Rural Women with Disabilities and Depression, Part One: Characteristics and Treatment Patterns

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 2.

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%

Education: College/graduate 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%

Primary disability:
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.

Although all 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.

Table 3. Level & Classification of Depression
Scores	Level	Frequency/percent
0-13	Minimal	16 (11.9%)
14-19	Mild	17 (12.7%)
20-28	Moderate	41 (30.6%)
29-63	Severe	60 (44.8%)

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 should:

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 of rurality.

References:

Beck, A., Steer, R., & Brown, G. (1996). Manual for Beck Depression Inventory-II. San Antonio: Psychological Corporation.

Hughes, R., Nosek, M., & Robinson-Whelen, S. (2007). Correlates of depression and rural women with physical disabilities. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 36(1), 105-114.

Hughes, R., Robinson-Whelen, S., Taylor, H., Petersen, N., & Nosek, M. (2005). Characteristics of depressed and non-depressed women with physical disabilities. Archives of Physical Medicine and Rehabilitation, 80, 473-479.

Hughes, R., Taylor, H., Robinson-Whelen, S., & Nosek, M. (2004). Depression self-management for women with disabilities. [Final Report]. Houston: Baylor College of Medicine, Department of Physical Medicine and Rehabilitation.

Hughes, R., Swedlund, N., Petersen, N., & Nosek, M. (2001). Depression and women with spinal cord injury. Topics in Spinal Cord Injury Rehabilitation. 7(1) 16-24.

Levine, P., Lishner, D., Richardson, M., & Porter, A. (2001). Face on the data: Access to health care for people with disabilities living in rural communities. In R. Moore III (Ed.), The hidden America: Social problems in rural America for the twenty-first century. 179-196. Cranbury, NJ: Associated University Press.

McGrath, E., Keita, G. , Strickland, B., & Russo, N. (1990). Women and depression: Risk factors and treatment issues. Washington, DC: American Psychological Association.

Mazure, C., Keita, G.., & Blehar, M. (2002). Summit on women and depression: Proceedings and recommendations. Washington, DC: American Psychological Association. Retrieved 6/25/07, from http://www.apa.org/pi/wpo/women&depression.pdf

Mulder, P., Shellenberger, S., Streiegel, R., Jumper-Thurman, P., Danda, C., Kenkel, M., et al. (2000). The behavioral health care needs of rural women: An APA report to Congress. Washington, DC: American Psychological Association. Retrieved 6/25/07, from http://www.apa.org/rural/ruralwomen.pdf

National Institute of Mental Health. (2005). Depression: What every woman should know. [Pamphlet]. Bethesda, MD.

Nosek, M., & Howland, C. (1992). The role of independent living centers in delivering rehabilitation services to rural communities. American Rehabilitation, 18(1), 2-6, 47.

Probst, J.C., Laditka, S., Moore, C.G., Harun, N., & Powell, M. P. (2005). Depression in rural populations: Prevalence, effects on life quality, and treatment-seeking behavior. Retrieved 6/24/07 from http://rhr.sph.sc.edu/report/SCRHRC_Depression_Rural_Exec_Sum.pdf

Probst, J., Laditka, S., Moore, C., Harun, N., Powell, M., & Baxley, E. (2006). Rural-urban differences in depression prevalence: Implications for family medicine. Family Medicine, 38(9), 653-660.

Power, A. K. (2003). Remarks at the 34th meeting of SAMHSA National Advisory Council, Panel on Rural and Frontier Workforce Issues. Retrieved 6/24/07 from http://mentalhealth.samhsa.gov/newsroom/speeches/121103.asp

Robinson-Whelen, S., Hughes, R.B., Taylor, H., Hall, J.W. & Rehm, L.P. (2007, in press). Depression intervention for rural women with disabilities. Rehabilitation Psychology.

Sawyer, D., Gale, J., & Lambert, D. (2006). Rural and frontier mental and behavioral health care: Barriers, effective policy strategies, best practices. Retrieved 7/17/07 from http://www.narmh.org/pages/Rural%20and%20Frontier.pdf

Singh, G. & Siahpush, M. (2002). Increasing rural-urban gradients in U.S. suicide mortality, 1970-1997. American Journal of Public Health, 92(7), 1161-1167.

Szalda-Petree, A., Seekins, T., & Innes, B. (1999). Rural facts: Women with disabilities: Employment, income, and health. Missoula: The University of Montana Rural Institute. Retrieved 12/10/05 from http://rtc.ruralinstitute.umt.edu/RuDis/DisWomenFact.htm

U.S. Department of Health & Human Services. (2000). Healthy people 2010: Understanding and Improving health and objectives for health. 2nd Ed. Washington, DC: U.S. Government Printing Office.

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.