connections with health and illness. Literature pertaining to spirituality, health, and the culture of those residing in the Appalachian region was reviewed. Although the review suggests that connections between spirituality and health exist, empirical evidence is limited, somewhat dated, and lacks viable conclusions relative to the diverse needs of the Appalachian population. Focused research that addresses strongly linked operationally defined variables is needed to strengthen the evidence for clarity about distinct applications to practice.

Creating Change

Stigma is a social justice problem that plagues persons with psychiatric disabilities, their families, and society. It fuels the fear underlying discrimination; undermines consumer self-efficacy; and blocks rehabilitation, recovery, and social integration. The author hopes to create a passion for change and suggest a way that everyone can help stop stigma. This approach is simple: to nurture the artistic talent many clients possess and connect them with public venues for their artworks. On display, too, will be the “ability” in “disability.” This will reduce stigma while building self-efficacy and empowerment. Anecdotal evidence supports this hypothesis. However, research is needed; a design for a study to test this hypothesis is described. Significantly, an antistigmal arts intervention can be conducted by any aware practitioner; one does not need to be an art therapist or have any background in art, only a desire to make a difference and resources on which to draw.

Rural African American clergy: are they literate on late-life depression?

This exploratory study examined rural African American clergy's knowledge of and experience in providing support to African American elders with late-life depression. Interviews were conducted with nine African American clergy who oversaw rural churches in central Kentucky. Jorm and colleagues provide a conceptual framework for mental health literacy to explore participants' knowledge of late-life depression. Although few clergy had direct experience with counseling a depressed older adult, all the clergy were considered literate regarding late-life depression and its treatment. These findings have implications for social workers building collaborative community treatment relationships.

Depression and poverty among rural women: a relationship of social causation or social selection?

CONTEXT AND PURPOSE

Depression among rural women is a major public health concern. The purpose of this study was to test the competing theories of social causation and social selection to assess the relationship between depression and economic status for a sample of rural, low-income women in the United States.

METHODS

Structural equation modeling was used to analyze data from Rural Families Speak, a US Department of Agriculture-funded multi-state, longitudinal study of rural low-income families (N = 413).

FINDINGS

Results indicated that the social causation theory yielded a better approximation of the relationship between economic status and depression (RMSEA = 0.50 for a model based on this theory) than the social selection theory (RMSEA = 0.067).

CONCLUSIONS

The association between lesser economic status and depressive symptoms is pressing in rural areas, given the high prevalence of both depression and poverty. These findings further emphasize the need for improved mental health services in this vulnerable population.

Food insecurity and maternal depression in rural, low-income families: a longitudinal investigation

OBJECTIVE

The purpose of the present study was to examine the relationship between household food insecurity and maternal depression in a rural sample to determine whether food insecurity predicted mothers' depression over time or vice versa.

DESIGN

The study employed a prospective design using three waves of data from 'Rural Families Speak', a multi-state study of low-income rural families in the USA. Food insecurity was measured using the Core Food Security Module and depression was measured using the Center for Epidemiologic Studies-Depression Scale. A structural equation model was fit to the data using the AMOS software package.

SETTING

Sixteen states in the USA (California, Indiana, Kentucky, Louisiana, Massachusetts, Maryland, Michigan, Minnesota, Nebraska, New Hampshire, New York, Ohio, Oregon, South Dakota, West Virginia, Wyoming) between 2000 and 2002.

SUBJECTS

Subjects included 413 women with at least one child under the age of 13 years living in the home.

RESULTS

Findings based on the 184 subjects with complete data indicated that the causal relationship between household food insecurity and depression is bidirectional (P = 0.034 for causation from depression to food insecurity, P = 0.003 for causation from food insecurity to depression, chi(2)/df = 1.835, root-mean-square error of approximation = 0.068, comparative fit index = 0.989). Findings based on all 413 subjects after imputation of missing values also indicated bidirectionality.

CONCLUSIONS

The recursive relationship between food insecurity and depression has implications for US nutrition, mental health and poverty policies. The study highlights the need to integrate programmes addressing food insecurity and poor mental health for the population of rural, low-income women.

The state of nursing science - cultural and lifespan issues in depression: part I: focus on adults

Depression is a devastating disorder, affecting approximately 17 million persons within the United States. The manifestation of depressive phenomena is a complex, dynamic, biopsychosocial process involving lifespan and cultural aspects. Unless appropriately treated, depression persists over time having a significant negative effect on life and increasing the risk of suicide. Psychiatric mental health (PMH) nurses are uniquely positioned to address this epidemic health concern. This manuscript is Part I of the review of current nursing literature on adult depression. This review can be used to enhance PMH nurses' knowledge of current nursing research and their efforts in addressing prevention, early intervention, education and treatment of adults who experience depression.

The cumulative effect of rural and regional residence on the health of older adults

OBJECTIVE

This study considers whether rural status or living in a particular region of the United States has effects on mental and physical health. The analyses examine whether there are independent and interactive effects of rural status and region of residence on health, beyond individual level factors related to poverty.

METHODS

Ordinary least squares (OLS) regression models are used to examine the relationships between rural and regional residence and health across three time periods.

RESULTS

Negative health effects of rural residence were found only in the South region. Positive health effects of rural residence were found only in the Midwest region. There are no observed health risks associated with rural or regional residence across group.

DISCUSSION

The results indicate a cumulative risk of rural and Southern residence for older men and women. Living in a rural place in the midwestern United States seems to provide unique sources of health benefits.

Alcohol and other drug disorders, comorbidity, and violence: comparison of rural African American and Caucasian women

Tremendous health disparities exist across various segments of the United States population with rural women particularly at risk. African Americans have higher rates of death, disease, and disability than Caucasians. Although prevalence rates for alcohol and other drug use vary across studies, African American women generally report less use than Caucasians. However, African Americans disproportionately experience negative health and social consequence of AOD use. The findings of this study provide rare information about substance abuse in rural African American women. Specifically, this manuscript reports differences between rural African American and Caucasian women (n=267) on AOD use, comorbid Axis I disorders, and violence.