Depression is a common mental health problem
in which a person may experience persistent sadness, be unable to enjoy formerly
pleasurable activities, and feel worthless or hopeless. Undetected and untreated
depression causes substantial physical and social limitation and may lead to
suicidal thoughts or actions. More than 80% of people with depression improve
with appropriate treatment (National Institute of Mental Health [NIMH], 2005).
Each year, one in ten Americans experiences depression (NIMH, 2005).
Environmental risk factors for depression include unemployment, poverty,
exposure to abuse and violence, and other life stressors. Women experience these
risk factors at higher rates regardless of where they live or whether they have
a disability, and they are twice as likely as men to have a major depressive
episode (McGrath et al., 1990).
Approximately 26% of women living in rural areas have disabilities. They face
two additional risks for depression: having a disability and living in a rural
setting. According to “Healthy People 2010", 30% of women with disabilities are
prevented from being active by feelings of sadness or depression, compared to 8%
of women without disabilities (US Department of Health and Human Services,
2000). Research suggests that depression is more prevalent in rural areas and
barriers to accessing mental health services are more pervasive (Probst et al.,
2005; Probst et al., 2006). Barriers include the overburdened primary health
care system, poverty, inadequate funding for mental health services, lack of
mental health providers, scarce public transportation, geographic isolation,
stigma, and concerns about confidentiality (Sawyer, Gale, & Lambert, 2006;
Levine et al., 2001; Mulder et al., 2000; Power, 2003).
Research shows that urban women with physical disabilities have a high
prevalence of depression (Hughes et al., 2005; Hughes et al., 2004; Hughes et
al., 2001). Rural women’s rate of depression is twice that of other women
(Power, 2003) and rural women with disabilities face additional risks and unique
barriers, such as poorer health, less education, and greater dependence on
government programs than their urban counterparts (Szalda-Petree et al., 1999).
Moreover, the lack of trained personal care providers may force them to rely on
family for personal assistance – a situation that may not be in their best
interest (Nosek & Howland, 1992). To learn more, Dr. Rosemary Hughes and
colleagues at Houston’s Center for Research on Women with Disabilities conducted
a study called “Depression and Rural Women with Disabilities: Testing a Center
for Independent Living-based Self-Management Program”.
Method: The study tested the effectiveness of a peer-led depression
self-management intervention for rural women with physical disabilities. Part
One of this series focuses on the analysis of data gathered from 134 women at
the time they enrolled in the study: demographic and disability-related
characteristics, patterns of treatment for depression, and demographic and
disability-related correlates of depression and depression treatment (Hughes et
al., 2007). Part Two of this series will report on the depression
self-management program itself.
Table 1 lists nine Centers for Independent Living (CILs) recruited and selected
for the study. Each serves consumers in rural areas. CILs recruited, screened,
and enrolled participants, and conducted the depression self-management program.
Description of Table 1.
Table 1. Collaborating CILs
Alpha One, South Portland, Maine
Arizona Bridge to Independent Living, Phoenix
Caring & Sharing CIL, Largo, Florida
Delta Resource CIL, Pine Bluff, Arkansas
North Country Independent Living, Superior, Wisconsin
San Juan Center for Independence, Farmington, New Mexico
The IL Center of Eastern Indiana, Richmond
The Whole Person, Inc., Prairie Village, Kansas
Western Alliance CIL, Asheville, North Carolina
Each CIL designated a female staff member with a physical
disability to complete training on the recruitment process, confidentiality and
privacy issues, informed consent procedures, and documentation protocols. To
recruit participants, centers placed newsletter and newspaper ads, posted
in-house flyers, and mailed flyers to consumers, churches, and others.
Participants were adult women (18 or older) with health conditions causing
mobility or self-care limitation, disability of at least one year’s duration,
and a score of a predetermined level on a depression measure. Women were
ineligible if they were actively suicidal, presented with health conditions
(e.g., active psychosis) that could interfere with group participation, or had
lower than mild depression levels. Each participant provided information on age,
race/ethnicity, income, employment, education level, and relationship status.
Disability-related questionnaire items asked about type, severity and duration
of primary disability; age at onset; and use of assistive devices and personal
assistance. Other items asked about general health, mobility, social
integration, and social support.
This study primarily focused on the severity and treatment of depression.
Researchers measured depression severity with Beck, Steer and Brown’s (1996)
21-item “Beck Depression Inventory-II” (BDI-II). The BDI-II measures “depressive
symptomatology”, but for brevity's sake, this report uses the term “depression.”
Participants noted whether they had been treated for depression within the
previous three months, and if so, whether they had received medication,
counseling, or both.
Results: Table 2 summarizes participants’ characteristics. Description of Table
Table 2. Participant
Characteristics (N = 134)
Age: M = 52.1 yrs; SD = 10.60; range = 23-75 yrs
Race/Ethnicity: White, non-Hispanic = 104; 77.6%
school attendance or degree = 102; 76.1%
Employment: No paid employment = 103; 76.9%
Disability Duration: M = 14.98 yrs; SD = 14.03; range = 1-57 yrs
Married or living as married = 53; 39.6%
Use personal assistance = 121; 90.3%
Use at least one assistive device = 100; 74.6%
Joint/connective tissue disease = 61; 45.5%
Neuromuscular disease = 17; 12.7%
Multiple sclerosis = 15; 11.2%
Spinal impairment = 14; 10.4%
Other = 27; 20.1%
Nearly 75% of the women reported moderate to severe
symptoms of depression and 20% reported suicidal thoughts.
participants reported depression (many had high levels of symptomatology), more
than a third had not been recently treated for depression. Of those currently in
treatment for depression, most received medication only, a few received
counseling only, and about 20% received both. At risk for severe depression were
younger women, women with more pain and/or limited mobility, and/or those less
satisfied with their social networks. Women who were socially integrated, with
stronger social support and more satisfaction with social networks, reported
lower levels of depression. Table 3 shows participants' BDI-II results. Description of Table 3.
3. Level & Classification of Depression
Discussion and Limitations: This is the first known
study of depression and rural women with disabilities. Results strongly suggest
that depression and its treatment are critical issues for rural women with
physical disabilities. Most participants reported significant psychological
distress (see Table 3). Given that higher suicide rates have been found in rural
than in urban areas (Singh & Siahpush, 2002), the finding that nearly 20% of the
women were having suicidal thoughts is alarming. At risk for severe depression
were women who were younger, those with more pain, more limited mobility, and/or
less satisfaction with their social networks.
Despite high levels of depression, only about one in three women had been
recently treated for depression. According to the NIMH (2005), most people with
depression do well on a combination of medication and psychotherapy. However,
most of the study participants who were treated received medication only. This
may reflect the multiple barriers to accessing mental health care services in
rural areas. Although many participants said they received counseling for
depression, the questionnaire did not define “counseling.” Some may have
received limited help for depression or may have defined counseling as help from
a non-professional. The use of a self-report measure of depression was another
limitation. Appropriate use of a clinical, face-to-face evaluation could have
more-accurately diagnosed clinical depression.
Conclusions and Next Steps: To increase the early detection and treatment of
depression in rural women with disabilities, a disability service provider
- Learn about depression and its symptoms.
- Organize support groups for rural women with disabilities.
- Look for signs of depression. Talk with consumers and others directly and
privately about depression they may be experiencing.
- Suggest that a woman who appears depressed visit a doctor or other health or
mental health care provider. Offer to accompany her to the provider’s office.
- Train staff and consumers on the symptoms and treatment of depression.
- Provide resources on depression (e.g., web addresses for the American
Psychological Association, the American Psychiatric Association, and NIMH)
Our next step will be to publish Part 2 of this report, which will describe a
depression intervention program, report on the results of the clinical trial
(Robinson-Whelen et al., 2007), and offer depression self-management tips. Our
long term plan is to secure funding to continue our work on depression,
including new lines of research on depression and rural men with disabilities, a
clinical trial of depression self-management for rural men and women with
varying types of disability, and a study of depression and abuse in the context
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For more information, contact: Rosemary Hughes, Ph.D.
Research and Training Center on Disability in Rural Communities, The University
of Montana Rural Institute, 52 Corbin Hall, Missoula, MT 59812-7056
(888) 268-2743 Toll-free; (406) 243-4200 TTY; (406) 243-2349 Fax; http://rtc.ruralinstitute.umt.edu
This report was supported by grant #H133B030501 from the National Institute on
Disability and Rehabilitation Research, U.S. Department of Education. The
opinions expressed reflect those of the author and are not necessarily those of
the funding agency. This report was prepared by Rosemary Hughes, © RTC: Rural,
2007. It is available in large print, Braille, and as a text file.