Development process for a theoretical model

In this study, significant factors for predicting menopausal depression and their relationships were constructed based on previous studies, and these are illustrated in Figure 1. It was hypothesized that educational and economic statuses not only influence menopausal depression directly, but also indirectly via other parameters such as attitudes towards menopause and aging, social support, and social conflicts. It was also hypothesized that attitudes towards menopause and aging directly influence menopausal depression. The empirical support for each of these paths is presented.

The hypothetical model.

In many previous studies, educational and economic statuses were presented as specific indices for individuals predisposed to depression, and they were presented as demographic variables with a considerable influence on depression (Bloch 2002; Cho et al 1999; Kessler 2003; Kim 2000; Nam and Cho 1997 and Shors and Leuner 2003). Especially, in the variable of economic status, almost all previous studies reported that middle-aged women with low income showed a higher degree of depression compared with those with higher income.

Previous studies have shown that the perceived health status of middle-aged women is directly related to menopausal depression (Choi 1998 and Kim 2000). There was also a close relationship shown between attitudes towards menopause and aging and menopausal depression (Chi 1983; Choi 1998; Kaufert et al 1998; Lopez and Silva 1999 and Rita et al 2002). Most studies have shown that middle-aged menopausal women have a negative attitude towards menopause, thinking that menopause would accelerate aging and cause problems in sexual life, and aggravate their health status.

Positive support from members of social networks, such as husband, children, relatives, and friends, was significantly related with protection from depression (Ham et al 2002; Han 1997; Major et al 1997; Vinokur and van Ryn 1993 and Yoo 2000). Especially, emotional and informational support from friends who are also suffering from middle-age crises had a positive effect on alleviating the negative effects of menopausal stress on depression (Park, 1999).

Previous studies on menopausal depression focused only on the positive function of social relationships, which is a social support, and paid little attention to the negative effects of social network. However, recently it was reported that the social network could be a positive resource like social support, and at the same time could cause tension and stress (Ham et al 2002; Han 1997; Major et al 1997; Park 1999; Rauktis et al 1995 and Yoo 2000). Moreover, when we consider the results of studies (Ham et al 2002; Park 1999 and Yoo 2000) showing that even when frequencies of social conflicts are lower than those of social support, the experiences of the former had a greater effect on menopausal depression, indicating that studying both the positive and negative aspects of the social network is necessary. From the above considerations, it was hypothesized in this study that a poor perception of health status and lower educational and financial statuses were related to little positive support from members of the social network, and that more conflict with members of the social network and negative attitudes toward menopause and aging would be related to more menopausal depression.

Methods

Design

This study is a cross-sectional structural model-verification study in which a hypothetical model predicting menopausal depression based on previous studies was constructed, and the appropriateness of the model was verified by collected data.

Sampling

In this study, the data were collected by distributing questionnaires to middle aged women who conveniently selected in two Korean cities. From the distributed 500 questionnaires, 401 were collected (response rate 80.2%). Among these, the data from 305 subjects who belong to the aged 45 to 55 years (the typical range of menopausal ages) were used for ultimate analysis.

DEPRESSION AFFECTS approximately 5% of today’s teenagers (Shaffer et al., 1996a) and is considered the fourth most important disease in the estimation of disease burden (Murray and Lopez, 1996). The impact of adolescent depression on the individual and society is far reaching, as depression in teenagers has been found to significantly increase the risk of major depression and anxiety disorders, social dysfunction, nicotine dependence, alcohol dependence and abuse, educational underachievement, unemployment, early parenthood, suicide attempts and completed suicide (Fergusson and Woodward 2002 and NHMRC (National Health and Medical Research Council), 1997. Depression in young people: Clinical practice guidelines, Australian Government Publishing Service, Canberra.NHMRC 1997). Suicide, perhaps the most serious potential outcome of depression, was the third leading cause of death in 10 to 20 year olds in the United States from 1999 to 2001 (Centers for Disease Control and Prevention, 2003). Research suggests that as many as 7% of teenagers who develop major depressive disorder may commit suicide as young adults (Weissman, et al., 1999). This relationship between major depression and suicide cannot be overlooked, as research repeatedly shows that between 90% and 98% of teenagers who complete suicide are found to have a psychiatric diagnosis (Brent et al 1999; Marttunen et al 1991 and Shaffer et al 1996b).

Given this strong correlation between depression and suicide, it was our belief that a school-based depression education curriculum would offer effective suicide prevention, while addressing the immense morbidity of major depression. Nurses are well poised to play a collaborative and integral role in developing, implementing and evaluating such a curriculum. As an initial step in developing and testing an adolescent depression education program, it was important to understand students’ baseline knowledge of depression to develop the content around gaps in knowledge. No studies were found that surveyed this group about knowledge of depression. What we know is largely anecdotal or based on individual clinical experiences. The purpose of this article is to report the findings of a survey of 5,645 adolescents, conducted to assess teenagers’ knowledge of depression and bipolar disorder. Description of the education program and reports of the posttest results are presented in a separate publication (Swartz et al., 2004).

Background

The high school population is an optimal target group for depression education because of the aforementioned high rate of suicide in this population coupled with the fact that depressive disorders often start in adolescence, with marked increase in period prevalence estimates from middle to late adolescence (Fergusson and Horwood 2001 and Hankin et al 1998). High schools themselves are excellent venues for health education programs, as schools are recognized as the most universal setting for delivering services to children and consequently are a major focus of the effort to improve children’s mental health services (Weist et al 2001 and Leaf et al 1996). Furthermore, today’s adolescents are accustomed to being taught in school about a myriad of health issues, from eating disorders to smoking to cardiovascular health to sex education (Wade et al 2003; Thomas 2002; Hoelscher et al 2004 and Buston et al 2002).

With regards to depression, however, we have found no publication to date, describing a school-based depression education program, although there are several reports of school based depression prevention programs (Burns and Hickie 2002; Merry et al 2004; Shochet et al 2001 and Oria et al 2001). There are many reports of suicide prevention programs; however, in a large survey of such programs (Garland, Shaffer, & Whittle, 1989), the authors found only 4% of these studies adhered to the theory that suicide is usually a consequence of mental illness. Of these programs, 95% included in the survey espoused the view that youth suicide is most commonly a response to extreme stress or pressure and could happen to anyone. Many of these programs have been criticized for denying the role of mental illness in suicide and normalizing suicidal behavior (Burns & Patton, 2000). Despite the lack of knowledge about the best way to educate teenaged children about suicide, 75.1% of U.S. high schools require that some sort of suicide prevention curriculum be taught (School Health Policies and Programs Study, 2000). Given this combination of inconclusive research on how to best teach suicide prevention, and the large number of schools requiring suicide prevention be taught, it seems imperative that we consider educating our teenagers about the illness of depression as a means to address both the morbidity and mortality of the illness. Furthermore, a collaborative approach to this type of education is fundamental for lessening the burden on our education systems and to strengthen the relationships among the education, mental health and public health systems (Weist et al 2001 and Weist and Christodulu 2000). The Adolescent Depression Awareness Program (ADAP) was developed to address these needs for depression education to be taught in high schools.

Method

ADAP was initiated in 1999 by a team of psychiatrists and psychiatric nurses from the Johns Hopkins University School of Medicine, and the Depression and Related Affective Disorders Association (DRADA), a nonprofit community-based organization and support group. Based on their clinical experiences and knowledge of the field, this team developed ADAP based on the fundamental premise that depression education is a critical means towards suicide prevention in teenagers. The mission of ADAP is to develop a school-based curriculum to educate high school students, teachers and parents about teenage depression. Over the 5 years since its inception, the ADAP team has developed and assessed a 3-hour curriculum which is currently being taught in local high schools by psychiatric nurses and psychiatrists. Thus far, ADAP has trained nine psychiatrists and psychiatric nurses to teach this curriculum. To date, it has been taught to over 5500 students in high schools in three East Coast states and the District of Columbia. ADAP’s development has been further enhanced by a strong collaborative approach, with a team that incorporates the expertise of psychiatric health care professionals, high school teachers and counselors, business professionals and teenagers and families affected by depression and suicide.

The ADAP team designed the program to incorporate rigorous methodology in curriculum development and assessment of students’ learning and attitude changes. Each time the curriculum is taught, the students are given a pretest of their depression knowledge before the program is presented. The same survey is given as a posttest approximately 6 weeks after completion of the curriculum to evaluate changes in students’ knowledge. For the purpose of this article, however, we will focus on the pretest results to provide the important data on the scope of knowledge of teenagers before the intensive intervention. This will fill an important gap in our understanding of the current status of teen knowledge in this area. Data are reported for 5 years of the program.

Setting and participants

The 5,645 students included in the survey were from 29 different public, private, and parochial high schools in three eastern states and the District of Columbia. The protocol received exemption status from the institutional internal review board as no identifying information or personal data were collected from the students. The schools were selected in two ways. In some cases the school contacted DRADA or ADAP staff directly and requested the curriculum be brought to the school. In other cases, the school was part of a large public school district that was already working with the ADAP team to incorporate the curriculum into all of its ninth grade health classes. Although we did not collect demographic data on individual students, the schools are well recognized as economically and ethnically diverse. As well, the students had a broad range of cognitive abilities, from honors students to those receiving special education services

ALTHOUGH THE GOAL of the national policy on deinstitutionalization was to shift mental health care services from hospitals to the community, acute inpatient hospitalization remains a reality. In fact, the critical demand for acute inpatient psychiatric services is reflected by the recent increase in inpatient admissions (The National Association of Psychiatric Health Systems, [NAPHS], 2002). The contribution of acute care in the treatment of individuals with mental illness is not known or widely researched. In fact, President Bush has identified acute care as one of the four areas of mental health services deserving future research (The President’s New Freedom Commission on Mental Health, 2003. Achieving the promise: Transforming mental health care in America , July 22). Retrieved August 13, 2003, from http://www.MentalHealthCommission.gov .New Freedom Commission on Mental Health, 2003). Moreover, as a result of the changes in the mental health delivery system, quality of care has become a major concern to stakeholders and society at large. One way quality of care delivered by acute care psychiatric facilities can be assessed is through the examination of client outcomes after inpatient treatment.

The purpose of this article is to conduct a methodological review of the literature that examines the prediction, assessment and measurement of client outcomes after treatment in acute care psychiatric facilities. The literature is analyzed critically to identify the gaps in knowledge related to outcomes as valid quality indicators and outcomes that are sensitive to nursing care. Finally, the Quality Health Outcomes model (Mitchell et al., 1998) is proposed to conceptualize outcomes of acute inpatient psychiatric treatment that are sensitive to nursing interventions and the organization of nursing care (See Fig 1).

Quality Health Outcomes Model. Reprinted with permission from Mitchell et al., 1998. © 1998 Blackwell Publishing Ltd.
Background and significance

Mental illness is the leading cause of disability in the United States and other market economies (The World Health Organization [WHO], 2001). Payments for hospital care for psychiatric and addictive disorders are on the rise for the first time in 5 years (NAPHS, 2002). Thus, mental illness inflicts a phenomenal cost to society. More importantly, the emotional, social and physical sequelae of mental illness compromise the quality of life for those afflicted.

Two quality forums, the Maryland Hospital Association Quality Indicator Project and the National Association of Psychiatric Health Systems proposed the following quality indicators for psychiatric treatment: self-injurious behaviors, unplanned departures, transfers/discharges to inpatient acute care, readmissions, restraint/seclusion use, symptom improvement, level of functioning and client satisfaction. It is not known if the literature supports the use of these quality indicators as valid measures of quality care. Identifying client outcomes related to nursing care is critical to establish empirical evidence that supports the effectiveness of psychiatric nursing.

Methodology

This state of the science follows the guidelines outlined by Ganong (1987) for conducting rigorous literature reviews in nursing.

Purpose

The purpose of this synthesis is to identify research that examines the outcomes of individuals after treatment in acute care psychiatric hospitals and psychiatric units in general hospitals. The following hypotheses were tested: Empirical evidence will not support the use of readmission rates as a valid quality indicator, but will support the use of symptom improvement, client function, self injurious behaviors and client satisfaction as valid quality indicators There is a paucity of literature related to quality indicators/outcomes for acute inpatient psychiatric treatment that are currently conceptualized as nursing sensitive.

Literature search

The databases used to conduct the literature search were: Medline, CINAHL, HealthSTAR/Ovid HealthSTAR and psycINFO. To narrow the scope of the review, 1991 was the year chosen to begin data collection. A nodal point in the transformation of the health care system, 1991 was a time when quality of care, specifically client outcomes, became a significant concern with the introduction of managed care. The following search terms and combinations were used to identify articles for review: psychiatric outcomes, treatment outcomes and psychiatric hospitals, inpatient psychiatric hospital and outcome measurements, quality and outcomes and inpatient psychiatric hospitals, outcomes and inpatient psychiatric hospitals, psychiatric facilities and outcomes, psychiatric units and client outcomes, psychiatric units and treatment outcomes, outcome assessment and acute psychiatric hospitals/psychiatry and psychiatric nurses and quality assessment. To make the search more specific, five of the quality indicators mentioned previously were combined with the key words psychiatric hospitals/hospitalization and outcomes. The decision was made not to search for two of the quality indicators: transfers/discharges to inpatient acute care and seclusion/restraint. The rationale for not searching for these quality indicators is because they are largely conceptualized as process elements of care. Finally, manual reviews of reference lists were conducted throughout the review process to discover seminal articles for inclusion. The systematic data collection process was a measure taken to avoid introducing bias into the selection of articles.

Sample

Forty-seven research studies are included in this state of the science. Studies were included if they were specific to adult psychiatric clients treated in acute care psychiatric hospitals or a psychiatric unit in a general hospital; routinely collected client outcomes obtained from administrative data; clinical outcome data specific to readmissions, symptoms, function, client satisfaction and self-injury that are collected in psychiatric treatment facilities; methods used to measure the outcomes; and/or factors that relate to predicting outcomes after acute care treatment. Studies were not included if they were specific to child and adolescent or geriatric clients treated in acute care psychiatric hospitals or general hospitals with a psychiatric unit; outcomes after care in long-term psychiatric treatment facilities; outcomes after treatment with medications; and/or outcomes after the implementation of an experimental treatment not associated with standard care.

THERE IS A CATCH phrase that dominates the clinical landscape of medical and psychiatric mental health care-evidence-based practice (EBP). Indeed, on any given day these phrases can be heard to be uttered in the hallways of our academic institutions as well as our clinical institutions; and are often narrowly interpreted to mean practices that have a proven efficacy based on empirical study and data. Certainly, in this era of EBP, research dissemination and utilization have been given deserved emphasis in the context of clinical practice. Yet, at the risk of seeming antiscience (which I am not), I wonder whether we have taken EBP and Best Practices so far down the research path that we have lost sight of the role of clinical judgment and forgotten that research outcomes cannot always be translated down to the particulars of an individual clinical case. And, perhaps we have become so enamored with EBP and Best Practices that, especially among our colleagues in academic settings, we no longer value clinical scholarship that is narrative, reflective, or otherwise nonempirical in nature-witness the increased emphasis on databased manuscripts in appointments and promotions criteria in our academic institutions and the emphasis on EBP in the classroom, clinical, and written assignments of our graduate psychiatric mental health nursing programs.

Surely I can’t be opposed to evidence in the context of psychiatric mental health nursing practice! Of course not! But, I have witnessed the disappearance of certain types of evidence that concerns me. I have watched it disappear from these pages as well as from our academic programs and our practice dialogues. It is sadly rare that authors submit clinical narratives, think pieces or substantive case discussions to this journal. I have had people tell me that because Archives of Psychiatric Nursing is a research journal they would not think of submitting “softer” manuscripts for our consideration. Yet it is these “softer” pieces that will likely illuminate the important variations from the empirical norm-the clinical case that defies the evidence; or the untoward response to tried and tested pharmacological interventions. I have also had psychiatric mental health nurses tell me that they don’t read Archives of Psychiatric Nursing because it is about research not practice! It seems pretty obvious to me that one cannot be about clinical research without being about practice. It is equally obvious that research alone does not and cannot define the entire domain of practice.

So, just what is the evidence in EBP? I think it is the carefully considered combination of research evidence, clinical evidence based on assessment and observation, inputs from the individual patient, and expert clinical judgment based on all of these things. Our science is not nearly so refined that there is only one best practice or intervention for a given clinical problem. For the most part we are faced with choices among practices for which there is competing evidence that must be fit to the individual clinical situation.

How do we inform the choices we make in practice? In real life we consult with our practice colleagues who are experts in the area in question; read the research literature; and consult with our patients who are, afterall, the experts in their own personal preferences, values and reactions to treatment. And, how will we refine our capacity to evaluate such evidence if we don’t write about it and share it in public forums that might allow for examination and discourse?

When is the last time you made a clinical decision that did not follow the linear path of the “evidence”? What were the factors that made you choose a different path? How did things turn out for that patient? How do you explain the outcome given the deviation from the evidence? This is the stuff of an intriguing manuscript and it belongs in a journal like Archives of Psychiatric Nursing precisely because we are about clinical research and practice and the only way we can fulfill this mission is with all the evidence, not just the empirical evidence.

I encourage you to think about your practice and the types of evidence that inform your clinical judgments. I particularly encourage you to think about those contrary cases that seem to defy the empirical evidence. Don’t restrict your thoughts to late-night private musings or discourse with a few trusted colleagues. Put it on paper and dare to expose it to review and dissemination so that we can begin to recapture the evidence of clinical judgment and clinical narrative alongside the evidence of research-only then will we have all the stuff we need for EBP and only then will Archives of Psychiatric Nursing fulfill its commitment to shape psychiatric mental health nursing practice.

THE WORLD HEALTH Organization estimates that major depression is now the fourth most important cause worldwide of loss in disability-adjusted life-years and will be the second most important cause by 2020 (World Health Organization, 2004). Depression is a frequently occurring psychiatric disorder with a prevalence of approximately 5% in the general population (Bebbington et al 1981 and Weissman et al 1988). It is estimated that at least one-third of all individuals are likely to experience an episode of depression during their lifetime (Rorsman, Grasbeck, Hagnell, Lanke, Ohman, Ojesjo, & Otterbeck, 1990). In Taiwan the lifetime rates for major depression was 1.5 cases per 100 adults (Weissman, Bland, Canino, Glorisa, Faravelli, Greenwald, Hwu, Joyce, Karam, Lee, Lellouch, Lepine, Newman, Rubio-Stipec, Wells, Wickramaratne, Wittchen, & Yeh, 1996). Depressive disorders are persistent, recurring illnesses that cause great suffering for patients and their families (Williams, Mulrow, Chiquette, Elaine, Noël, Aguilar, Christine, & Cornell, 2000).

Depression results in high personal, social, and economic costs through suffering, disability, deliberate self-harm, and health care provision. The personal burden of depression includes higher mortality and impairment in multiple areas of functioning. The attendant economic costs to society and personal burden to patients and families are enormous. In the United States, the estimated costs of treating depression and the costs incurred by lost productivity exceeded $44 billion in 1990 (Greenberg, Stiglin, Finkelstein, & Berndt, 1993). Despite the availability of drug and psychotherapeutic treatments, much depression remains undiagnosed or inadequately treated (Freeling, Rao, Paykel, Sireling, & Burton, 1985). Although there is much research about depression, few studies have focused on the effects of music in improving depression (Aldridge, 1993), particularly in psychiatric inpatient.

Three types of therapy for major depressive disorder (MDD) have proven efficacy: pharmacotherapy, psychotherapy, and electroconvulsive therapy (Thase, Greenhouse, Frank, Reynolds, Pilkonis, Hurley, Grochocinski, & Kupfer, 1997). The most frequently used treatment for major depression is antidepressant medication (Depression Guideline Panel, 1983). As many as 30% to 35% of patients do not respond to treatment although the development of new and effective medications for depression (Baldessarini 1985; Baldessarini 1989 and Silver & Yudofsky 1988). Furthermore, medications also may induce unwanted side effects that can impair patients’ quality of life and reduce compliance (Silver & Yudofsky, 1988). Even among patients who show improvement with short-term antidepressant use, there is a significant risk for relapse within 1 year after treatment termination (Craighead et al 1998 and Keller, M.B., 1988. Diagnostic issues and clinical course of unipolar illness. In: Francis, A.J. and Hales, R.E., Editors, 1988. Review of Psychiatry, American Psychiatric Press, Washington, DC, pp. 188–212.Keller 1988). Therefore, nonpharmacological methods that promote a mind-body interaction without side effects should be tested to reduce depression in MDD patients.

Depression is one of the most common reasons for using complementary and alternative therapies (Ernst, Rand, & Stevinson, 1998). In 1991, 40% of the US adult population used at least one such therapy for 1 year (Astin, 1998). It is estimated that about 20% of those who suffering from depression had used an unconventional therapy within the past year (Eisenberg, Kessler, Foster, Norlock, Calkins, & Delbanco, 1993). Depression is among the 10 most frequent indications for using alternative therapies, and music is one of the remedies for this condition (Astin, 1998). Complementary and alternative therapies are popular in Taiwan. A survey revealed that 90% of Taiwanese families frequently combined a variety of approaches in treating illnesses (Wu & Hu, 1980).

Only three researchers have examined the therapeutic effect of music on depression. Each found that music had beneficial effects (Chung 1992; Hanser & Thompson 1994 and Lai 1999), but there were methodological problems of small sample size and lack of consideration of confounding factors. Moreover, none studied the effects of music on major depression in psychiatric inpatients.

Music is known to effect the individual by sympathetic resonance. Based on a psychophysiological theory synthesized from the literature, certain type of music induces relaxation and please responses (Lai & Good, 2002), which reduce activity in the neuroendocrine and sympathetic nervous systems, resulting in decreased anxiety, heart rate, respiratory rate, and blood pressure (Good et al 1999; Standley 1986 and Zimmerman et al 1988). Music has been found to increase circulating endorphin (Mockel, Rocker, Stork, Vollert, Danne, Eichstadt, Muller, & Hochrein, 1994), which is associated with moods (Gerra, Zaimovic, Franchini, Palladino, Guicastro, Reali, Maestri, Caccavari, Delsignore, & Brambilla, 1998). Thus, a music intervention was expected to improve depression. Addressing music selection is important when conducting music intervention. Music preference plays a large role because people generally like what they know and dislike the unfamiliar (Lai & Good, 2002). However, little is know about the effects of music on depression in psychiatric patients. Thus, the aim of the study was to test the hypotheses that, while controlling for identified covariates, subjects who used music as therapy at 6pm each day for 2 weeks would have (1) better depression scores and (2) better individual subscores of depression over time than those who did not use music.

Methods

Subjects

Patients with major depressive disorder diagnosed by a psychiatrist according to the Diagnostic and Statistical Manual of Mental disorder 4th edition (DSM-IV) in a psychiatric ward of a psychiatric hospital in southern Taiwan were included in the study. Exclusion were current alcohol or substance abuse, primary psychiatric diagnosis other than MDD, ongoing participation any other alternative or complementary therapies, and were those who with suicidal ideation.

A total of 54 subjects were expected to achieve a power of .8 at ALPHA = .05, one-tailed, with a medium effect size, a medium correlation (r = .50) among three repeated measures, and using repeated measures analysis of covariance on depressive scores, the size of each group was computed to be 27 (Stevens, 1996). The subjects in both groups received either Efexor (venlafaxine HCl) 75 mg/#1 twice daily or Prozac (fluoxetine HCl) 20 mg/#1 daily during time the study was conducted.

DATA FROM THE World Health Organization shows that depressive disorders are much more frequent among women than men (Ustun & Kessler, 2002). This holds true for Latinos, the largest ethnic group after Anglos in the United States (U.S.; U.S. Census Bureau, 2003). Among the estimated 38 million Latinos, most (24 million) are of Mexican descent (U.S. Census Bureau, 2003) and among Latinos of Mexican descent, the lifetime rates for major depressive episode are two times higher for women compared with men (Vega et al., 1998). Also, women of Mexican descent experience an earlier onset of depressive symptoms than men ( Sorenson, Rutter, Aneshensel, 1991; Vega, Warheit, & Meinhardt, 1984). Poverty increases women’s vulnerability to depression ( Kessler et al 2001; Miranda & Green 1999 and Miranda et al 1997) and more Latinas live in poverty in the U.S. compared with whites or Asians (U.S. Census, 2001). Furthermore, Latinos living in the U.S. are more likely than any other racial group to be without health insurance (U. S. Census Bureau, 2001. Annual Demographic Survey March CPS Supplement [On-line], Available: http://www.bls.census.gov/cps/ads/2001/susenote.htm .U.S. Census, 2001).

Compounding this is the fact that symptomatic Latinos are less likely than non-Latino whites to report previous appropriate mental health care for the treatment of any mental illness (Alegria et al 2002; Hough et al 2002; Wells et al 2001 and Padgett et al 1994) including depression (Miranda et al., 2003). Research also shows that up to 50% of Latinos (Sue, 1977) who receive mental health care discontinue treatment after their first visit ( La Roche 2002 and Lopez 1997). Cultural insensitivity of mental health professionals is a barrier, affecting patients’ trust of their therapists and acceptance of their treatment plan La Roche 2002; Lopez 1997 and Sue 1998). Lack of self-recognition of the need for mental health treatment (Kessler et al., 2001) and social stigma ( Rubenstein et al 1999 and Rubenstein et al 1999) are also barriers to appropriate mental health treatment for depression among Latinos. All of these factors may influence perceptions about the cause of symptoms ( La Roche 2002 and Lopez 1997). This then can influence whether, and how, a person manages their symptoms of depression.

The Symptom Management Model (SMM; UCSF School of Nursing Symptom Management Faculty Group 1994 and Dodd et al 2001) offers a useful approach for the study of the perceptions of women of Mexican descent related to the causes of their depressive symptoms. The model points out that symptoms are subjective experiences that reflect changes in a person’s bio-psycho-social function, sensation, or cognition. Once an individual appraises their symptoms they are able to make meaningful judgments about the cause, treatability, and potential impact of their symptoms on their life. These perceptions and judgments form the basis of the individual’s symptom management strategies. To effectively manage the symptoms, however, the SMM holds that personal, environmental, and health/illness factors should be taken into consideration (Dodd et al., 2001). Because no published research has explored the perceptions of Latina women related to the source of their depressive symptoms, little is known about their sense of the cause of their distress. Such data could aid in the design of treatment programs, making them more attractive to low income, Latina women who are struggling with depression, but reluctant or unable to access care. Therefore, this article is focused on the perceived reasons behind episodes of sadness, hopelessness, or depression experienced by low income, Latina women of Mexican descent who are at risk for depression.

Guided by the SMM (Dodd et al., 2001) this secondary analysis was done with a subsample of 107 women from a larger cross-sectional study which included survey data from 315 women of Mexican descent (see Heilemann, Lee, & Kury, 2002). Women who were at risk for depression as identified by the Center for Epidemiologic Studies Depression (CES-D) scale and who also reported a qualitative, subjective reason for their most recent episode of sadness, hopelessness, or depression were included in this analysis. Our first aim was to describe the women in terms of person variables (including income, education, partner status), environment variables (including language preference and place of birth as parameter estimates of acculturation), and health/illness variables (including risk factors such as trauma history and alcohol, cigarette, or substance use). Our second aim was to analyze and describe reasons given by the women for their most recent episode of sadness, hopelessness, or depression.

Method

Sample

Survey methods were used to collect cross-sectional data from a convenience sample of women from three family community clinics and one closely associated dual immersion school (Spanish/English) in a Northern California community. Women of Mexican descent between 21 and 40 years of age who could read and write in Spanish or English were eligible to participate. Because it was likely that those who were not citizens would be reluctant to participate if a signature was required, written consent was waived by the Committee on Human Research and verbal consent was obtained. Each participant received $10.00 in cash and a small gift after completion of the questionnaire. Of approximately 380 women approached, 55 declined participation and 325 completed the study. Ten women were later excluded because they indicated on the questionnaire that they were not of Mexican descent, which resulted in a total sample of 315. For this secondary analysis, we include only the data from 107 women with CES-D scores of 16 or higher who also gave short answer qualitative answers to the question about the reason for their experience of sadness, hopelessness, or depression within the last month, including data from women who stated that they are “always” depressed. In a related question about worry, some but not all of the 107 women, extended their discussion of the reason for their depression. This data was also included in the analysis.

DEPRESSION IS THE most common psychiatric disorder, affecting more than one in four Americans (Satcher, 1999). Of the 30,000 Americans who commit suicide every year, 90% have some mental disorder, often depression (Hyman, 2000). Although depression can be effectively treated, potential consumers conceal their symptoms and are reluctant to seek treatment. The present study explores the issue of how negative attitudes toward depression influence care seeking choices for depression.

The mental health community has long grappled with stigma as a barrier to care and recently the issue has gained momentum. The Surgeon General’s Report on Mental Health cited the public’s stigmatization of all mental illness as a leading cause of underdiagnosis and undertreatment (Satcher, 1999). The President’s New Freedom Commission on Mental Health (2003) recommended that decisive action be taken to reduce the stigma of care seeking, pronouncing that no matter how good our nation’s mental health services are, they are pointless if people will not use them.

Seeking care for depression is complicated by the disorder itself. Depression creates global negativity and dangerously deflates self-esteem. Because of stigma, admitting that the problem could be depression may cause further damage to feelings of self worth-“Only weak people get depressed. If I am depressed, I am weak.” Even when people accept that depression may be the problem, care seeking is complicated by the mystery of the mental health care system. Potential consumers are unaware of what kind of help they need, don’t know where help is available, and are uncertain that there would be any benefit to seeking care. Learning from the experience of others is impeded by fear of stigmatization-people often conceal that they were treated for depression. This concealment also serves to increase the sense of failure and isolation of the depressed individual-“No one else is such a loser.”

Two large national studies shed light on the public’s attitude toward depression. In the United Kingdom, 25% of respondents endorsed statements indicating that individuals with severe depression were dangerous, and 20% claimed that these individuals could “pull themselves together” (Crisp, 2001). Americans interviewed for the General Social Survey (National Opinion Research Center, 1996) identified those with depression as “likely to do something violent to others” at a rate of 33%, and nearly 37% believed that a person with major depression would get better without help. This perception of a lack of need for treatment is supported by the notion that depression was more often attributed to stress (54%) than chemical causation (21%). More than a third of the respondents reported that they were definitely or probably unwilling to interact with an individual with depression.

Negative perceptions regarding depression can be better understood by Weiner’s (2000) attribution model. According to this model, stigmas are the result of negative perceptions regarding whole categories people. We categorize others to enhance a sense of order, to provide explanations for others’ behavior, and to emphasize the difference between the afflicted and ourselves. Two perceptions most often linked to discrimination against mental illness are controllability and dangerousness (Corrigan et al., 2001). The more control persons with mental illness are thought to have over their condition, the more likely others will assign blame and ascribe responsibility. Dangerousness results in fear and avoidance.

It stands to reason that people who hold stigmatizing views of depression would also hold negative attitudes toward seeking care for depression. The purpose of this study was to increase our understanding of how attitudes toward mental health care is influenced by negative perceptions, especially from consumers representing a cross-section of the general population. This study examines the influence of stigma on care-seeking for depression with the expectation that there would be an inverse relationship between stigmatizing attitudes and intention to seek help for depressive symptoms.

Methods

Sample

Subjects for this study were adults recruited from waiting rooms of two healthcare facilities. One was a suburban primary care office and the other was an urban adult health clinic. Participants were patients and companions of patients waiting to be seen. The goal was to obtain a sample of both men and women that was diverse in age and race. A total of 134 individuals were asked to participate in the study. About 91% (122) agreed and completed the questionnaires. Accounting for missing data and incomplete questionnaires there were 117 useable surveys.

Measures

Study participants completed a Demographic Data Form. This form consisted of demographic items and person-level variables including gender, age, marital status, race, political affiliation, orientation to political issues, socioeconomic status, and religious affiliation

The second inventory used was the Attribution Questionnaire developed by Corrigan et al. (2001). The questionnaire presented a vignette describing a person suffering from depressive symptoms as drawn from criteria listed in the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR, Fourth Edition (American Psychiatric Association, 2000). Subjects were asked questions which measured their emotional reactions and behavioral responses to the person with depression using a seven-point Likert-type scale. There were 27 questions which represent nine factors, measured by three items each. Six of these factors are derived from attribution theory and address responsibility, affective mediation (anger or pity), and behavioral reactions (help, coercion, and punishment). Three additional factors represent specific issues related to mental illness and stigma-the attribution of dangerousness, the affective response of fear, and the behavioral reaction of avoidance.

MENTAL ILLNESS, a leading cause of disability and premature mortality in America, contributes to the use of a significant portion of health care resources. Individuals suffering from mental illness have a diminished neurobiologic threshold and subsequent increased vulnerability to environmental stressors. This vulnerability predisposes individuals to a characteristically chronic course of symptomatic episodes of relapse and remittance. An acute episode or exacerbation of psychiatric symptoms may lead to profound functional disability (Teasdale, J.D., Segal, Z.V., Williams, J.M.G., Ridgeway, V.A., Soulsby, J.M. and Lau, M.A., 2000. Prevention of relapse/recurrence in major depression by Mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology 68 4, pp. 615–623. Abstract | Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (306)Teasdale, et al., 2000; Young et al., 2001). Finding innovative and effective interventions for the treatment of serious mental illness are of major concern for our society (Astin, 1998). In Part I of this two-part article, the authors introduced principle concepts of mindfulness, and reviewed current research in the usefulness of mindfulness practice for treatment of psychiatric illnesses. The structure and content of mindfulness-based cognitive therapy (MBCT) was detailed and provided the theoretical basis for this treatment approach. In Part II of this article, we present a more detailed exploration of mindfulness-based therapeutic approaches for all phases of psychotherapy, and identify relevant research questions that will provide an empirical base to guide clinical practice. A case study illustrating mindfulness-based therapeutic interventions.

In mindfulness-based cognitive therapy, or MBCT (Segal, Williams, & Teasdale, 2002) blend mindfulness-based stress reduction program practices (Kabat-Zinn, 1990) with traditional principles and practices of cognitive therapy. The use of mindfulness-based interventions promotes meditative practice of increasing insight through focused attention on conscious thoughts, feelings, and bodily sensations. Segal and his colleagues created an approach where mindfulness is considered the primary skill to teach vulnerable individuals practices for preventing relapse of depressed mood, a heralding symptom of mental illnesses, particularly major depression disorder.

Research finding have shown that previously depressed individuals struggle with a mood-induced bias that focuses on negativity in their lives (Teasdale, et al., 2000). Informed by these findings, Segal and colleagues developed MBCT to prevent relapse in individuals recovered from chronic depression. Mindfulness is considered the primary skill to teach vulnerable individuals to prevent relapse of symptoms of mental illnesses (Segal et al., 2002). Traditional cognitive therapy models have focused on changing depressive thinking through self-dialogue, imagery, role-playing, reframing, examining evidence for thought validity, and restructuring thought patterns. The primary aim of MBCT is to prevent depressed mood that often heralds the onset of relapse.

Major assumptions and practices of MBCT are shared with traditional cognitive therapy. The central assumption is that an individual’s vulnerability to relapse is the result of that individual’s proclivity, or cognitive bias, towards negative thinking in the presence of depressed mood. This proclivity is triggered at the neuronal level by environmental, biological, and/or psychological stressors. For vulnerable individuals, even normal day-to-day sadness and/or anxiety can have the serious consequence of precipitating a ruminative pattern of negative thinking, a pattern that may ultimately culminate in relapse of depression. Research has shown that vulnerable individuals experience a cognitive bias towards maladaptive patterns of negative thinking precipitated by depression and individuals become less resilient with each recurring episode of depression (Segal, et al. 2002, Segal, Gemar, & Williams, 1999; Miranda & Pearsons, 1988, 1990; Segal, Williams & Teasdale, 1996 as cited in Segal et al., 2002). In their study of groups of previously depressed individuals, Segal et al., (2002) found MBCT to be successful in lengthening the duration of remission from depression. The efficacy for MBCT in diverse patient populations suffering from other psychiatric illnesses has not been explored. However, studies of clinical populations of individuals where mindfulness approaches have been integrated into therapy lends support for its use with individuals. Linehan (1995) has used mindfulness-based principles and practices within the dialectical behavioral therapy approach since the 1980s. Consistent with Linehan’s approach, MBCT’s psychoeducational framework teaches individuals skill-building techniques to manage their mental illness. In both therapeutic approaches but particularly, MBCT, core interventions are experiential, empowering, and educational. Integration of MBCT interventions can occur throughout all phases of individual psychotherapy.

Introductory phase of MBCT

The introductory phase of MBCT offers patients and therapists the opportunity to develop rapport and mutually assess the suitability of treatment prior to the working stages of therapy. Integration of MBCT for individuals in psychotherapy begins by explaining the philosophy and practices underpinning the therapy. Patient concerns and questions regarding this therapeutic method should be addressed during this introductory stage of therapy. For example, patients frequently inquire about the religious references for mindfulness and may be assured that mindfulness is addressed in all world religions including Judeo-Christian religions. Specific references to the Torah and the Bible may be helpful for concerned patients (Hirst, 2003) such as “Take therefore no thought of tomorrow; for tomorrow shall take thought for the thing of itself” …Matthew 6:34 (Revised Standard Version). This early phase of MBCT psychotherapy focuses on the development of the therapeutic alliance between patient and therapist. Exploration of the identified problem areas, treatment approaches, and treatment goals and expectations are also standard topics during this phase. These early introductory sessions also address the individual’s barriers to a cultivation of mindfulness. Personal recognition of obstacles, including time constraint, and resistance to change, is explored. Therapy interventions combine psychoeducational approaches and a focus on meditative practice for cultivating mindfulness. Individuals are taught the concept of interpreting thoughts as simply mindful events or mental constructions, and not truths and they learn to recognize how one particular objective situation can elicit very different individual reactions and responses. This exercise helps patients to draw conceptually links among thoughts, feelings, and behaviors, referred to in traditional cognitive therapy as the ABC model of distress. These mindfulness skills are later incorporated into the working phase of therapy.

MENTAL ILLNESS IS a leading cause of disability and premature mortality in America and contributes to a significant portion of health care resources. Studies in neuropsychiatry and neurobiology show that serious mental illness, including mood and anxiety disorders, diminishes a vulnerable individual’s neurobiological threshold for environmental stressors. This vulnerability results in a chronic course of periods of relapse and remittance of symptoms. The recurrent nature of these episodes of psychiatric symptoms are associated with varying degree of functional disability characterizing the chronic course of mental illnesses (Teasdale et al 2000 and Young et al 2001).

Effective interventions for the treatment of mental illness are of major concern for advanced practice psychiatric nurses (APPN). Increasingly, innovative therapeutic treatment approaches that address the chronic nature of mental illness and relapse are being addressed in the psychiatric literature (Segal, Williams & Teasdale, 2002). Increasing evidence supports the use of nontraditional, or alternative therapy (AT) treatment approaches, for relieving emotional and physical distress in patients with physical and mental illness (Snyder & Lindquist, 1998). In one study among outpatients with psychiatric disorders, (N=213), Knaudt et al. (1999) found alternative therapies including, regular periods yoga, exercise, and meditation, often used in combination with conventional medicine treatments, significantly improved symptoms of their illness. Cuellar, N., Cochran, S., Ladner, C., Mercier, B., Townsend, A., Harbaugh, B. and Douglas, D., 2003. Depression, and the use of conventional and nonconventional Interventions by rural patients. Journal of the American Psychiatric Nurses Association 9 5, pp. 151–158. Abstract | Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (2)Cueller et al. (2003) found demographic disparity in the provision of AT where it is more likely to be offered to urban populations. This finding supports Astin’s study (1998), which found predictors of use of AT included higher education, urban residents, persons with a holistic health philosophy, and commitment to global issues and personal and spiritual growth. Mindfulness-based therapeutic interventions, one example of AT, is an approach that promotes use of meditative practices and its aim is to offer patients increasing insight through focused attention on conscious thoughts, feelings, and bodily sensations. This approach complements and expands traditional psychiatric/psychological approaches to the treatment of emotional suffering as it encompasses the spiritual aspects of the human experience.

Mindfulness-based approaches have been shown to relieve distress and increase perceived sense of control for individuals with chronic medical and psychiatric illnesses (Miller et al 1995; Borysenko 2002 and Kabat-Zinn et al 1985). Mindfulness-based therapeutic interventions teach patients an alternative perspective from which to view their situation, a more detached perspective to observe ones stream of changing thoughts, feelings, and bodily sensations. Mindfulness interventions teach patients to become increasingly more attentive to the moment by engaging in a state of attentiveness to observe their inner thoughts and feelings as well as their outer world of actions and perceptions. The aim of this therapeutic approach is fundamentally to teach patients with mental illness ways to improve distress and manage their suffering (Borysenko, 1988). Mindfulness is explored in the next section.

Overview of mindfulness

Mindfulness has been gaining widening acceptance in the Western world, especially with respect to its application in the relief of human distress and suffering (Hirst, 2003). It is only in the past 20 years that Western physicians, neuroscientists, and mental health professionals have begun to comprehend the wisdom of 2,500 years of Buddhist philosophy and recognize the interrelationship between emotional states and physical and mental well being (Goleman, 1997). According to Buddhist tradition, mindfulness, sometimes referred to as awareness, or insight (vipassana), is a state of being purposefully attentive to one’s moment-by-moment experience. This includes an awareness of one’s own perpetuating and maladaptive mental habits impeding personal growth and understanding (Kabat-Zinn 1990; Goleman 1997; Gunaratana 2002 and Snyder & Lindquist 1998). Mindfulness is a highly disciplined skill and its cultivation and therapeutic usefulness requires training and daily meditative practices (Kabat-Zinn, Lipworth, & Burney, 1985).

Mindfulness requires individuals to engage in self-awareness, self-acceptance, and a personal desire to change habitual ways of thinking and behaving. All experience is treated equally with respect to mindfulness, including thoughts, feelings, and bodily sensations. Nothing is suppressed or expressed and change is experienced as an inevitable passing flow of life. Mindfulness requires individuals to accept their various states of mind implicitly, and then fully observe these states of mind, described as somewhat like taking the stance of a detached witness. Moreover, mindfulness requires that individuals become fully aware of their perceptual experiences, and create a sense of balance and tolerance for ones conscious experience. This detached stance enables one to respond rather than react to ones habitual ways of thinking, moving, and doing. Mindfulness offers individuals skills, such as meditation of the breath and relaxation practices, with which to calmly and purposely respond to ones experience of distress (Santorelli, 1992).

According to Gunaratana (2002), rehearsal of mindfulness practices offers individuals a new way to experience the world and the impact of mental illness on their own lives. Buddhist tradition describes purposeful attention to the moment as “engaging in the being mode,” which is believed to displace habitual patterns of thought that otherwise might lead one towards maladaptive functioning. Contrasted with the being mode, habitual reaction to one’s mental activity, such as compulsive maladaptive behavior, is referred to as “engaging in the doing mode” (Kabat-Zinn 1990 and Goleman 1997). Individuals with chronic mental illness frequently engage in the doing mode, which promotes habitual and ruminating patterns of negative thoughts associated with maladaptive responses to their illness. Buddhist teachings understand the being mode as a mental mode, that is, a structure of the mind. Similarly, in Western thought, the cognitive model of depression and anxiety, understands these mental modes as structures of the mind. According to the cognitive model of depression and anxiety (Young, Weinberger, & Beck, 2001), these mental modes are reflected in an individual’s thoughts, feelings, and behaviors and may perpetuate pain and suffering for individuals experiencing medical and psychiatric illnesses. Mindfulness-based stress reduction interventions reflect this understanding of the being mode as key for offering efficacious tools and treatment for individuals with mental illnesses. Both informal and formal methods of mindfulness practice are taught to individuals. Informal methods include: awareness of the present moment; maintaining this “presence” through difficult physical or emotional experiences such as painful medical treatments or grief; and being conscious of the self in activities of daily living. Formal methods of mindfulness practice include: meditation; breathing exercises; and yoga (Prewitt, 2000). Jon Kabat-Zinn has integrated both informal and formal methods in his mindfulness-based stress reduction programs.