Conceptual Models of Depression in Primary Care Patients: A Comparative Study

"That Was a State of Depression by Itself Dealing with Society": Atmospheric racism, mental health, and the Black and African American faith community

Despite increased societal focus on structural racism, and its negative impact on health, empirical research within mental health remains limited relative to the magnitude of the problem. The current study-situated within a community-engaged project with members of a predominantly Black and African American church in the northeastern US-collaboratively examined depressive experience, recovery, and the role of racism and racialized structures. This co-designed study featured individual interviews (N = 11), a focus group (N = 14), and stakeholder engagement. A form of qualitative, phenomenological analysis that situates psychological phenomena within their social structural contexts was utilized. Though a main focal point of the study was depressive and significantly distressing experience, participant narratives directed us more towards a world that was structured to deplete and deprive-from basic neighborhood conditions, to police brutality, to workplace discrimination, to pervasive racist stereotypes, to differential treatment by health and social services. Racism was thus considered as atmospheric, in the sense of permeating life itself-with social, affective, embodied, and temporal dimensions, alongside practical (e.g., livelihood, vocation, and care) and spatial (e.g., neighborhood, community, and work) ones. The major thematic subsections-world, body, time, community, and space-reflect this fundamental saturation of racism within lived reality. There are two, interrelated senses of structural racism implicated here: the structures of the world and their impact on the structural dimensions of life. This study on the atmospheric nature of racism provides a community-centered complement to existing literature on structural racism and health that often proceed from higher, more population level scales. This combined literature suggests placing ever-renewed emphasis on addressing the causes and conditions that make this kind of distorted world possible in the first place.

The Value of Medicare Coverage on Depressive Symptoms Among Older Immigrants

BACKGROUND AND OBJECTIVES

The immigrant population, the primary driver of U.S. population growth, is aging and many immigrants remain uninsured. Lack of health insurance limits access to care, aggravating the already high level of depression for older immigrants. However, there is scarce evidence on how health insurance, particularly Medicare, affects their mental health. Using the Health and Retirement Study, this study examines the effect of Medicare coverage on depressive symptoms of older immigrants in the United States.

RESEARCH DESIGN AND METHODS

Exploiting the fact that many immigrants are not covered by Medicare after passing age 65, we use a difference-in-difference model with propensity score weighting to compare differences in depressive symptoms pre- and post-age-65. We further stratify the sample by socioeconomic status and by race/ethnicity.

RESULTS

Medicare coverage was significantly associated with a reduction in the probability of reporting depressive symptoms for immigrants with low socioeconomic status, especially for those below median wealth levels. The beneficial effect of Medicare coverage was also statistically significant for non-White immigrants-Black, Hispanic, and Asian/Pacific Islander-even when holding socioeconomic status constant.

DISCUSSION AND IMPLICATIONS

Our findings imply that immigration policies that expand health care protection to older immigrants can lead to further health benefits and reduce existing disparities for the aging population. Policy reforms such as providing limited Medicare access to immigrants who paid sufficient taxes but are still awaiting permanent residency status could increase coverage for the uninsured and improve participation of immigrants in the payroll system.

Assessment of illness representations in mental disorders: A mini review

Health beliefs, and especially illness representations, have been widely used to understand clinical outcomes and psychosocial adjustment in people with physical diseases. However, this area of research has been under-explored in the field of mental health, and the few studies that have been conducted have used very different methods. Therefore, the aim of our study was to identify the tools and methods that have been used to evaluate illness representations in psychiatry. To this end, a mini review has been conducted and 58 articles were retained. This mini review highlights that the quantitative method is the most used, and that the scales mobilised are often adapted for the study, but not validated. Indeed, multiple modifications and adaptations have been made by the authors (e.g. deletion of subscales, addition of items), which lead to questions about the reliability of what is measured. In the future, it is essential to have a validated generic tool for mental disorders, which could be based on the Illness perceptions questionnaire for schizophrenia.

The ASHA (Hope) Project: Testing an Integrated Depression Treatment and Economic Strengthening Intervention in Rural Bangladesh: A Pilot Randomized Controlled Trial

Depression, a debilitating disorder, is highly prevalent among low-income women in low- and middle-income countries. Standard psychotherapeutic approaches may be helpful, but low treatment uptake, low retention, and transient treatment effects reduce the benefit of therapy. This pilot randomized controlled trial examined the effectiveness and feasibility of an integrated depression treatment/economic strengthening intervention. The study took place in two villages in the Sirajganj district in rural Bangladesh. Forty-eight low-income women with depressive symptoms (Patient Health Questionnaire (PHQ-9) score ≥ 10) were recruited and randomized to intervention or control arms. The intervention included a six-month group-based, fortnightly depression management and financial literacy intervention, which was followed by a cash-transfer of $186 (equivalent to the cost of two goats) at 12 months' follow-up. The cash transfer could be used to purchase a productive asset (e.g., agricultural animals). The control arm received no intervention. Findings showed significant reduction in depression scores in the intervention group. The mean PHQ-9 score decreased from 14.5 to 5.5 (B ± SE, -9.2 ± 0.8 95% CI -10.9, -7.5, p < 0.01) compared to no change in the control group. Most other psycho-social outcomes, including tension, self-esteem, hope, social-support, and participation in household economic decision-making, also improved with intervention. An integrated depression treatment and financial empowerment intervention was found to be highly effective among rural low-income women with depression. Next steps involve formal testing of the model in a larger trial.

Caregivers' causal attributions of their relatives' mental illness and the association with stigma

Causal attributions of mental illness have received substantial attention given their influence on help-seeking patterns of individuals and the level of engagement with health services. Few studies, however, have examined caregivers' perspectives of their relatives' illness. The current study aimed to examine caregivers' causal attributions of their relatives' mental illness and its association with perceived stigma in a multi-ethnic Asian sample. Primary caregivers (N = 350) of psychiatric outpatients were recruited from a psychiatric hospital. The attribution and stigma sections of the Family Interview Schedule (FIS) were utilized to obtain caregivers' causal report of their relatives' illness and stigma perception. Logistic regressions were performed to examine the socio-demographic and diagnostic correlates of the four categories of causal attributions (psychosocial, biological, drug-/substance use-related, supernatural). The majority of caregivers identified psychosocial causes, followed by biological, supernatural, and lastly drug-/substance use-related causes for their relatives' illness. Marital status, religion, employment status and the diagnosis of depressive disorders were significant correlates of biological attributions. Ethnicity and not knowing their relatives' diagnosis were significantly associated with psychosocial attributions. For drug-/substance use-related attributions, ethnicity was the only significant correlate. Supernatural attributions did not yield any significant associations. Caregivers who endorsed drug-/substance use-related reasons also reported significantly higher stigma than caregivers who did not endorse these attributions. A tendency to endorse biological and psychosocial causes for their relative's illness was noted among caregivers. Further research on caregivers' causal attributions is warranted to account for and replicate current study findings.

Quantitizing and qualitizing (im-)possibilities in mixed methods research

Mixed methods research has gained momentum over the past decade, but critics rightly charge that the integration of qualitative and quantitative data remains an unresolved methodological issue. While each of the dualistic and canonized methodological paradigms has its own way of handling analysis, researchers in mixed methods as a new paradigm have invested considerable efforts in more complex mixed analysis. They use the quantitizing of qualitative data and qualitizing of quantitative data as the strategies to effect data integration in mixed methods research. While attempts have been made to achieve quantitizing and qualitizing of data, few empirical studies have been conducted in a two-phase convergent parallel mixed methods design to investigate such data conversion approaches, especially dichotomization, within a single inquiry. To contribute to this ongoing methodological quest, this article explores the possibilities and impossibilities offered by either strategy to convert narratives into numerical data and numerical data into narratives.

Prevalence of depressive symptoms and factorial invariance of the Center for Epidemiologic Studies (CES-D) Depression Scale in a group of Mexican indigenous population

Introduction: The short version of the Center for Epidemiologic Studies (CES-D) Depression Scale is a viable tool for screening depressive symptomatology in the general population, but its factorial invariance for indigenous populations in Latin America has not been reported. Objective: To describe the differences in the prevalence of depressive symptomatology and the factorial invariance of the short version of the CES-D scale for the Mexican indigenous population. Materials and methods: We conducted a cross-sectional study with a representative sample of 37,165 Mexican adults aged 20 to 59 years. Indigenous identity was determined by self-report of being a speaker of an indigenous language. Eight groups of analysis were created according to gender, literacy, and being indigenous. An exploratory factor analysis was used to describe the prevalence of depressive symptoms as measured by the short version of the CES-D, as well as the configuration factorial invariance of the profiles. The variance-covariance matrices of the pairs of profiles were compared using the modified Mantel test. Results: The prevalence of depressive symptoms was 16.8% (95% CI: 13.4-20.3) for indigenous women who could read, 21.3% (95% CI: 15.5% 27.1) for indigenous women who could not read, 8.5% (95% CI: 6.0-11.1) for indigenous men who could read, and 10.4% (95% CI: 5.2-15.6) for indigenous men who could not read. No significant differences in the factorial loads of the profiles were found. Conclusion: The prevalence of depressive symptoms in indigenous people is lower than in the nonindigenous population. The factorial invariance of the CES-D scale was high for the indigenous population.

Becoming a patient-illness representations of depression of Anglo-Australian and Sri Lankan patients through the lens of Leventhal's illness representational model

BACKGROUND

Depression is prevalent globally. While the uptake of mental health services is poor in the general community, the lack of service engagement is particularly profound in migrant and refugee communities. To understand why there is under-utilisation cross-cultural comparisons of how people make sense of mental illnesses such as depression are essential.

AIMS

To verify how differing cultural aetiologies about depression influence mental health service use, this study investigated illness representational models of depression held by Sri Lankan migrants and Anglo-Australians living with depression.

METHODS

In-depth interviews ( n = 48) were conducted with Sri Lankan migrants and Anglo-Australians living with depression to explore their illness beliefs. Data were analysed using Leventhal's illness representational model.

RESULTS

Significant overlaps in illness representational models were noted but distinctive differences were found between causal and chronicity beliefs; Sri Lankan migrants more frequently endorsed depression as a time-limited condition underpinned by situational factors, whereas Anglo-Australians endorsed a chronic, biopsychosocial model of depression.

DISCUSSION AND CONCLUSION

Findings highlight the importance of forging a shared understanding of patient beliefs in the clinical encounter to ensure that interventions are coherent with illness beliefs or at least work towards improving mental health literacy. Differences in illness beliefs also provide insights into possible interventions. For example, psychosocial interventions that align with their illness beliefs may be more suited to Sri Lankan migrants than pharmaceutical or psychological ones.

Cross cultural variations in psychiatrists' perception of mental illness: A tool for teaching culture in psychiatry

A frequent debate in psychiatry is to what extent major psychiatric diagnoses are universal versus unique across cultures. We sought to identify cultural variations between psychiatrists' diagnostic practices of mental illness in Boston Massachusetts and Bangalore, India. We surveyed psychiatrists to identify differences in how frequently symptoms appear in major mental illness in two culturally and geographically different cities. Indian psychiatrists found somatic symptoms like pain, sleep and appetite to be significantly more important in depression and violent and aggressive behavior to be significantly more common in mania than did American psychiatrists. American psychiatrists found pessimism about the future to be more significant in depression and pressured speech and marked distractibility to be more significant in mania than among Indian psychiatrists. Both groups agreed the top four symptoms of psychosis were paranoia, lack of insight, delusions and auditory hallucinations and both groups agreed that visual hallucinations and motor peculiarities to be least significant. Despite a different set of resources, both groups noted similar barriers to mental health care access. However, American psychiatrists found substance abuse to be a significant barrier to care whereas Indian psychiatrists found embarrassing the family was a significant barrier to accessing care. Because psychiatrists see a large volume of individuals across different cultures, their collective perception of most common symptoms in psychiatric illness is a tool in finding cultural patterns.

Why underserved patients do not consult their general practitioner for depression: results of a qualitative and a quantitative survey at a free outpatient clinic in Paris, France

BACKGROUND

The prevalence of depression in the general population is 5 to 10% but can exceed 50% in the most socially vulnerable populations. The perceptions of this disease are widely described in the literature, but no research has been carried out in France to explain the reasons for not consulting a general practitioner during a depressive episode, particularly in people in the most precarious situations. The objective of this study was to describe the reasons for not seeking primary care during a depressive episode in a socially vulnerable population.

METHODS

An exploratory sequential design with a preliminary qualitative study using a phenomenological approach. Subsequently, themes that emerged from the qualitative analysis were used in a questionnaire administered in a cross-sectional observational study at a free outpatient clinic in Paris in 2010. Lastly, a logistic regression analysis was performed.

RESULTS

The qualitative analysis revealed four aspects that explain the non-consulting of a general practitioner during a depressive episode: the negative perception of treatment, the negative perception of the disease, the importance of the social environment, and the doctor-patient relationship. The quantitative analysis showed that close to 60% of the patients who visited the free clinic were depressed and that only half of them had talked with a care provider. The results of the statistical analysis are in line with those of the qualitative analysis, since the most common reasons for not seeing a general practitioner were the negative perception of the disease (especially among the men and foreigners) and its treatments (more often among the men and French nationals).

CONCLUSIONS

Close to 50% of the depressed individuals did not seek primary care during a depressive episode, and close to 80% of them would have liked their mental health to be discussed more often by a health professional. Better information on depression and its treatments, and more-systematic screening by primary care personnel would improve the treatment of depressed patients, especially those in the most precarious situations.

"Head take you": causal attributions of mental illness in Jamaica

Causal attributions are a key factor in explanatory models of illness; however, little research on causal attributions of mental illness has been conducted in developing nations in the Caribbean, including Jamaica. Explanatory models of mental illness may be important in understanding illness experience and be a crucial factor in mental health service seeking and utilization. We explored causal attributions of mental illness in Jamaica by conducting 20 focus groups, including 16 community samples, 2 patient samples, and 2 samples of caregivers of patients, with a total of 159 participants. The 5 most commonly endorsed causal attributions of mental illness are discussed: (a) drug-related causes, including ganja (marijuana); (b) biological causes, such as chemical imbalance, familial transmission, and "blood"; (c) psychological causes, including stress and thinking too much; (d) social causes, such as relationship problems and job loss; and (e) spiritual or religious causes, including Obeah.

Causal beliefs about depression in different cultural groups-what do cognitive psychological theories of causal learning and reasoning predict?

Cognitive psychological research focuses on causal learning and reasoning while cognitive anthropological and social science research tend to focus on systems of beliefs. Our aim was to explore how these two types of research can inform each other. Cognitive psychological theories (causal model theory and causal Bayes nets) were used to derive predictions for systems of causal beliefs. These predictions were then applied to lay theories of depression as a specific test case. A systematic literature review on causal beliefs about depression was conducted, including original, quantitative research. Thirty-six studies investigating 13 non-Western and 32 Western cultural groups were analyzed by classifying assumed causes and preferred forms of treatment into common categories. Relations between beliefs and treatment preferences were assessed. Substantial agreement between cultural groups was found with respect to the impact of observable causes. Stress was generally rated as most important. Less agreement resulted for hidden, especially supernatural causes. Causal beliefs were clearly related to treatment preferences in Western groups, while evidence was mostly lacking for non-Western groups. Overall predictions were supported, but there were considerable methodological limitations. Pointers to future research, which may combine studies on causal beliefs with experimental paradigms on causal reasoning, are given.

Baseline characteristics and Latino versus non-Latino contrasts among Bronx A1C study participants

We describe baseline demographic and psychosocial characteristics of low-income, diverse diabetes adults enrolled in a telephonic intervention trial. Environment for the study was New York City (NYC) A1C Registry program. Baseline data were analyzed from 941 participants randomized to either telephonic/print or print-only intervention to improve glycemic control. Summary statistics for key variables were calculated; we highlight baseline contrasts between Latino and non-Latino participants. There were high proportions of Latino (67.7%) and non-Latino Black (28.0%) participants from South Bronx. Mean age was 56.3 years, almost 70.0% were foreign born, and 55.8% preferred Spanish language. Mean A1C was 9.2% and mean body mass index (BMI) 32.1 kg/m(2). There were significant contrasts between Latino and non-Latino participants for behavioral and psychosocial variables. This telephonic intervention study succeeded in randomizing a large number of low-income, diverse participants with poor diabetes control who are under-represented in studies. Latino versus non-Latino differences at baseline were striking.

Normal Aging or Depression? A Qualitative Study on the Differences Between Subsyndromal Depression and Depression in Very Old People

PURPOSE OF THE STUDY

The aim of this study was to make a qualitative comparison of experiences of being in very old people with subsyndromal depression (SSD), in relation to the experiences of very old people with syndromal depression or nondepression. Through investigation and deeper understanding of the interface between depressive disease and normal aging, clinicians might give more accurate prevention or treatment to those very old persons who need such help.

DESIGN AND METHODS

Semistructured qualitative interviews were conducted for 27 individuals of 87-88 years of age, who were categorized in the 3 strata of nondepressive, SSD, and syndromal depression. Transcripts were analyzed using qualitative content analysis within each stratum and later with a comparison between the strata.

RESULTS

The content analysis resulted in 4 themes in people with SSD, as defined by a self-report depression screening instrument, giving a comprehensive picture of SSD in very old people, and also showed qualitative differences between the SSD, syndromal depression, and nondepressive groups. A main finding was that SSD differs qualitatively from syndromal depression but not clearly from nondepression.

IMPLICATIONS

The results might indicate that SSD in very old people is not related to pathology but to normal aging, even though the condition correlates with negative health parameters. Overlooking certain psychosocial aspects of living in the very old may pose a risk of both underdiagnosis and overdiagnosis in the spectrum of depressive disorders.

"Tension" in South Asian women: developing a measure of common mental disorder using participatory methods

BACKGROUND

Although common mental disorder (CMD) is highly prevalent among South Asian immigrant women, they rarely seek mental treatment. This may be owing in part to the lack of conceptual synchrony between medical models of mental disorder and the social models of distress common in South Asian communities. Furthermore, common mental health screening and diagnostic measures may not adequately capture distress in this group. Community-based participatory research (CBPR) is ideally suited to help address measurement issues in CMD as well as to develop culturally appropriate treatment models.

OBJECTIVES

To use participatory methods to identify an appropriate, culturally specific mental health syndrome and develop an instrument to measure this syndrome.

METHODS

We formed a partnership between researchers, clinicians, and community members. The partnership selected a culturally specific model of emotional distress/illness, "tension," as a focus for further study. Partners developed a scale to measure Tension and tested the new scale on 162 Bangladeshi immigrant women living in the Bronx.

RESULTS

The 24-item "Tension Scale" had high internal consistency (α = 0.83). On bivariate analysis, the scale significantly correlated in the expected direction with depressed as measured by the Patient Health Questionnaire (PHQ-2), age, education, self-rated health, having seen a physician in the past year, and other variables.

CONCLUSIONS

Using participatory techniques, we created a new measure designed to assess CMD in an isolated immigrant group. The new measure shows excellent psychometric properties and will be helpful in the implementation of a community-based, culturally synchronous intervention for depression. We describe a useful strategy for the rapid development and field testing of culturally appropriate measures of mental distress and disorder.

What we talk about when we talk about depression: doctor-patient conversations and treatment decision outcomes

BACKGROUND

Efforts to address depression in primary care settings have focused on the introduction of care guidelines emphasising pharmacological treatment. To date, physician adherence remains low. Little is known of the types of information exchange or other negotiations in doctor-patient consultations about depression that influence physician decision making about treatment.

AIM

The study sought to understand conversational influences on physician decision making about treatment for depression.

DESIGN

A secondary analysis of consultation data collected in other studies. Using a maximum variation sampling strategy, 30 transcripts of primary care consultations about distress or depression were selected from datasets collected in three countries. Transcripts were analysed to discover factors associated with prescription of medication.

METHOD

The study employed two qualitative analysis strategies: a micro-analysis approach, which examines how conversation partners shape the dialogue towards pragmatic goals; and a narrative analysis approach of the problem presentation.

RESULTS

Patients communicated their conceptual representations of distress at the outset of each consultation. Concepts of depression were communicated through the narrative form of the problem presentation. Three types of narratives were identified: those emphasising symptoms, those emphasising life situations, and mixed narratives. Physician decision making regarding medication treatment was strongly associated with the form of the patient's narrative. Physicians made few efforts to persuade patients to accept biomedical attributions or treatments.

CONCLUSION

Results of the study provide insight into why adherence to depression guidelines remains low. Data indicate that patient agendas drive the 'action' in consultations about depression. Physicians appear to be guided by common-sense decision-making algorithms emphasising patients' views and preferences.

How patients understand depression associated with chronic physical disease--a systematic review

BACKGROUND

Clinicians are encouraged to screen people with chronic physical illness for depression. Screening alone may not improve outcomes, especially if the process is incompatible with patient beliefs. The aim of this research is to understand people's beliefs about depression, particularly in the presence of chronic physical disease.

METHODS

A mixed method systematic review involving a thematic analysis of qualitative studies and quantitative studies of beliefs held by people with current depressive symptoms. MEDLINE, EMBASE, PSYCHINFO, CINAHL, BIOSIS, Web of Science, The Cochrane Library, UKCRN portfolio, National Research Register Archive, Clinicaltrials.gov and OpenSIGLE were searched from database inception to 31st December 2010. A narrative synthesis of qualitative and quantitative data, based initially upon illness representations and extended to include other themes not compatible with that framework.

RESULTS

A range of clinically relevant beliefs was identified from 65 studies including the difficulty in labeling depression, complex causal factors instead of the biological model, the roles of different treatments and negative views about the consequences of depression. We found other important themes less related to ideas about illness: the existence of a self-sustaining 'depression spiral'; depression as an existential state; the ambiguous status of suicidal thinking; and the role of stigma and blame in depression.

CONCLUSIONS

Approaches to detection of depression in physical illness need to be receptive to the range of beliefs held by patients. Patient beliefs have implications for engagement with depression screening.

Qualitative cross-sectional study of the perceived causes of depression in South Asian origin women in Toronto

OBJECTIVE

To explore how South Asian origin women in Toronto, Canada, understand and explain the causes of their depression.

DESIGN

Cross-sectional in-depth qualitative interviews.

SETTING

Outpatient service in Toronto, Ontario.

PARTICIPANTS

Ten women with symptoms of depression aged between 22 and 65 years of age. Seven were from India, two from Sri Lanka and one from Pakistan. Four were Muslim, three Hindu and three Catholic. Two participants had university degrees, one a high school diploma and seven had completed less than a high school education. Eight were married, one was unmarried and one a widow.

RESULTS

Three main factors emerged from the participant narratives as the causes of depression: family and relationships, culture and migration and socioeconomic. The majority of the participants identified domestic abuse, marital problems and interpersonal problems in the family as the cause of their depression. Culture and migration and socioeconomic factors were considered contributory. None of our study participants reported spiritual, supernatural or religious factors as causes of depression.

CONCLUSION

A personal-social-cultural model emerged as the aetiological paradigm for depression. Given the perceived causation, psycho-social treatment methods may be more acceptable for South Asian origin women.

Identifying depression in South asian patients with end-stage renal disease: considerations for practice

Depression is a prevalent burden for patients with end-stage renal disease (ESRD) and one that is under-recognized and consequently under-treated. Although several studies have explored the association between depression symptoms, treatment adherence and outcomes in Euro-American patient groups, quantitative and qualitative exploration of these issues in patients from different cultural and ethnic backgrounds has been lacking. This review discusses the methodological issues associated with measuring depression in patients of South Asian origin who have a 3- to 5-fold greater risk of developing ESRD. There is a need to advance research into the development of accurate screening practices for this patient group, with an emphasis on studies utilizing rigorous approaches to evaluating the use of both emic (culture-specific) and etic (universal or culture-general) screening instruments.