|
Article Excerpt
Converging evidence suggests that women disadvantaged by poverty or racial and ethnic minority status are more likely to experience depression than the rest of the U.S. population (Bruce, Takeuchi, & Leaf, 1991; Kessler, 2003; Kessler & Neighbors, 1986). At the same time, they are less likely to seek or remain in treatment for depression in traditional mental health settings. What might account for this problem, and what can mental health clinicians do about it? Here we briefly describe the problem and then discuss the practical, psychological, and cultural barriers to seeking and remaining in mental health care for women of color and white women who are depressed and economically disadvantaged. Also presented is a description of the engagement interview--not a therapy, per se, but a brief, therapeutic strategy designed to be implemented before treatment to address and resolve barriers to treatment seeking.
DEPRESSION AND LACK OF TREATMENT ENGAGEMENT AMONG ECONOMICALLY DISADVANTAGED WOMEN
Individuals living on low incomes have higher prevalence rates of mental health problems than the general population (U.S. Department of Health and Human Services [HHS], 1999; Williams & Collins, 1995). Longitudinal data, for example, have indicated that poor individuals have twice the risk of major depression, controlling for age, race, socioeconomic status, and history of psychiatric episodes (Bruce et al., 1991). Moreover, being a woman with low socioeconomic status is associated with increased risk of depression. Depression is the leading cause of disability among women in the world today (Murray & Lopez, 1996), with women having twice the risk of depression as men (Kessler, 2003).
For women disadvantaged by poverty and racial or minority status, however, findings are even more disturbing. Nearly one-fourth of African American and Latina women live in poverty, and more than 33 percent of women who head their own household are poor (U.S. Census Bureau, 2004). Women of color and white women who live at or near the poverty line experience at least twice the rate of depression as do women at the middle income level (Hobfall, Ritter, Lavin, Hulszier, & Cameron, 1995). More specifically, high levels of depressive symptoms are common in young minority women who are economically disadvantaged and in mothers with young children who are living on welfare or low incomes, with 25 percent meeting the criteria for major depression (Miranda, Chung, et al., 2003; Siefert, Bowman, Heflin, Danziger, & Williams, 2000). Indeed, epidemiologic studies have documented a peak in first onsets of depression for women in their childbearing and childrearing years (Kessler et al., 1994), which confers a profound mental health risk on child mental health and functioning (Field, 2000).
Despite this increased risk and prevalence of mental health disorders among disadvantaged individuals, many either do not seek mental health services or drop out after an initial visit or after their distress is alleviated (Greeno, Anderson, Shear, & Mike, 1999; Sue, Fujino, Hu, Takeuchi, & Zane, 1991). One study of 1,636 patients with depressive and anxiety disorders observed that over a one-year period, only 25 percent of patients with depressive disorders received appropriate treatment (either pharmacotherapy or psychotherapy). African Americans were less likely to receive appropriate treatment, and among those entering psychotherapy, only half attended at least four sessions (Young, Klap, Sherbourne, & Wells, 2001). In a 2001 supplement to his mental health report (HHS, 1999), the Surgeon General indicated that racial and ethnic minorities, compared with whites, were less likely to receive mental health care, and when they did receive care, it was more likely to be poor in quality. Similarly, in a recent National Comorbidity Survey replication, Wang and associates (2005) found that most people with mental disorders, especially racial and ethnic minorities and those with low incomes, remained either untreated or did not receive minimally adequate treatment.
More specifically, we know that women who are depressed and economically disadvantaged rarely seek or receive treatment in mental health settings (Miranda, Azocar, Komaromy, & Golding, 1998; Siefert et al., 2000), particularly minority women (HHS, 2001), despite the availability of specific and effective treatments. This service underutilization by the most vulnerable women is of great concern because the course of depression becomes recurrent in 50 percent to 70 percent of new cases, the risk of recurrence rises with each successive episode, and the severity of subsequent episodes tends to increase (Kupfer, 1991). Thus, failure to engage and retain women who are economically disadvantaged in potentially beneficial and efficacious mental health services constitutes a significant public health problem. What are some of the factors that account for this failure?
PRACTICAL BARRIERS TO CARE
Epidemiologic and qualitative research studies (Armstrong, Ishike, Heiman, Mundt, & Womack, 1984; Maynard, Ehreth, Cox, Peterson, & McGann, 1997) have identified cost, not being insured, limited time and competing priorities, loss of pay from missing work, inconvenient or inaccessible clinic locations, limited clinic hours, transportation problems, and child care difficulties as practical barriers to service use by people living on low incomes. Many individuals with low incomes experience so many economic and practical difficulties that seeking treatment may be seen as just one more burden (Hall, 2001). Thus, an engagement strategy for women of color and white women who are depressed and economically disadvantaged will need to include problem solving to address practical barriers to care.
PSYCHOLOGICAL BARRIERS TO CARE
Perceived stigma about depression may pose another significant psychological barrier that prevents white and minority women who are depressed and living on low incomes from seeking or staying in mental health care. Stigmas about mental illness are widely endorsed by the general public. People with depression or mental illness have been portrayed as incompetent, crazy, or violent, but nonetheless in control of and responsible for causing their condition (Corrigan et al., 2000). Individuals with depression may internalize these attitudes and avoid seeking treatment or discontinue treatment prematurely. Sirey and colleagues (1999) found that perceived stigma toward individuals with mental illness was significantly associated with treatment discontinuation in elderly patients with depression. In a study of perceived stigma and barriers to seeking mental health treatment in women who were depressed, economically disadvantaged, and attending a public care obstetrics and gynecology clinic, 51 percent of these women reported worrying about what their family or friends would think about their depression, 40 percent said they were embarrassed to discuss their depression with anyone, and 26 percent didn't think they could be helped by mental health care (Scholle, Hasket, Hanusa, Pincus, & Kupfer, 2003). Because women with depression may have two or three stigmatizing conditions, they may be even more likely to avoid treatment. Thus, an engagement strategy for women of color and white women who are depressed and economically disadvantaged will address stigma and provide adequate information about the causes and treatability of depression--that depression is not the woman's fault and that a variety treatments are effective in alleviating depression.
Individuals with depression suffer from low energy and fatigue, reduced problem-solving ability and concentration, and low self-esteem, symptoms that interfere with treatment seeking. Research suggests that when women who are depressed report past physical or sexual abuse, they may be even less motivated to engage in treatment. Recent evidence obtained in public primary care clinics (Miranda et al, 1998; Scholle et al., 2003) suggests that women living in poverty (about 20 percent of whom have major depression) report high levels of sexual or physical abuse in both childhood and adulthood. Moreover, interpersonal trauma during childhood was associated with an avoidant attachment style in relationships (Mickelson, Kessler, & Shaver, 1997), a style characterized by strong self-reliance and mistrust of depending on others. Although a helpful strategy for dealing with adversity, strong self-reliance has been linked with difficulties in engagement, collaboration, and adherence in psychotherapy (Tyrell, Dozier, Teague, & Fallot, 2001) and in health care regimens (Ciechanowski, Katon, Russo, & Walker, 2001). Thus, an engagement strategy for women of color and white women who are depressed and economically disadvantaged and report physical or sexual abuse will recognize and accommodate an interpersonal style of strong self-reliance.
CULTURAL BARRIERS TO CARE
As Belle (1990) suggested, women living in poverty are exposed to more chronic stressors than the general population, but have fewer familial, social, and community resources to manage them. They experience more frequent, more threatening, and more uncontrollable life events, including community crime and violence, substance abuse and addiction in their families and neighborhoods, discrimination unstable employment, crowded living arrangements, physical health problems, and imprisonment or unavailability of their partners or husbands. Moreover, their social networks can serve as conduits of stress, just as well as they can serve as sources of support (Riley & Eckenrode, 1986). Thus, an engagement strategy for women of color and white women who are depressed and economically disadvantaged requires a scope broad enough to conceptualize depression in these women as critically linked with multiple social problems and chronic stress.
Furthermore, cultural insensitivity or ignorance on the part of mental health clinicians presents a significant barrier to treatment engagement and retention in women of color living on low incomes (Miranda,...
|
