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USE OF DEPRESSION MEASUREMENT INSTRUMENTS IN ASSESSING AND TREATING CLIENTS WITH UNIPOLAR DEPRESSION Diana G. Peck B.A., California State University, Sacramento, 2009 PROJECT Submitted in partial satisfaction of the requirements for the degree of MASTER OF SOCIAL WORK at CALIFORNIA STATE UNIVERSITY, SACRAMENTO SUMMER 2010 USE OF DEPRESSION MEASUREMENT INSTRUMENTS IN ASSESSING AND TREATING CLIENTS WITH UNIPOLAR DEPRESSION A Project by Diana G. Peck Approved by: ______________________________, Committee Chair Jude M. Antonyappan, Ph.D., M.S.W. _____________________________ Date ii Student: Diana G. Peck I certify that this student has met the requirements for format contained in the university format manual, and that this project is suitable for shelving in the Library and credit is to be awarded for the project. ______________________, Director Robin Carter, D.P.A. _______________________ Date Division of Social Work iii Abstract of USE OF DEPRESSION MEASUREMENT INSTRUMENTS IN ASSESSING AND TREATING CLIENTS WITH UNIPOLAR DEPRESSION by Diana G. Peck This exploratory study analyzed the extent to which clinical practitioners use depression measurement instruments in assessing unipolar depression, and examined the choice of theoretical approach and the selection of treatment models in ongoing therapy for this mental disorder. The thirty participants who participated in this study were professional clinical practitioners working in rural mental health settings in California. Research data was collected through surveys and face-to-face interviews with the respondents. Findings indicated that 73 percent of the respondents used at least one form of a depression measurement instrument. However, only 28 percent of the interviewees reported continual use of these instruments in future treatment sessions for the monitoring of depressive symptoms. Furthermore, the instruments used do not appear to be associated with the choice of treatment options provided by these practitioners. Study findings support the need for further education on the availability of specific measurement instruments, taking into consideration the inherent needs of a diverse iv client population. The need for regular use of these instruments offers valuable updated information to both the client and the clinician in response to the specific treatment modality employed to manage and treat depression. ______________________________, Committee Chair Jude M. Antonyappan, Ph.D., M.S.W. _______________________ Date v ACKNOWLEDGMENTS I would like to thank my thesis advisors, Dr. Susan Taylor and Dr. Jude M. Antonyappanon for their remarkable patience. I would also like to give a special thank you to Dr. Elizabeth O’Keefe, who gave of her precious time to help me overcome my many challenges throughout the thesis process. Next, I would like to thank my kind and humble friend, Crisostomo Yalung, whose gracious gift of time, sense of humor, and spiritual nature I could never have lived without, and to my other many supporters. I would also like to say thank you to the entire Mental Health Cohort under the fine leadership of Dr. Susan Taylor, Dr. Sylvia Navari, and Professor Doris Jones. Everyone in the cohort definitely held the vessel for me. I also wish to express my undying gratitude to the wonderful Social Work Department administrative staff. Without them, I would still be in the undergraduate program. Furthermore, I would like to mention how much I appreciate every professor at California State University, Sacramento that I have had the pleasure to know. The preparation I have received in the undergraduate program, enhanced by the final touch of my graduate professors, has prepared me for what I am certain will be a fulfilling career in the service of others. An additional thank you goes out to the staff members and wonderful clients of the Amador County Behavioral Health Department who have helped me grow. No acknowledgement would be complete without mentioning the support, acceptance, and love of my family, my husband Clayton, my daughters Schonze and Cherish, my grandchildren, Nicolas and Alana, and my dogs, Miles, Emma, Sassy, and Bear. I also wish to thank my wonderful vi friend, Tracy Ament, for her many hours of unconditional assistance both in editing and in listening. Finally, I would like to thank my wonderful, awe inspiring grandmother, who has given my life purpose, and my two sisters, Colleen and Pamela, the trinity makes us strong. I thank my cousins Russ and Paul, who have given me the opportunity to fulfill my dreams. You have changed our family for all eternity. vii TABLE OF CONTENTS Page Acknowledgments....................................................................................................... vi List of Tables ............................................................................................................. xii Chapter 1. THE PROBLEM ..................................................................................................... 1 Introduction ...................................................................................................... 1 Background of the Problem .............................................................................. 3 Statement of the Research Problem ...................................................................4 Purpose of the Study ..........................................................................................5 Theoretical Framework ......................................................................................6 Definition of Terms............................................................................................9 Assumptions.....................................................................................................12 Justification ......................................................................................................13 Limitations .......................................................................................................14 2. REVIEW OF THE LITERATURE ...................................................................... 15 Introduction ..................................................................................................... 15 History of Depression ..................................................................................... 16 Description of Depression................................................................................21 Diversity Issues ................................................................................................26 Gender ..................................................................................................27 viii Age .......................................................................................................27 Culture and immigration ......................................................................27 Spirituality............................................................................................29 Suicide and diversity ............................................................................30 Factors Related to Depression .........................................................................31 Substance abuse ...................................................................................31 General medical conditions..................................................................32 Grief .....................................................................................................32 Brain development ...............................................................................34 Oppression ...........................................................................................35 Abuse and violence ..............................................................................35 Thinking styles .....................................................................................38 Isolation................................................................................................41 Rural communities ...............................................................................42 Self-control ..........................................................................................45 Co-occurring disorders.........................................................................46 Measurement Instruments Used to Assess Depression....................................47 The Hamilton Rating Scale for Depression .........................................48 The Beck Depression Inventory...........................................................49 The Burns Depression Checklist ..........................................................50 The Zung Self-rating Depression Scale ...............................................51 ix The Edinburgh Postnatal Depression Scale .........................................53 The Geriatric Depression Scale ...........................................................54 Treatment for Depression ................................................................................59 Client readiness ....................................................................................59 Medication management ......................................................................61 Cognitive Behavioral Therapy .............................................................62 Interpersonal Psychotherapy ................................................................62 Behavior Modification .........................................................................63 Narrative Therapy ................................................................................64 Systems Theory....................................................................................64 Combined Therapy...............................................................................66 Multimodal Treatment Approach ........................................................67 Psychosocial Education .......................................................................71 Applying the Theoretical Framework ..............................................................71 Summary ..........................................................................................................73 3. METHODOLOGY ................................................................................................77 Introduction ......................................................................................................77 Study Design ....................................................................................................77 Study Questions ...............................................................................................78 Population and Sampling Procedures ..............................................................79 x Protection of Human Subjects .........................................................................80 Data Collection and Instrumentation Tools .....................................................81 Sources of Data ................................................................................................83 Data Analysis ...................................................................................................83 4. FINDINGS .............................................................................................................85 Introduction ......................................................................................................85 Demographic Information ................................................................................86 Descriptive Information on Client Assessment Tools and Treatment Approaches/Models .........................................................................................88 Tests of Association .........................................................................................97 5. CONCLUSIONS..................................................................................................106 Summary ........................................................................................................106 Limitations .....................................................................................................106 Conclusions, Implications, and Recommendations .......................................107 Micro-level .........................................................................................107 Mezzo-level........................................................................................107 Macro-level ........................................................................................109 Appendix A. Approval by the Committee for the Protection of Human Subjects by the Division of Social Work...........................114 Appendix B. Informed Consent to Participate as a Research Subject .....................115 Appendix C. Survey and Interview Questionnaire ..................................................117 References ..................................................................................................................122 xi LIST OF TABLES Page 1. Table 1 Professional Demographics .....................................................................87 2. Table 2 Treatment Approaches .............................................................................89 3. Table 3 Instruments Used by Professionals ..........................................................90 4. Table 4 Client Diversity Issues Affecting Choice of Depression Instrument ......92 5. Table 5 Client Diversity Issues Affecting Choice of Treatment Model ...............94 6. Table 6 Preferred Treatment Modality .................................................................95 7. Table 7 Treatment Model Used ............................................................................96 8. Table 8 Use of Psychoeducational Material and Referral to Self-Help Groups...................................................................................................................97 9. Table 9 Use of Depression Measurement Instruments and Social Work or Non-Social Work Professional .............................................................................98 10. Table 10 Use of Depression Measurement Instruments and Gender of Professional...........................................................................................................99 11. Table 11 Use of Depression Measurement Instruments and Choice of Treatment Approach ...........................................................................................100 12. Table 12 Use of Depression Measurement Instruments and Type of Depressive Disorder............................................................................................102 13. Table 13 Use of Depression Measurement Instruments and Use of Treatment Model ................................................................................................104 14. Table 14 Use of Depression Measurement Instruments and Use of Psychoeducational Material ................................................................................105 xii 1 Chapter 1 THE PROBLEM Introduction The United States is one of the most diverse and affluent nations in the world. Compared with the populations of other nations, one might expect that the American people should have a higher sense of security and safety. However, interestingly, there is a pervasive occurrence of unipolar depressive disorders within the national population. The World Health Organization (2004) maintains that mental disorders are the leading cause of disability in the United States and Canada for ages 15-44, and that Major Depressive Disorder specifically is the leading cause of disability in the United States in this age range. Major Depressive Disorder affects approximately 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year (Kessler, Chiu, Demler, & Walters, 2005). This phenomenon leads to adverse consequences affecting not only the individual, but also the family, local community, and the larger society. Depressed medical patients have increased disability, escalated health-care utilization, and higher rates of mortality from suicide and other causes, as well as decreased productivity and reduced health-related quality of life (Ciechanowski, Walker, Katon, & Russo, 2002). In the year 2000, the economic burden due to the costs related to depression rose to $83.1 billion. Of that total, $26.1 billion, 31 percent, were direct medical costs including patient care, $5.4 billion, seven percent, were suiciderelated mortality costs, and $51.5 billion, 62%, were workplace costs including 2 productivity and absenteeism (Greenberg, Kessler, Birnbaum, Leong, Lowe, Berglund, & Corey-Lisle, 2003). Multiple factors are often attributed to the etiology of depression. Factors that are commonly associated with affecting a person’s mood include genetics, emotional disposition, thought processes, family role models, environment, life events, and the spiritual nature of the individual. Factors may be internal, for example, low self-esteem and poor coping skills. They may also be external, such as, lack of social support, social status, and money (Dumais, Lesage, Phil, Alda, Rouleau, Chawky, Roy, Mann, Benkelfat, & Turecki, 2005). The researcher, at the time of working on this study, was involved in an internship program for her masters study of social work in a county-funded mental health agency located in Amador County. At this internship, the researcher provided clients with assistance on their treatment goals, and facilitated a depression support group. On a weekly basis, group members were provided the Burns Depression Checklist, revised, (Burns-D-R). This instrument measures the severity of depression across domains that include thoughts and feelings, activities and personal relationships, physical symptoms, and suicidal urges. Scores are assigned according to indications of severity, from mild to severe impairment, and provide a quantitative assessment that is useful in following the course of the mental illness and/or possible responses to therapy (Burns, 1999, p. 729). Clients reported that the Burns Depression Checklist was useful in helping them track their symptoms of depression. They also reported that the instrument provided insight as to the behaviors associated with depressive episodes, and 3 assisted them in identifying the steps they could take to decrease their feelings of depression. The increasing occurrence of depression has generated interest in the researcher to embark upon an exploratory study to examine the extent to which diagnostic instruments are being used in the assessment of depression, the severity of the diagnosed disorder, and the association of this identification with an effective form of treatment. The study begins with a brief introduction to the topic of unipolar depression, followed by a review of the existing literature associated with the assessment and treatment of this often debilitating mental illness. The study intends to collect relevant information regarding whether certain mental health professionals, identified as social workers, marriage and family therapists, and psychiatrists, tend to use particular scales based upon their use of the medical model, wellness and recovery approach, or hybrid model that includes both. Data have been gathered from rural county clinicians with practice experience in the field of mental health. Background of the Problem With the progress in medical and therapeutic sciences, many aspects of depression are better understood. Thorough assessment, appropriate diagnosis, and corresponding treatment interventions are basic effective steps toward recovery (Weisz, Sandler, Durlak, & Anton, 2005). When left unattended, depression can lead to impairment in social and occupational functioning. It may cause increased loss of pleasure and activity, and an escalation in negative thinking. Symptoms may intensify to a point of suicidal ideation. 4 If symptoms go untreated, the sufferer may act upon thoughts of suicide (Walsh, 2002). Traditionally, an assessment is conducted by a professional in order to diagnose the existence, form, and severity of depression being experienced by the client. Upon such determination, the client and the therapist develop an appropriate treatment plan based on the assessment and other relevant factors. With the ever-increasing possibility of symptom severity progression, and due to the seriousness of this illness that has frequently led to death, accurate diagnosis, prevention and early intervention of depression are important considerations. Preventive interventions seek to identify early signs of maladjustment and offer problem-solving techniques before full-blown disorders develop. Maurice Lorr (1954) stated in his research paper entitled “Rating Scales and Check Lists” that the use of checklists, charts, and rating scales for the objective recording and later evaluation of change in the behavior and symptoms of psychiatric patients is not new. In the early 1900s, devices such as the Phipps Psychiatric Clinic Behavior Chart had already been used on psychiatric wards to record patient change. Lorr (1954) cited Moore’s (1933) previous research, which contained 36 carefully constructed scales in measuring abnormal emotional conditions. Recently, charts and diagnostic instruments have been developed to allow for more accurate identification of client afflictions. Statement of the Research Problem Given that the reality of the challenges presented by depressive disorders are evident, and that there is a wide range of diagnostic instruments available for use, this research hopes to examine the extent to which clinical practitioners use these 5 instruments in their assessments, and whether the choice of theoretical approach and ongoing treatment of unipolar depression is affected by their use. Purpose of the Study This study aims to explore the topic of depression by identifying the extent to which practitioners use diagnostic instruments, the identification of the instruments most used, and how they may relate to the selected theoretical approach for client treatment. The following questions represent the main purpose of the study. Are practitioners who apply the wellness and recovery or hybrid approach more or less likely to use diagnostic instruments compared to those who use a medical model for treatment? Is the type of Depressive Disorder associated with a practitioner’s use of assessment instruments? Does the use of diagnostic instruments assist the clinician in determining the specific theoretical approaches used to treat depression? This research hopes to ascertain which problem-solving techniques practitioners find most helpful in working with depressed clients, and hopes to add to the knowledge base regarding sound treatment practices. This analysis intends to provide useful psycho educational information to mental health professionals. Inconsistent assessment techniques may lead to improper diagnosis and ineffective treatment, which may thereby decrease the ability of the sufferer to heal. As diversity issues related to age, gender, ethnicity, culture, and spirituality often impact how individuals experience and manage the symptoms of depression, selecting an appropriate depression assessment instrument can be helpful in increasing the validity of the collected results. Such information may eventually lead to the development of a 6 clearly identified, evidence-based, universal approach to the assessment, diagnosis, and treatment of depression. Theoretical Framework The theoretical framework used in this study is based on the Cognitive Behavior Theory. To understand depression as a disorder, the use of this theory, and how individuals see themselves and the world around them, can be useful in attempting to respond to the research question. Thinking influences feelings from moment to moment. Whereas behavior analysts search for environmental conditions responsible for behavior–behavior relations, cognitive researchers are interested in the negative cognitive content present during depressive episodes. Research confirms the role of language associated with the presence of negative perceptions that occur along with depression, and it is evident that negative thinking, which frequently elicits an avoidance response, is predominant in most depressive episodes (Kanter, Landes, Busch, Rusch, Brown, Baruch, 2006). The contents of a person’s ruminations often do not make sense and should not be reinforced. Cognitive-Behavioral Therapy (CBT) is an evidence-based treatment that focuses on maladaptive patterns of thinking and the beliefs that activate such thinking (Ziegler, 2002). This therapy approach works well with individuals who suffer from depression, as it addresses behavioral deficits, negative cognitive schemas, and a lack of effective interpersonal skills. Disruptive cognitive distortions often lead to inappropriate and emotionally painful responses (Ellis, 2000). For example, an 7 individual who is depressed may have the belief, "I am worthless and I always have been." The goal for the clinician in this situation is to encourage the individual to view this belief as an assumption rather than a fact. The ability to change the thoughts in one’s own mind is referred to as cognitive reframing. With this technique, clients are encouraged to reduce the use of words like “never” or “always,” as they learn to restructure self-destructive negative thoughts by questioning the evidence behind them (Hofmann & Asmundson, 2008). As unrealistic thoughts are challenged, they begin to lose power. Cognitive Behavioral Therapy teaches clients about the consequences of their behavior and enhances their problem-solving abilities. Clients are encouraged to develop coping skills in order to handle feelings of frustration in stressful situations. During sessions, clients learn to verbalize their thoughts and feelings, such as those related to sadness, despair, guilt, and worthlessness, without injury. When clients are depressed, they are encouraged to monitor routine thoughts so that they may begin to recognize possible patterns of faulty thinking, and learn to develop more useful options (Ziegler, 2002). Clients learn to recognize their triggers as they identify false thoughts (Schnurr, Friedman, Engel, Foa, Shea, & Chow, 2007). They begin to rely on more constructive ways of thinking as they start to interpret their environment with less prejudice and respond to stressful situations with increased skill (Bond & Dryden, 2002). Over time, and with practice, this becomes more natural and clients have the opportunity to develop a clearer thinking style. 8 An important component of CBT is the establishment of a therapeutic alliance between clinician and client. In CBT, the clinician is an active participant. The role of the clinician is to listen to the stories of their clients, while educating them and their family members about depression (Dattilio, 2009). Clinicians assist clients in the development of appropriate coping skills, while encouraging them to try new things, and to increase the number of pleasurable events by scheduling activities. The clinician helps the client recognize progress, and together they formulate a plan to prevent relapse (Dobson, Hollon, Dimidjian, Schmaling, Kohlenberg, & Gallop, 2008). Research studies show that CBT is as effective as antidepressant medications in the treatment of individuals with depression and is beneficial in preventing relapse. Cognitive Behavior Therapy is often used in addition to medication treatment and focuses on psychoeducation with clients about their particular mood disorder. Studies indicate that patients who receive this combination of therapy have better outcomes than patients who do not receive the additional component of CBT in treatment (Dobson, et al., 2008). American psychologist Albert Ellis developed rational emotive behavior therapy (REBT) in the 1950s. He is considered to be one of the originators of the paradigm shift toward cognitive psychotherapy, and has been described as the “grandfather” of cognitive behavioral therapy (Freeman, Simon, Beutler, & Arkowitz, p. 604, 1989). In a National Academies news release dated October 9, 2006, regarding the presentation of the 2006 Gustav O. Lienhard Award for the advancement of personal health services, The Institute of Medicine named Aaron T. Beck the father of Cognitive Therapy. The 9 award honored Beck for his development of the theory and practice of cognitive therapy, which has been used to treat nearly 5 million patients in the United States and millions more across the world. His theories are widely used in the treatment of clinical depression. Beck comprehended the need for individual assessment to identify specific thinking adaptations by determining a person’s positive and avoidance relationships. He realized that clinicians treating depression should engage in detailed, personal, and historical functional assessments that recognize the role of avoidance and verbal behavioral processes that inform treatment course and technique (Kanger, Busch, Weeks, & Landes, 2008). Beck developed a number of self-report measures of depression and anxiety including the Beck Depression Inventory (BDI), the Beck Hopelessness Scale, the Beck Scale for Suicidal Ideation (BSS), the Beck Anxiety Inventory (BAI), and the Beck Youth Inventories (Ziegler, 2002). The BDI is one of the most widely used depression measurement instruments employed by both researchers and clinicians. Others include the Burns Depression Checklist (Burns-D), the Edinburgh Postnatal Depression Scale (EPDS), the Geriatric Depression Scale (GDS), the Zung Self-Rating Depression Scale, and the Hamilton Depression Rating Scale (HAM-D). The use of depression measurement instruments to monitor change is congruent with a CBT approach. Definition of Terms Key terms that are used often in this study are defined in this section. Assessment – is a professional review of needs, which is done when services are first sought. The assessment includes a review of physical and mental health, 10 intelligence, work performance, family situation, and behavior. The assessment identifies the client’s strengths, as well as the strengths of the family and social support systems. Upon completion of the assessment, the client can decide upon the type of treatment and supports, if any, are needed (SAMHSA, 2006). Association – is the relationship, connection, or correlation between two variables. It is the process of forming mental connections or bonds between sensations, ideas, or memories (Merriam-Webster, 2003). Client –is a person who engages the professional advice or services of another; a person under treatment for a psychiatric illness or disorder (Merriam-Webster, 2003). In order to receive services with the Amador County Behavioral Health Services, a client qualifies as follows: must be an Amador County resident; must be eligible for MediCal or County Mental Services Program (CMSP), or must be self-pay (without medical insurance) and income eligible as established by the California Department of Mental Health, Welfare and Institutions Code (W&I) 5717 and 5718; and must be diagnosed with one of the following five Axis I diagnoses: 1) Major Depressive Disorder; 2) Bipolar Disorder; 3) Schizophrenia; 4) Schizoaffective Disorder; or 5) Post Traumatic Stress Disorder (PTSD) (Office of Administrative Law, 2010). Clinician – an individual qualified in the clinical practice of medicine, psychiatry, or psychology as distinguished from one specializing in laboratory or research techniques, or in theory (Merriam-Webster, 2003). For the purposes of this study, Amador County Mental Health clinician refers to any of the following: Licensed Clinical Social Workers, Associates of Social Work, Masters of Social Work Intern, 11 Licensed Marriage and Family Therapist, Intern in Marriage and Family Therapy, Licensed Psychologist, Psychiatrist, or clinician with a Content Specific Degree (i.e., Alcohol and Other Drugs (AOD) counselor). Diagnostic instruments for depression – are instruments used to measure depression across specified domains. Domains may include thoughts and feelings, activities and personal relationships, physical symptoms, and suicidal urges. Scores are assigned according to indications of severity (i.e., from mild to severe impairment), and provide a quantitative assessment that is useful in following the course of the mental illness and/or in identifying possible responses to therapy (NIMH, 2002). Rural Community – Amador County is determined to be outside an urbanized area, and thus has been designated as a rural community by the U.S. Bureau of the Census. The Bureau defines a rural community in comparison to its definition for an urbanized area, which is identified as an area that includes a central city and the surrounding densely settled territories that together have a population of 50,000 or more (U.S. Census Bureau, 1995). Therapeutic Alliance – is defined as the collaborative bond between therapist and patient, and is considered to be an essential ingredient in the effectiveness of psychotherapy (Krupnik, Sotsky, Simmens, Moyer, Elkin, Watkins, & Pilkonis, 1996). Treatment – intervention, a remedy or cure; care provided to improve a situation, especially medical procedures or applications intended to relieve illness or injury; administration or application of remedies to a patient, a disease or a symptommedication, surgery, psychotherapy, etc. to heal the client (Merriam-Webster, 2003). 12 Unipolar Depressive Disorders – depressive disorders involve the body, mood, and thoughts, and manifested by a combination of symptoms that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. They affect the way one feels about oneself, and the way one thinks about the world around them. Unipolar Depressive Disorder, also known as Major Depressive Disorder or Clinical Depression, contains symptoms of depression only, versus bipolar depression, which presents with symptoms of both depression and mania. Unipolar depression may occur only once, but often appears repeatedly over a lifetime, with severe symptoms and psychotic features which impairs one’s social and occupational functioning, or less severe one called dysthymia (long-term chronic, non-impaired functioning, but minimizes ability to feel good) (Ghaemi, Ko, & Goodwin, 2002). Assumptions There are three basic assumptions in this research study. The first assumption is that appropriate depression rating scales are being under-utilized Secondly, it is assumed that there is a need for future research in the incorporation of self-report depression rating scales, completed at regular intervals, to help the client stay abreast of any changes in self, or environment. Lastly, this study assumes that awareness, acceptance, and acknowledgment of the various aspects of their mental condition will help facilitate the process of individual empowerment through the participation of the client in their own recovery process. 13 Justification Despite the frequent occurrence of mood disorders in different diagnoses, there has been minimal recent research targeting the assessment of depression using depression severity instruments in order to design effective treatment approaches as well as continuously monitor symptoms. This research is aimed at helping the clinical social worker become more involved in the therapeutic process and have a more direct impact in the development of depression treatment plans with clients. The outcome of this study will further legitimize the efforts of clinical social workers practicing in the area of mental health that could lead to a better appreciation of their role toward holistic healing of the clients. This research hopes to benefit the social work profession by providing new quantitative and quantitative data on the subject of how various instruments and treatment options can influence the recovery process of an individual diagnosed with unipolar depression. Additionally, this research hopes to provide information regarding how the use of diagnostic instruments can serve to increase awareness of the resources and social work support systems necessary to assist individuals with these disorders. In examining depression, the Code of Ethics outlined by the National Association of Social Workers (NASW) (1999) remains an excellent guide in social work practice. Section 6.04, c, on the Social and Political Action, of the NASW Code of Ethics emphatically states: Social workers should promote conditions that encourage respect for cultural and social diversity within the United States and globally. 14 (They) should promote policies and practices that demonstrate respect for difference, support the expansion of cultural knowledge and resources, advocate for programs and institutions that demonstrate cultural competence, and promote policies that safeguard the rights of and confirm equity and social justice for all people. The traumatic impact that depression has on individuals and their systems is substantial. Individuals may or may not require unique treatment options based on their differences, but the choice for a variety of available services needs to be addressed. Social workers are compelled to support individuals by providing the best possible care. Limitations This research is limited in its scope. The exploration is directed towards individuals with unipolar depression only. The study has been limited to practice in rural settings and cannot be easily generalized to be applied to practice in urban populations. The small sample size of clinicians used in the study (n = 30), is not an adequate representation of all clinicians. The delivery of mental health services is, in itself, in the midst of major change. It is expanding from the medical and psychodynamic models of treatment to encompass a wellness and recovery-oriented approach. This may affect the current diagnostic instruments being used. This researcher believes that the findings from this analysis will help to identify further areas of study for improving assessments and continuing symptom severity monitoring, and to offer effective treatment of unipolar depression. 15 Chapter 2 REVIEW OF THE LITERATURE Introduction This chapter is a compilation of resources on the study of depression, and will discuss subjects that are related to this research topic. In addition to the stated issues, this researcher relies upon authoritative text written about the importance of the therapeutic alliance between client and clinician, and the additional difficulties faced by rural communities. The themes in this literature review are organized to give the reader information about the problem identified in Chapter 1. The first theme discusses the history and nature of this mood disorder across a time span of two thousand years. This will be followed by a definition of depression, utilizing the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (2000). The next theme of the literature review centers upon the various ways that diversity issues relating to age, gender, ethnicity, culture, and spirituality influence individual experiences and thus the management of depression symptoms. Following this definition is a discourse on several internal and external factors that relate to the exacerbation and/or cause of depression. The subsequent area of focus is in the identification of appropriate depression measurement instruments to assist in the increased accuracy of assessment. The final area of discussion will apply to the theme of effective depression treatment strategies that lead to a targeted choice of therapeutic options for selection by the client. 16 Clinical depression can be unbearable. Symptoms can be both psychological and physiological, and can be mitigated, sometimes with medication, sometimes with psychotherapy, and sometimes combining both psychotherapy and medication. The psychological symptoms can consist of anhedonia, apathy, negative thinking, irritability, low self-esteem, and thoughts of suicide. These symptoms may also include increased or decreased appetite, weight gain or weight loss, restlessness, sleep disturbances, psychomotor retardation, and impaired concentration. These indicators may be associated with all types of clinical depression, but major depression can have the additional symptom of psychosis. People who experience psychosis along with depression endure the additional hardship of extremely delusional themes of guilt, worthlessness, and low self-esteem, and are at a higher risk for suicide (Burns, 1999, p. 729). For the theoretical framework of this study, I have selected Cognitive Behavior Therapy. The study of depression, viewed from within the Cognitive Behavioral Theory provides the option of a brief, goal-directed approach, or one that allows for a longer-term commitment if necessary. This modality lends itself to both individual and group settings. It is a skills-based, empowerment approach, which lends itself well to the practice of social work. History of Depression The concept of depression, recognized as an illness, can be traced back to ancient times. The Kahun Papyrus, dating back to the 1900s B.C., is an incomplete document that relates the morbid states as attributed to the displacement of the uterus. 17 Hysterical disorders are clearly recognized in the papyrus as illustrated by the following, “a woman who loves bed, she does not rise and does not shake it.” It is clear that the concept of hysterical disorders was known and attributed to the movement of the uterus, long before Hippocrates used the term hysteria to describe these illnesses (Okasha, 1999). The Book of (the) Heart, in the Eber’s Papyrus dates back to the 1600s B.C., and is an ancient Egyptian medical document that was translated by Norwegian physician Bendix Ebbell in 1937. In his translation, the Eber’s papyrus identifies a condition of severe despondency that is equivalent to our modern definition of depression. He also lists symptoms of dementia, retardation, negativism, delirious states, and disorders thought to be comparable to schizophrenia (Okasha, 1999). Okasha reports that in the times of the Egyptian Pharaohs, the concept of mental illness was monistic, and was attributed to bodily etiology. Within this magicoreligious culture, the therapeutic approach to this disorder was treated both physically and therapeutically. The concept of disease as retribution for offending the gods was prevalent in most cultures. The equating of disease with sin was particularly characteristic of the Babylonians. However, with the contribution of Greek medicine, disease was no longer wholly regarded as a supernatural phenomena, it was approached from a scientific point of view and defined as “an important and radical step in human thought” (Ackernecht, 1982). 18 In the early Christian church, powerful religious views took a different turn. While the theory of humors tied symptoms to changes in the body, many were accredited to spiritual causes. A dissertation by Dr. Stanley Jackson (1986) emphasized the notion of "acedia" presented by the early Christian church. First described in Egyptian desert monks in the fourth century A.D., the symptoms included dejection, sorrow, lethargy, weariness, carelessness and neglect. Results of their lifestyles were considered a sin and the cure was to be found in religion. An important part of Jackson’s work was in the separation of the concept of acedia, which was considered blameworthy, from melancholia, for which the sufferer was to be shown sympathy. He noted that the milder manifestations of depression are often judged to be laziness, and this he called the curse of individuals who suffer from depressive disorders. People who have a minor physical illness do not have to deal with the same stigma. The image of "accidie" as a cardinal sin, together with the guilt experienced by many sufferers, and the theological notions of demonic possession, led to the burning of many depressed women as witches. Many medieval writers confused the two concepts of sin and illness, and this often affected the common perceptions of depressive conditions (Jackson, 1986). The Holy Bible refers to the affliction of depression in the book of Samuel of the Old Testament. Samuel 1, Chapter 16 (versus 14-16 and 23), 14: But the Spirit of the LORD departed from Saul, and an evil spirit from the LORD troubled him. 15: And Saul's servants said unto him, Behold now, an evil spirit from God troubleth thee. 16: Let our lord 19 now command thy servants, which are before thee, to seek out a man, who is a cunning player on an harp: … that he shall play with his hand, and thou shalt be well. 23: And it came to pass, when the evil spirit from God was upon Saul, that David took an harp, and played with his hand: so Saul was refreshed, and was well, and the evil spirit departed from him (Kraft, 1995). Fourth century philosopher, Aristotle (McKeon, 2001), speculated about the many prominent philosophers, politicians, poets, and artists, who were apparently vulnerable to melancholy, and he distinguished this condition as being different from the unhappiness that occurs in everyday life. Supernatural views still persisted at this time, as some forms of melancholia were believed to be a "divine madness" associated with prophecy. Hippocratic writings nearly a century later described melancholy as "despondency, restlessness, sleeplessness, aversion to food, irritability, and fear and sadness that is prolonged.” Melancholia was thought to arise from an imbalance in the humors of the body. The word melancholia is formed from the Greek words for black bile, an excess of which was supposed to account for the condition. Together with yellow bile, a combination of blood and phlegm, black bile, formed the explanatory system of the four humors which was to last for another two thousand years. Sir Aubrey Lewis wrote, “Melancholia is one of the great words of psychiatry. Suffering many mutations, … it has endured into our own times, a part of medical terminology no less than of common speech." (Lewis, 1934). Dr. Jackson expanded upon this topic, 20 explaining that his interest was in “melancholia as a disease or syndrome, and not as a symptom.” (Jackson, 1986). According to Jackson, a 17th century scholar by the name of Pitcairn described melancholia as a defect of the normal "vivid motions" of the blood, which was considered to have turned black with sludge. His clinical separation of hypochondriasis from depression was an important concept for this time. He considered hypochondriasis to consist of a list of physical complaints, along with a non-psychotic depressed state, which was different from depression (Jackson, 1986). Freud contributed his explanation to the concept of depression through his psychoanalytical approach. This interpretation influenced the first two editions of the DSM, and would be replaced by the more operational criteria provided in the third and fourth copies of the DSM. Dr. Jackson's study of the relationships of melancholia to mania, hypochondrias, grief, and religion was comprehensive and informative. For those who propose particular causes and/or treatments, the story of melancholia exemplifies the four perspectives of psychiatry enunciated by McHugh and Slavney, 1983, “It (melancholia) can be a disease, a temperament, a learned form of behavior, and, in all cases, an individual's life story.” Various authors over a two-thousand year period have described melancholia or depression as a lasting and familiar clinical entity. Not only has the concept of depression survived, but it has also been referenced in all cultures with existing historical records. An historical review helps us to understand some of the current 21 common misconceptions that have been handed down through the generations, and have often led to stereotypical judgment and stigma. Description of Depression Mental disorders are common in the United States and internationally. An estimated 26.2 percent of Americans, approximately one in four adults, ages 18 and older suffer from a diagnosable mental disorder in a given year. When applied to the 2004 U.S. Census Population Estimate, this figure translated to 57.7 million people (U.S. Census Bureau, 2005). The most prevalent mental illness is Major Depressive Disorder, which affects approximately 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year (Kessler, Chiu, Demler, & Walters, 2005). Mental disorders are the leading cause of disability in the U.S. and Canada for ages 15-44, and Major Depressive Disorder, in particular, is the leading cause of disability in the U.S. for this age group (WHO, 2004). Many people suffer from more than one mental condition at a given time. Nearly one-half of those with any mental disorder meet criteria for two or more disorders, with severity strongly related to dual diagnosis (Kessler, et al., 2005). As described in the Merriam-Webster’s Collegiate Dictionary (2003) the definition of the word depression can, itself, conjure up a feeling of despair: depression - “low spirit, sadness, gloominess, dejection; a decrease in functional activity.” “psychologically defined, an emotional condition, either neurotic or psychotic characterized by feelings of hopelessness and inadequacy.” 22 In the United States, mental disorders are described using professionally defined criteria found in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (APA, 2000). The American Psychiatric Association (APA) designed the first Diagnostic Statistics Manual in 1952, to provide standard criteria in a common language for the classification of mental disorders, for use by clinicians, health insurance companies, researchers, policy makers, pharmaceutical regulation agencies, and pharmaceutical companies. The publication has been dramatically revised a few times since its inception. The fifth edition, DSM-V, has recently been released for public review and field trials, and has been scheduled for release in May 2013 (APA, 2009). Many countries, including the United States, use the International Classification of Diseases (ICD), which lists medical and mental health categories for billing purposes An ICD code is a numeric diagnostic code used by insurance companies to determine whether they will pay for treatment. The codes used in the ICD are designed to correspond with the coding system used in the DSM. The sanctioned use of the new ICD revision, ICD-10, is scheduled for 2013 (CDC, 2010). The APA describes the etiology of depression in individuals according to biological and environmental factors, problems with social support systems, interpersonal communication, and grief. As a resource for the education of psychopathology, the criteria address the areas of biology, psychodynamics, cognitive and behavioral functioning, interpersonal relationships, and ecosystems (APA, 2000). The DSM-IV-TR classifies Depressive Disorders under the category of the mood spectrum, and provides criteria for the particular types of unipolar depression, 23 each with varying degrees of severity, length of cycles, and so forth. These disorders include Major Depressive Episode, Depressive Disorder Not Otherwise Specified, Dysthymic Disorder, Major Depressive Disorder, either single episode, or recurrent. Major Depressive Disorder is the most prevalent and most damaging of the unipolar depressive disorders. The DSM-IV-TR lists the required criteria for the diagnosis of Major Depressive Disorder. This criteria states that the client must have at least five of the following symptoms, and these symptoms must have been present during the same two week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood, or loss of interest or pleasure. If symptoms are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations they are not included. Further symptoms include depressed mood most of the day (self-addressed as sad or empty, or observation made by others, such as appears tearful). Note: In children and adolescents, can be irritable mood. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). Significant weight loss or weight gain, or decrease or increase in appetite. Insomnia or hypersomnia nearly every day. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). Fatigue or loss of energy nearly every day. Feelings of worthlessness or excessive or inappropriate guilt, which may be delusional, nearly every day, not merely self-reproach or guilt about being sick. Diminished ability to think or concentrate, indecisiveness, nearly every day. Recurrent thoughts of death, recurrent suicidal 24 ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide (DSM-IVTR, p. 365). The symptoms should not meet criteria for a Mixed Episode (see p. 365). The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. In the assessment, diagnosis, and treatment of depression in adults there are choices between the medical model, the wellness and recovery approach, and a hybrid method which includes both (Cook, Copeland, Hamilton, Jonikas, Razzano, Floyd, Hudson, MacFarlane, & Grey, 2009). In the use of the medical model, individuals with severe persistent mental illness may become socialized by the medical community to focus crisis toward a more medical experience. However, other factors such as supportive relationships and outside activities, which are typically beyond the scope of the medical model, also play a part in the understanding of crisis experiences. Therefore, it is suggested that participants consider their crises from a medical, social and interpersonal perspective (Ball, Links, Strike & Boydell, 2005). 25 The medical model describes the approach to illness that is dominant in Western medicine. It aims to find medical treatments for diagnosed symptoms and treats the human body as an intricate machine (Warner, 2004). Critics of this model state that because mental illness cannot be diagnosed with tests in the same manner as broken bones, heart disease, or diabetes, use of the medical model for the diagnosis and treatment of mental illness is contradictory. In addition, this model focuses on the disease and the treatment course as determined by the diagnosis (Murphy, 2006). The recovery approach, on the other hand, is individualized for each person, and wellness and recovery are goals for mental health care. Clients learn to become self-reliant outside of the mental health system (Ridgway, 2001). Within this approach, transformation is the term that is applied to the overall change in the mental health system that now focuses beyond simply providing services. The added component of a system of accountability, which measures outcomes in the effectiveness of services, ensures that the recovery model is being employed and positive results are being recognized (Rosenheck, 2000). Evidence-based practices and full service partnerships are two ways that transformation of the system is occurring. The philosophy and principles of recovery provide client-operated services that include vocational and educational assistance, and housing, as well as services that focus on social and multicultural relationships and community integration activities (Pir, 2009). Within the Wellness and Recovery Approach, clients support each other and receive services in order to assist each other in maintaining their current level of care within the community. Clients are encouraged to 26 assist other clients in achieving wellness, meaningful social connections, and community reintegration (McQuistion, Goisman, & Tennison, 2000). Full Service Partnerships (FSPs) are a component of the wellness and recovery approach. These partnerships provide clients with voluntary programs designed to insure that they receive a broad range of supports to enhance their recovery and develop an on-going sense of wellness. Each enrolled individual is assigned to a team and to a case manager with a low enough caseload to insure availability. Services include linkages to available services or benefits as defined by the client and/or family in consultation with the case manager (Cohen, Adams, Dougherty, & Clark, 2007). Services are judged effective by how well clients progress on measurable outcomes of well-being. Clients are considered to be fully served when they receive the complete spectrum of mental health services and other community supports needed to advance their wellness, recovery, and resilience (Farkas, Gagne, Anthony, & Chamberlin, 2005). Diversity Issues Within the field of psychotherapy, there is an increased interest in terms of diversity, with consideration for gender and cultural distinctions, urban and rural variations, and the differences relating to diverse coping techniques. However, there are disadvantages to overstating these variations, as an overemphasis on differences can create false dichotomies. For example, one might begin to think in terms of women’s depression and men’s depression only, or might decide that medication management is less favorable for Latinos than for Caucasians, or that elderly people suffer from depression due to loss and grief. A view of two extremes does not represent the 27 average, but instead it is gender-based tendencies and cultural norms that reflect a more accurate portrayal (Banse, Gawronski, & Rebetez, 2010). Gender. Major Depressive Disorder is more prevalent in women than in men (Kessler, Berglund, Demler, Jin, Koretz, Merikangas, Rush, Walters, & Wang, 2003). While women suffer a higher rate of anxiety with depression, men experience a higher rate of alcohol use in conjunction with depression (Melartin, Rytsala, & Leskela, Lestela-Meilonen, Sokero, & Isometsa, 2002). Age. Major depressive disorder can develop at any age, and many people experience their first episode of depression in their late teens or early adulthood. The incidence of depression increases with age. The median age at onset is between 32 to 40 years (Kessler, Berglund, Demler, Jin, & Walters, 2005). The elderly are at a high risk of developing depression due to such issues as lack of transportation, loss of friends and acquaintances, loss of loved ones, and the existence of a variety of health problems. Culture and immigration. Immigration and education are major sources of acculturation and are likely to have an impact on the perception of illness (Karasz, 2008). What it takes to be considered ill differs in many ways between western and non-western societies (Incayawar, 2008). There are various cultural definitions of depression as a disease. In western, middle class communities, unhappiness is reason enough to seek treatment. However, in many South Asian populations sadness and loss of interest do not qualify as symptoms of illness. In South Asian communities, depressive episodes are more often expressed somatically. Within these populations, sadness seems to become significant only after it causes bizarre behaviors, or serious 28 medical problems. South Asians who seek treatment for depression are likely to be experiencing more severe symptoms, such as psychosis (Karasz, 2008). Immigration can be a stressful process (Rodriguez et al., 2002). Immigrants regularly face discrimination, deplorable living conditions, low pay, inadequate housing, and separation from family and community (Alderete, Vega, Kolody, & Aguilar-Gaxiola, 1999) which can influence overall psychological health. A prevalence of both depression and anxiety in Latino immigrant populations suggests that Latinos may experience elevated levels of psychological difficulty (Singh & Siahpush, 2001). There is a high rate of somatization among Latinos, and cultural beliefs may influence the ways in which individuals respond to health and illness (Santiago-Rivera et al., 2005). Some culturally specific illnesses are common to Latinos who adhere to traditional beliefs. These beliefs appear to have origins in the supernatural. According to the Diagnostic and Statistical Manual- IV (DSM-IV), there are culturally specific psychological disorders that affect Latinos. For instance, empacho refers to an upset stomach, while Mal de ojo, translated as evil eye, has symptoms like fever, headaches, sleep, and crying (Santiago-Rivera et al., 2005). Additionally, susto is a Latin American folk illness attributed to having a frightening experience, which often includes soul loss. It is not necessarily the soul that is thought to have left the body, but rather a vital force (Glazer, Baer, Weller, Garcia-de Alba, & Liebowitz, 2004). Immigrants have also reported seeking treatment for culture-bound syndromes like ataques de nervios. Instead of visiting physicians or mental health practitioners, Latinos may seek help from traditional folk healers who use time-honored healing practices 29 such as the use of herbal treatments, folk remedies, Santeria (Murguía et al., 2003), and the magico-religious practice of the burning or sprinkling of mercury (Wendroft, 1995). Mexican immigrants and migrant workers may suffer higher levels of depression compared to the general population (Hovey & Magana, 2002), with recent immigrants suffering from higher rates of suicide. Studies highlight relevant sociocultural and behavioral influences to high levels of depression (Hovey & Magana, 2002) at least partly explained by a lack of social support. For Latino immigrants experiencing adversity, presence of meaning in life is related to other aspects of well-being, personality traits, and religious variables. In this culture, the missing component of meaning in life affects coping skills and can easily manifest into suicidal ideation (Edwards & Holden, 2001). In measuring psychological well-being in Latino populations, the rigorous translation of the Brief Symptom Inventory (BSI) has provided hopeful results (Young & Evans, 1997). Spirituality. Mental health systems throughout the United States are undergoing the process of incorporating spirituality into mental health care. A recent achievement is the California Mental Health & Spirituality Initiative that began in June 2008 with funding from 40 of the 58 county mental health authorities. The more recent incorporation of spirituality into the mental health arena provides a holistic approach to the treatment of serious mental health problems such as depression, bipolar disorder, PTSD, and schizophrenia. Spirituality includes, but is not limited to religion. There are many ways to define “spirituality” and “religion,” and the Center for Multicultural Development – California Institute for Mental Health (2009), provides the following 30 definitions: Spirituality is a person’s deepest sense of belonging and connection to a higher power or life philosophy that may not necessarily be related to a religious institution. A religion is an organization that is guided by a codified set of beliefs and practices held by a community, whose members adhere to a worldview of the holy and sacred that is supported by religious rituals. Spirituality is a core component of cultural competency, and the center goes on to say that the public/private mental health system in California recognizes that cultural competency, including the ability to understand different worldviews, is necessary for effective practice. Spirituality represents a core value within many ethnic and cultural communities and is often considered a primary resource. Faith-based organizations are a vital source of community leadership for individuals, families, and neighborhoods. Therefore, spirituality can be regarded as an essential connector for ethnic and cultural communities and for understanding wellness, illness, intervention, and recovery. The Center for Multicultural Development is committed to the inclusion of multicultural voices that represent California’s broad array of faith traditions and practices (California Institute for Mental Health, 2009). Suicide and diversity. Persons of any age or race, or of either gender, may contemplate suicide as part of their depression. More than 90 percent of people who commit suicide have a diagnosable mental condition, most commonly a depressive disorder and/or a substance abuse disorder (NIMH, 2008). Although women attempt suicide two to three times more often than men do, the highest rates of suicide in the U.S. are found in white males over age 85. Generally, about 15 percent of patients who 31 have untreated depression for more than one month commit suicide. Many of these patients had sought medical help before their suicide, often within one month prior to their death (Kochanek, Murphy, Anderson, & Scott, 2004). In 2006, 33,300 people, approximately 11 per 100,000, died by suicide in the U.S. (CDC, 2009). Factors Related to Depression The etiology of depression can be multi-faceted. Genetic make-up of the brain may be involved. In addition, both internal and external forces may be related through internal thoughts and feelings or by environmental factors. Determining the origin of a client’s depression through the professional use of appropriate severity measurement instruments leads to the development of more relevant treatment options. Major depression and addiction are mental health problems associated with stressful events in life, and are linked to high relapse and recurrence even after treatment. Some of the external factors that have been highly correlated to depression are general medical conditions, and substance abuse including alcohol, domestic, physical, and sexual abuse, grief, isolation, lack of a functional social system, relationship issues, oppression, and lack of basic resources. Substance abuse. Substance abuse, including alcohol has been related to depression, and is also considered to be a possible cause of depression. Substance abuse disorder, including alcohol, was diagnosed along with major depressive disorder in 25 percent of clients (Melartin, et al, 2002). The existence of rumination correlated to depression predicted increases in social problems related to substance use and predicted 32 future increases in substance abuse symptoms (Nolen-Hoeksema, Stice, Wade, & Bohon, 2007). General medical conditions. General medical conditions have been related to depression, and are also considered to be a possible cause of depression. Recent cognitive changes must be taken into consideration. Criterion A of Mood Disorder Due to a General Medical Condition states that a “mood disturbance may involve depressed mood … or elevated, expansive, or irritable mood (DSM, Appendix A, page 746). Medical problems, such as hyperthyroidism, multiple sclerosis, and brain tumors, may affect cognitive ability (Morrison, 2007). Morrison discusses that a physical examination can rule out for medical disorders, and if there is any suspicion of such a condition, the client should be referred to their primary care physician or the emergency room for medical assessment. Due to safety concerns, both substance abuse including alcohol, and general medical conditions must be ruled out early in the assessment process. Both disorders can be influenced by genetic predisposition and personal development within the family (Beck & Alford, 2006). Grief. Although depression can be closely related to grief, intense depression beyond a two-month period must be considered separate from normal depression. As stated in the DSM, under the criteria for major depression, the symptoms of depression are not to be better accounted for by bereavement, i.e., after the loss of a loved one, if the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, 33 psychotic symptoms, or psychomotor retardation (DSM). Beyond this length of time, Prolonged Grief Disorder (PGD) must be considered. Symptoms related to PGD go beyond the typical diagnosis of major depressive disorder (Prigerson, Vanderwerker, & Maciejewski, 2007). Research has shown that after the loss of a significant other, a large number of people develop debilitating symptoms of grief that are distinct from existing disorders in the DSM and predictive of enduring functional and health impairments with a persistently elevated set of specific symptoms of grief identified in those with problematic adjustment to a loss (Latham & Prigerson, 2004). The Inventory of Complicated Grief: a Scale to Measure Maladaptive Symptoms of Loss helps to identify the symptoms associated with Prolonged Grief Disorder (PGD) (Shear, Frank, Houck, & Reynolds, 2005). Prolonged Grief Disorder is defined as present when, after loss, a person suffers from one of three symptoms of separation distress, which include: 1) unbidden memories, or intrusive thoughts related to lost relationship; 2) intense spells or pangs of severe distress related to lost relationship; and 3) distressingly strong yearnings for that which was lost. Also present would be at least five of the following nine cognitive, emotional, and behavioral symptoms that have caused significant impairments in functioning for at least six months: 1) sense of self as confused or empty since the loss because a part of self died as a result of the loss; 2) trouble accepting the loss as real; 3) avoidance of reminders of the loss; 4) inability to trust others since the loss; 5) extreme bitterness or anger related to the loss; 6) extreme difficulty moving on with life (e.g., making new friends, pursuing interests); 7) pervasive numbness and absence of emotion since the loss; 8) feeling that life is 34 unfulfilling, empty, and meaningless since the loss; 9) feeling stunned, dazed or shocked by the loss. Along with separation distress and cognitive emotional and behavioral symptoms, symptoms of depression and prolonged grief may include poor appetite, feeling blue, worrying too much about things, feeling no interest in things, and blaming oneself for things (Stroebe, Stroebe, & Abakoumkin, 2005). Studies have shown that PGD represents a unique set of grief-related psychopathology that would be missed with an exclusive focus on depression or anxiety (Boelen, van den Bout, & de Keijser, 2003). Brain development. Brian Knutson, inspired by the work of Pavlov, showed an association between individual control and happiness. In his work, he used Magnetic Resonance Images (MRIs) to research this control Neural Responses to Monetary Incentives in Major Depression (Knutson, Bhanji, Cooney, Atlas, & Gotlib, 2008). In reference to the work of Knutson, Michael Lemonick states, “If we associate certain experiences and situations with being happy, and then they do make us happy, we are being influenced by our experiences and environment” (Lemonick, 2005). A recent study was conducted using magnetic resonance imaging (MRI) findings to research brain images. These images have shown the long-reaching effects of many clinical disorders, including depression (Minzenberg, New, & Siever, 2008). Functional magnetic resonance imaging (fMRI) was first used to compare responses of adult patients experiencing depression with those of healthy control participants. Both patients and healthy control participants were exposed to pictures of 35 faces with fearful, angry and neutral expressions. In response to the fearful faces, the fear hub showed exaggerated activity in the patients, while the anterior cingulate cortex (ACC) was relatively underactive. In control participants, the activity of the ACC showed an increase that dampened an overactive amygdale. An underactive amygdala suggests weak emotion regulation. Consistent with the fMRI results and earlier findings of anatomical MRIs used to compare grey matter in patients and healthy controls, grey matter density was increased in parts of the amygdala and decreased in parts of the ACC. This suggested an abnormality in the number of neurons in the emotion-regulation circuit. Further evidence links depression to impaired functioning of the serotonin chemical messenger system (Minzenberg, et al., 2008). Oppression. Oppression relates to how socioeconomic conditions cause an increase in depression. Exposure to environmental stress, via low social status and a lack of basic resources, reduces the opportunity for education, professional occupation, and a decent income. As noted by a rise in domestic violence during times of economic decline, we begin to understand how yet another external factor may lead to further depression (Weissman, 2007). Abuse and violence. Domestic violence is one of the many risk factors for depression. It is often related to lower socio-economic conditions due to unemployment, which is typically higher in oppressed populations. In minority neighborhoods, domestic violence causes a rise in frequent residence moves, and multiple stressful life events. (Caetano & Cunradi, 2003). Perpetrators are known to use strategies that shift the focus and blame to their victims. Perpetrators work 36 diligently to isolate victims from family and friends. When speaking with these individuals, perpetrators will often confide that they are having “trouble at home,” warning that the victim may come to them with “some story,” thus implying that the victim is lying, and may be mentally or emotionally unstable. The road to recovery from physical violence includes recovery from psychological fear, depression and anxiety, self-deprecation, discrimination, and economic roadblocks including a lack of resources. Clinicians must be aware that simple freedoms which are assumed to exist, for example, safety and freedom of choice (i.e., where to live, who to socialize with) are often unavailable to victims of domestic abuse (Wetendorf, 2007). Sexual victimization has been linked to significant mental health consequences, with the most commonly diagnosed mental illness being major depressive disorder (Campbell, Jones, & Dienenmann, 2002). Individuals with a history of sexual abuse and major depressive disorder showed evidence of a higher rate of disability in areas of mental health, bodily pain, role and social functioning. Abuse and depression were shown to be overlapping. Subjects with major depressive disorder were twice as likely to report having been abused at some point in their lives, compared to those without a depressive disorder. Recent abuse was associated with increased hospital admissions during the prior year, and was unrelated to direct physical effects of abuse (PicoAlfonso, Garcia-Linares, Celda-Navarro, Blasco-Ros, Echeburúa, & Martinez, 2006). Research findings also suggest that sexual and physical abuse have been linked with poor physical and mental health outcomes well into late life (Dube, Felitti, Dong, & 2003). Mental health consequences include depression, anxiety disorders, eating 37 disorders, sexual disorders, suicidal behavior, and substance abuse (Springer, Sheridan, & Kuo, 2003). Both sexual and physical abuse have been significantly associated with low levels of social support, lower rates of marriage, and a higher occurrence of broken relationships, and have also been significantly associated with a greater likelihood of attaining education beyond high school (Draper, Pfaff, Pirkis, Snowdon, Lautenschlager, Wilson, & Almeida, 2008). Many different pathways affect mood disorders. Biologically, the stress response is involved, and abnormalities in the hypothalamus, as well as the pituitary and adrenal glands are included. Autonomic responses have been documented in women who have suffered from abuse (Helm, Newport, & Helm, 2000). Increased activity in the biological pathways has been found to suppress immune functioning in women who have suffered from abuse (Altemus, Cloitre, & Dhabhar, 2003). Physiological symptoms are consistent in abuse survivors, and they affect both blood pressure and heart rate (Buckley & Kaloupek, 2001) linked to an increase in the risk of cardiovascular disease in middle-aged women (Batten, Aslan, & Maciejewski, 2004). A person’s emotions relate to mental health outcomes such as depression, posttraumatic stress disorder (PTSD), and suicidal behavior. Susceptibility to mood disorders is likely to increase the development of aggressive or impulsive personality traits, and impairment of an individual’s sense of personal control. An individual’s cognitive pathways include the beliefs and attitudes that shape daily life (Springer, et al., 2003). Cognitively, whether people consider themselves to be healthy or unhealthy seems to be of major importance (Kendall- 38 Tackett, 2002). A person’s social pathways link abuse and health outcomes through difficulties in establishing intimate relationships, low self-esteem, and psychological distress (Springer, et al., 2003). The effects of abuse appear to last a lifetime; however, maturity sometimes improves these effects in more resilient individuals who cope better under stress (Vaillant & Mukamal, 2001). Temperament and personality factors are also related to how well an individual deals with the effects of abuse (Weiss & Costa, 2005). Additionally, religious or spiritual coping has been shown to be a protective factor for suicidal behavior in depressed adult victims (Dervic, Grunebaum, & Burke, 2006). Evidence shows that cognitive behavioral therapy can relieve suffering in women with depression associated with abuse (Springer, et al., 2003), and community-based educational programs have been shown to improve a person’s sense of mastery and to reduce loneliness, depression, and stress (Vaillant & Mukamal, 2001). Thinking styles. People learn through the many events that occur over a lifetime. What they learn shapes their cognitive abilities, which then affects their needs. The term learned helplessness represents a psychological condition in which repeated exposure to out of control events delay voluntary responses to situations because the individual does not believe their actions can influence their external environment (Davis, Liotti, Ngan, Woodward, Van Snellenberg, & van Anders, 2008). Learned helplessness may result in the development of negative schemas. These schemas prevent individuals from recognizing an opportunity to improve a situation because they do not believe they possess the ability to influence ongoing life events. A sense of 39 powerlessness in the lowering of self-esteem directly affects the mood of many individuals (Davis, et al., 2008). A ruminative response style relates to the tendency for a person to focus repetitively on symptoms of distress and possible causes and consequences of symptoms without engaging in active problem solving (Nolen-Hoeksema, 2004). Prospective studies have found that a ruminative response style predicts depressive symptoms and disorders in adults (Lyubomirsky & Tkach, 2004). Nolen-Hoeksema speculated that young people who are susceptible to distress, or who experience early onset depression, are more likely to develop a ruminative response style, especially if they are not taught adaptive mood regulation skills. The lack of such skills may lead to excessive focus on distress and to feelings of helplessness in the ability to cope (Hyman, Gold, & Sinha, 2009). Distressed girls may be especially likely to receive parenting that reinforces a helpless, rather than instrumental, response to distress (Crick & Zahn-Waxler, 2003). Parents are more likely to encourage and reward sadness in girls than in boys (Garside & Klimes- Dougan, 2002). In contrast, parents may encourage active coping responses for boys, such as engaging in distracting behaviors (Crick & Zahn-Waxler, 2003). Thus, early experiences of distress or depression, particularly in girls, may contribute to the future development of a ruminative response style, which may contribute to later experiences of depressive symptoms. There are no known studies that test whether childhood or adolescent depression predicts development of a ruminative response style; prospective studies have supported this relation in adults (Nolen-Hoeksema, 2004). In addition to increasing risk for 40 depressive symptoms, a ruminative response style may increase risk for maladaptive behaviors used to avoid self-directed ruminations. Women and men who scored higher on a measure of rumination were more likely to report drinking to cope with distress and greater problematic substance use. In addition, rumination predicted increases in social problems related to substance use, particularly among women (Nolen-Hoeksema & Harrell, 2002). The locus of control refers to a person’s beliefs regarding life experiences, and whether these experiences are internal or external. These beliefs can be either general, or they can be specific to beliefs related to health, academics, or even mood (Sterling, 2007). The locus of control pertains to the extent that individuals believe they can control events that affect them. Individuals with a high internal locus of control believe that events result mostly from their own actions. They typically have an increased ability to manage their behavior. They are more likely to assume that their efforts will be successful, and therefore are more apt to seek information and knowledge. Those with a high external locus of control believe that outside factors determine events. Generally, the locus of control develops from family, culture, and past experiences (Thompson & Prottas, 2005). Social bonds learned within the family of origin either may create the inability to form and maintain bonds, or may lead to excessive interpersonal dependence. These issues often link social bonds to the basis of depression (Dorahy, Lewis, Schumaker, Akuamoah-Boateng, Duze, & Sibiya, 2000). 41 According to Ellis, types of discomfort, such as ego disturbance occur. Ego disturbance includes emotional tension resulting from the perception that one’s ‘self’ or personal worth is threatened, possibly leading to avoidance of situations where failure and disapproval might occur, and looking to other people for acceptance, displaying non-assertive behavior through fear of what others may think. Ellis also defined discomfort disturbance, which results from demands about others, “People must treat me right” and about the world, “The circumstances under which I live must be the way I want them to be” (Ellis, 2003). There are two types of discomfort disturbance. Low frustration-tolerance is based on beliefs such as, “The world owes me contentment and happiness,” which result from demands that frustration should not happen, and followed by catastrophizing when it does. Low discomfort-tolerance arises from demands that one should not experience emotional or physical discomfort, followed by catastrophizing if discomfort does occur. Low discomfort tolerance is based on beliefs like: “I must be able to feel comfortable all of the time.” (Mahon, Yarcheski, Yarcheski, & Hanks, 2007). Isolation. Loneliness and social exclusion are major issues for those with mental illness. Isolation may precede problems which lead to depression, as commonly occurs in rural communities due to distance from services, lack of transportation and lack of social support (Cattan, White, Bond, & Learmouth, 2005). Many clients report that they experience loneliness often, if not all the time. The separation between clinical treatment services and psychosocial rehabilitation programs for people with mental illness creates a system that is fragmented. It makes it easy for consumers to fall 42 through the cracks. For this reason, greater collaboration between psychosocial and clinical services is recommended with an emphasis on the encouragement of psychiatrists to refer people to local community programs (Elisha, Castle, & Hocking, 2006). Isolation also appears to exacerbate already existing depressive disorders. Isolation is correlated with the stigma suffered by those who have a mental diagnosis. Negative attitudes have caused lower rates of employment for the mentally ill, and often prevent people with a mental diagnosis from attaining successful integration or reintegration into their communities. Greater public acceptance must be encouraged so that people may more successfully reintegrate (Mayville & Penn, 1998). The preferred modes of intervention include the introduction of skills for those with mental illness, as well as strengthening the level of environmental supports (McReynolds & Garske, 2002). Rural communities. Rural communities often rely on an on-call crisis team that consists of part-time contractors. For those who have been hospitalized and are now returning home, this may cause a gap in follow-up services. Part-time subcontractors rarely attend weekly team meetings, and thus the loss of important reports and recommendations for client follow-up may be lost. In addition, if clients are incarcerated in a rural county jail, and they appear to be suicidal, they are held in a safety cell and cannot be released until a social worker clears them. Part-time, on-call crisis workers can take a while to arrive (Nelson, Johnson, & Bebbington, 2009). 43 Many rural counties do not have their own in-patient facilities, but instead contract out longer-term hospital admittances to out-of-county psychiatric care facilities. Out-of-county facilities are often many miles away. Closer beds often fill up quickly, causing the county to make a referral even further from home. This makes it difficult on the client and their family members, as often families do not have available transportation to visit loved ones. This isolates the client from their family and often impedes recovery (Bull, Krout, Rathbone-McCuan, & Shreffler, 2001). If the client has private insurance, this can cause further difficulty, and the social worker must often make additional calls to locate an available bed. Most facilities are non-medical inpatient facilities, and the client must first be deemed ambulatory. If the client is not medically cleared, they must remain in the hospital until they are cleared for transfer to an in-patient facility. Many rural hospitals do not feel capable of providing care for psychiatric patients (Hartley, 2007). Normally, most counties provide groups for Depression and Bi-polar Support, Anger Management, Trauma Victims, Victims of Abuse, and Co-occuring Disorders such as Anxiety and Depression, or Substance Abuse. However, many of these groups have been discontinued due to the 2009/2010 fiscal year budget cuts. Staff reduction and hiring freezes have put an additional burden on already strained rural county mental health departments, and some counselors have been demoted to Personal Service Coordinators to help keep them employed (Neiman, & Krimm, 2009). Small rural counties often cannot support a full-time psychiatrist, and may have one or two visiting psychiatrists. In order to prevent hospitalization, fast track 44 procedures for people who are in need of medication are supposed to be in place. However, with only a part-time medical staff available, this often does not exist. The number one concern that exists for clients is their safety. The second main concern is to avoid hospitalization whenever possible, with the common goal being to get the client back to baseline. This is difficult to carry out with limited resources. Most of the clients served in rural mental health clinics are MediCal recipients, followed next by a clientele who is indigent, frequently homeless, and without insurance. Patients with insurance are not accepted for treatment at County Mental Health, even though no other psychiatric care exists in many rural communities (Thomas, Ellis, Konrad, Holzer, & Morrissey, 2009). Due to budget downsizing, and decreased staff, employees are faced with making tough decisions not covered in their job descriptions, and may find themselves expressing uncertainty regarding modified tasks. Supervision is not always available, which leaves employees unable to acquire proper consultation. Supervisors themselves are overburdened, as they seek to balance the workload with diminished resources (Lok, Christian, & Chapman, 2009). The Amador County Mental Health Services Act Plan for Community Services and Supports (2006), states that multiple roles for service providers must not be forbidden. Staff needs to be holistic. Separation of mental health and substance abuse services must be replaced with integration, and full integration of patients, staff, and programs is stated as the most effective method. If rationing of services must be carried out, rationing by diagnosis must be replaced with rationing by life impact. 45 The Mental Health Services Act, implemented by voters with the passage of Proposition 63 in November 2004, includes the outlined components of: 1) funding; 2) capital facilities; 3) community planning; 4) community services and supports; 5) housing; 6) innovation; 7) prevention and early intervention; 8) technology; and 9) workforce, with an added emphasis on education. The integrative, well-rounded, full-service partnership approach is bringing about unprecedented change in the mental health system. Wellness and recovery services offered across the state of California often consist of the individualized attention people with severe mental illnesses need to utilize other programs that might be too difficult for them to access without help (Ragins, 2006). Self-control. Psychologist Martin Seligman proposed that people are in control of reaching their ultimate happiness by pursuing personal pleasures through their activities and professions, by engaging in meaningful relationships, and by applying their knowledge and skills to serve others (Wallis, 2005). In support of the concept that depression is related to external factors, researcher David Lykken (2001) maintained that people are in control of their psychological states, reporting that they can change their happiness levels widely, both up or down. Although in Lykken’s survey of 4000 subjects, the majority supported a genetic theory, eight percent reported that external factors, such as marriage, social status, and money, affected their happiness. The fact that people who suffer from depression identify external factors as causing their mood disorder, establishes a connection between depression and a response to outside factors (Easterbrook, 2005). 46 Co-occurring disorders. In the incidence of co-occurrence, patients with personality disorder had a greater likelihood of more lifetime depressive episodes than any other co-occurring disorders. There was also a variance when it came to relationships and living arrangements. It was found that those with both major depressive disorder and a personality disorder were more likely to live alone. A cohort study of depression with co-occurring disorders was assessed in clinical interviews. The study concluded that 79 percent of patients with major depressive disorder suffered from one or more co-occurring mental conditions. Anxiety disorder was present in 57 percent of the people diagnosed, personality disorders were present as a co-occurring illness in 44 percent of subjects, and substance abuse disorder, including alcohol, was diagnosed along with major depressive disorder in 25 percent of clients (Melartin, et al, 2002). The co-occurrence of depression correlated with substance abuse, general medical conditions, personality disorders, and mental conditions such as posttraumatic stress disorder, creates the need for special consideration. Co-occurring disorders, such as medical conditions and/or substance abuse issues, have been highly correlated to multiple hospital admissions and increased risk of suicide (Gellar, Fisher, & McDermeit, 1995). Understanding the trends associated with co-occurring disorders can assist mental health professionals in the proper formulation of an effective treatment plan to help clients with issues related to dual diagnosis. 47 Measurement Instruments Used to Assess Depression Primary, secondary, and tertiary prevention can be viewed in terms of when intervention is offered in relation to problem development. Intervention offered in the early stages of problem development is anticipated to be successful, and thus helpful in the prevention of later more serious dysfunction (Durlak, 1998). Primary prevention is used as a preemptive attempt to avert mental disorders from manifesting in the first place, and includes education as a deterrent to problem development. Secondary prevention involves early screening at the subclinical-level, where depression is typically observed as mild worrying, sadness, nervousness, and problems with sleep, but functional impairment is not present (Patel, Araya, Chatterjee, Chisholm, & Cohen, 2007). In addition, at the subclinical level, a person may be taught new coping skills to inhibit symptom progression. Secondary prevention can be seen from a population perspective. A particular population is screened or evaluated, and criteria are used to target certain members of the population for intervention. Intervention at this point should follow quickly after screening. Tertiary prevention includes intervention to reduce the duration and impact of established disorders; however, tertiary prevention is not treatment (Durlak, 1998). Current programs vary in how target groups are selected for intervention, how services are delivered, which types of treatment are conducted, and the goals of intervention (Stice, Rohde, Seeley, & Gau, 2008). 48 The presence of a depressive disorder in a patient with a medical illness may result in an increased degree of severity or length of disability, and even increased mortality rates (Rodin, Lo, Mikulincer, Donner, Gagliese, & Zimmermann, 2009). In order to minimize complications related to depression, such as immunological changes, increased possibility of self-harm behaviors, decreased medical compliance, and prolonged disability of medical patients, we must engage health care providers by offering thorough education about mental illnesses such as depression (KiecoltGlaser, 2002). Due to the severity of depressive disorders and the ever-increasing possibility of symptom progression, the use of severity scales to determine a person’s level of depression have been in use since the early 1900s. The first known rating scales were administered by professionals, such as a doctor or a nurse in an in-patient hospital setting. The Hamilton Rating Scale for Depression. The Hamilton Rating Scale for Depression (HAM-D or HRSD) hereafter referred to as the HAM-D, was first published in 1960 as an instrument for use in measuring the severity of depression in-patients who had already been diagnosed with a depressive disorder by a psychiatrist. The HAM-D is a professionally administered scale that was originally developed in a hospital setting. The questionnaire contains 21 questions used to measure the severity of a person's depression, and although introduced nearly 50 years ago, it has been updated by Hamilton several times, the last time in 1980. The HAM-D is still one of the most commonly used scales in measuring depression symptoms today. One of the reasons 49 for selecting the HAM-D for review is because it uses DSM criterion to diagnose depression. It focuses on symptoms such as insomnia, anxiety, and weight loss; however, it is important to note that the HAM-D does not rate the reversed symptoms of depression such as oversleeping versus not sleeping enough, overeating versus loss of appetite, and weight gain versus weight loss (Bagby, Ryder, Schuller, and Marshall, 2004). It has been proven that this scale offers reliability in assessing responses to treatment, with a high validity of .92 (Reynolds, Dew, Pollock, Mulsant, Frank, & Miller, 2006). The Beck Depression Inventory. The Beck Depression Inventory (BDI, BDI-II) was created by Dr Aaron T. Beck. The BDI was first published in 1961. The latest version, the BDI-II, was published in 1996. Typically, depression was described in psychodynamic terms as “inverted hostility against the self” (Beck, 2009). However, the Beck Depression Index was advanced for its time as it collated the patient’s verbal descriptions of symptoms and used these descriptions to structure a self-assessment scale capable of reflecting the intensity or severity of a given symptom. The instrument is a 21-question multiple-choice self-report inventory. It is one of the most widely used instruments for measuring the severity of depression and is used by health care professionals and researchers in a variety of settings. The development of the BDI marked a shift among health care professionals, who had until then viewed depression from a psychodynamic perspective, rather than viewing it as being rooted in the patient's own thoughts. Beck drew attention to the importance of sustained, inaccurate, and often intrusive negative thoughts about the self. He labeled these thoughts as 50 negative cognitions, and he maintained that these cognitions caused depression, rather than being generated by depression (Beck & Alford, 2006). In its current version the BDI-II is designed for individuals aged 13 and over, and is composed of items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex. The BDI has been used for measurement of gender and cultural depression issues. Used for over half a century, a substantial database has accumulated the clinical utility of the BDI (Beck, Steer, & Garbin, 1988). The correlations with sex, ethnicity, age, and the diagnosis of a mood disorder were highly significant. A correlation of .92 between the BDI and the clinician-administered HAM-D and a correlation of .93 between the BDI and the 17item computer-administered version of the HAM-D was reported. Results indicated that the BDI-II has a high level of internal consistency at r = .921, p < .01 (Kobak, Reynolds, Rosenfeld, Greist, 1990). The Burns Depression Checklist. The Burns Depression Checklist, a self-report, can be used to help the clinician further determine the areas being most affected by depression with the use of factorial subcategories. The addition of factorial analysis measures the severity of depression across domains that include thoughts and feelings, activities and personal relationships, physical symptoms, and suicidal urges (Burns, 1999, p. 728). Scores are assigned according to indications of severity, from mild to moderate to severe impairment, and provide a quantitative assessment that is useful in following the course of mental illness and/or possible responses to therapy (Burns, 51 1999, p. 729). The addition of the four factorial analyses allows clients to recognize the impact of depression in their day-to-day lives across these domains. The Burns D-R was significantly and positively correlated with the BDI-II, which is often used as a criterion measure. Elevated, medium, and low scores on the Burns D-R coincided with the elevated, medium, and low scores on the BDI-II, (Alloy, Jacobson, & Acocela, 1999). The high correlations observed between these two instruments support the suggestion that one of these instruments could be used in place of the other (Damron, 2005). The Zung Self-Rating Depression Scale. The Zung Self-rating Depression Scale (ZSDS) is a 20-item scale, which, similar to the BDI, is not split into subcategories like the Burns Depression Inventory. However, a clinically interpretable four-factor solution has been extracted. These consist of factor I a core depressive factor, factor II a cognitive factor, factor III an anxiety factor, and factor IV a somatic factor. From a clinical perspective, the grouping of depressive indicators into symptomatic dimensions is purely intuitive; however, this factor structure was validated and high coefficients of congruence were obtained (0.98 for factor I, 0.95 for factor II, 0.92 for factor III, and 0.87 for factors IV) (Romera, Delgado-Cohen, Perez, Caballero, & Gilaberte, 2008). The extracted factor structure of the ZSDS has been studied in various populations, such as healthy subjects over the age of 65 (Zung, 1967), pregnant women (Sugawara, Sakamoto, Kitamura, Toda, & Shima, 1999), patients with heart disease (Barefoot, Brummett, Helms, Mark, Siegler, & Williams, 2000), cancer (Passik, Lundberg, Rosenfeld, Kirsh, Donaghy, & Theobald, 2000), chronic muscle pain 52 (Estlander, Takala, & Verkasalo, 1995), students (Kitamura, Hirano, Chen, & Hirata, 2004), and workers (Kawada & Suzuki, 1993). Due to the under-diagnosis and undertreatment of depression in primary care settings (Thompson, Ostler, Peveler, Baker, & Kinmonth, 2001), as well as the possible future implications of different symptomatic profiles in the prognosis of depression, studying the symptomatic dimensions in individuals with depressive disorders is considered to be beneficial. Each of the 20 statements on the ZSDS must be completed, and are answered depending upon how much of the time each statement describes how the individual has been feeling during the past two weeks. Scores range from a one which denotes a little of the time, a two which represents some of the time, a three that symbolizes a good part of the time, and a four which signifies most of the time. Items are scored by looking up the response and the corresponding scores between one and four. The score is filled in for each statement under the last column labeled “score.” The total score is then calculated by adding up all 20 scores. The range in which most depressed people score on this scale is a range of 50-69. More than 70 equates to severe depression, with the highest total possible score being 80. If the score indicates depression, the individual is advised to see a health care or mental health professional for further evaluation and treatment (Zung, 1965). Research shows that the Zung Scale has been shown to be effective for use in the primary care setting, with approximately two thirds of patients with depression reporting somatic symptoms as the sole reason for consultation (Tylee & Gandhi, 2005). 53 The Edinburgh Postnatal Depression Scale. Postpartum depression is the most common complication of childbearing (Wisner, Parry, & Piontek, 2002). The 10question Edinburgh Postnatal Depression Scale (EPDS) is a valuable and efficient way of identifying patients at risk for perinatal depression. It is formatted along the lines of the Beck Depression Scale, in that there are no factor subcategories for the questions. The EPDS is easy to administer, can be completed in about five minutes, and uses a simple scoring method. It was proven to be an effective screening tool after a validation study of extensive pilot interviews was obtained using the Research Diagnostic Criteria for depressive illness obtained from Goldberg's Standardized Psychiatric Interview. The EPDS was found to have satisfactory sensitivity and specificity, and was sensitive to change in the severity of depression over time (Cox, Holden, & Sagovsky, 1987). Mothers are asked to check the response on the EPDS that comes closest to how they have been feeling in the previous seven days. All the questions must be answered. Answers should not be discussed with others at the time of screening, as answers must come from the mother, or pregnant woman, herself. Mothers who score above 13 are likely to be suffering from a depressive disorder of varying severity. A careful clinical assessment should be carried out to confirm the diagnosis, as the EPDS score is not meant to override clinical judgment. In situations where doubt exists, it may be useful to repeat the tool after two weeks. The scale is designed to screen for depression only, and will not detect mothers with anxiety neuroses, phobias, or personality disorders (Cox, et al., 1987). 54 The Geriatric Depression Scale. The Geriatric Depression Scale (GDS) is a 30item scale. The items are completed with simple yes or no answers that describe how the individual has been feeling over the past week. For each question, a check mark is put in the appropriate yes or no column. The response is reviewed and the corresponding score is noted with each check mark representing a score of one and the absence of a check mark denoting a score of zero. The total score is determined by adding up all of the check marks, or one values, in each column. A total score of 0-9 is considered to be normal, 10-19 denotes mild depression, and a score of 20-30 represents severe depression. If the score indicates depression, it is suggested that the individual see a health care or mental health professional for further evaluation and treatment (Wancata, Alexandrowicz, Marquart, Weiss, & Friedrich, 2006). It is generally agreed among most professionals that self-reports for the elderly should be specially designed. They should be short, easily understood, and appropriate in terms of the size of letters and in terms of the elderly person’s level of education. These reports should include relevant age-related items; and should provide normative data on the elderly population. The main sources of error found in relation to the use of self-reports among the elderly are relevance, social desirability in relation to the respondent’s wish to present him or herself in a favorable way, inhibition of response, anxiety, and understanding (Montorio, 1994). The GDS has been tested in specific populations, including elderly persons within the community, elderly medical inpatients, nursing home residents, and dementia populations. The GDS has been found to be a relevant self-report for the assessment of 55 depression in the elderly, given its advantage over other self-reports that are not as easily administered to this age group. However, the GDS does not maintain its validity in populations affected by dementia because it fails to identify depression in persons with mild to moderate dementia. The ambiguity of the definition of depression in old age, as differentiated from other disorders (e.g., dementia) and the role that other related factors play in the diagnosis (e.g., medication intake) are common problems (Rehm, 1988). In the assessment of depression in old age, the GDS is one of the most used depression self-reports. Because the GDS was created for the elderly, its items were based on characteristics of depression in the elderly (Coleman, Miles, Guilleminault, Zarcone, & van der Hoed, 1981). In the study of the initial conception of the GDS (Brink, Yesavage, Lum, Heersema, Adey, & Rose, 1982), the rational criteria of researchers and clinicians involved in geriatric psychiatry and gerontology was used. Thirty items from the original 100 items shown to be useful in distinguishing elderly depressed subjects from elderly normal subjects, with yes/no answers, were selected. None of the final 30 items was somatic, thus avoiding one of the problems with selfreports in the assessment of depression in the elderly, namely the confusion of somatic symptoms with physical disturbances that are common in old age (Rehni, 1988). The GDS has been compared with the Zung Self- Rating Scale for Depression and a version of the Hamilton Depression Rating Scale that was converted into a selfreport format. The GDS was found to be statistically significant, and correctly classified 84 percent of depressed elderly patients relating to sensitivity, and 95 percent of those 56 not affected by depression, as relates to specificity (Hickie & Snowdon, 1987). Each subject was interviewed to determine the presence or absence of a major depressive episode using criteria from the DSM. The validity of the GDS has been analyzed mostly with regard to elderly persons living independently in the community, and has also be validated when used with an inpatient population, 92 percent sensitive and 89 percent specific (Koenig, et al., 1988). The psychometric properties of the GDS, when used with the elderly in nursing homes, were not as satisfactory (Parmelee, Katz, & Lawton, 1989). Depressive features ranged from 55 percent to 100 percent sensitivity and an 81 percent specificity rate (Lesher, 1986). The GDS does not appropriately measure passing moods (Brink et al., 1982). The GDS has been compared with the BDI, and has been found to be statistically significant. Both measures are sensitive to treatment (Scogin, 1987). A factorial analysis of the GDS generated five factors constituting the scale. The first factor, sad mood, reflects persistent thoughts of sadness; the second factor, lack of energy, includes cognitive complaints that are translated into difficulties in concentration and a lack of initiative; the third, positive mood, is related to positive affect and a positive worldview; the fourth, agitation, reflects different aspects of anxiety; and the fifth, social withdrawal, is associated with passivity and the avoidance of social situations. This factor structure provides clinicians with measures that are more descriptive than a simple total score, and may be a useful way of interpreting GDS scores because it characterizes the patient’s subjective experience of depression. This supports the use for factorial analysis through use of subcategories like those found in 57 the Burns Depression Checklist. Finally, the GDS improves on the Zung Self-report Depression Scale as it is easier to answer, and therefore provides a higher rate of completion of the scale (Dunn & Sacco, 1989). Depression measurement instruments have become evidence-based methods of measuring the severity of depressive symptoms. They may be used one time or repetitively in intervals over the course of treatment. Depression is one of the most common illnesses seen by primary care physicians, and although physicians manage the majority of patients with major depression, 35 to 50 percent of cases go undetected (Katon, Russo, von Korff, Lin, Ludman, & Ciechanowski, 2008). The presence of a depressive disorder in a patient with a medical illness may result in an increased degree or length of disability and even increased mortality. Health care providers must be better informed about depression in medical patients to minimize complications. Several medical practitioners report that most depression questionnaires, developed to help them identify depression in the primary care setting (Burnham, 2010) are too cumbersome and time-consuming for routine use. However, there are two brief questions to help primary care physicians identify patients for further screening (Weissman, Olfson, & Leon, 1995). According to the DSM-IV-TR, aside from additional criteria choices, a major depressive episode must be present over a period of at least two weeks during which there is either depressed mood, or the loss of interest or pleasure in nearly all activities. There are two questions addressed on the Primary Care Evaluation of Mental Disorders 58 Procedure (PRIME-MD) about depressed mood and anhedonia. The first question is, “During the past month, have you often been bothered by feeling down, depressed, or hopeless?” The second question is, “During the past month, have you often been bothered by little interest or pleasure in doing things?” The original PRIME-MD study reported that a “yes” answer to one of these two questions was 86 percent sensitive (Whooley, Avins, Miranda, & Browner, 1997). The characteristics of depression support the use of self-report assessment procedures. Depression is a disorder that includes many symptoms that are internal to the individual and are not readily observable. Cognitive symptoms of guilt, selfdeprecation, suicidal ideation, hopelessness, helplessness, and feelings of worthlessness, are among the symptoms of depression that are subjective to the individual and are often obscure to others unless a formal evaluation is conducted. Some somatic symptoms such as insomnia and appetite loss may be difficult for others to observe, or may be attributed to physical or other causes, particularly if a larger constellation of depressive symptoms are not observed or identified (Reynolds, et al, 2006). It is the responsibility of the clinician to conduct a thorough initial assessment covering the biological, psychological, and social history of the client. Next, upon diagnosis of depression, the use of a measurement instrument can determine the current severity of symptoms. When used regularly, these scales can allow the client to recognize particular events that negatively affect their mood, to notice any particular cycles, and even to identify whether their depression is manifested in physical symptoms, or is highest in such areas as thoughts and feelings, or activities and personal relationships 59 (Burns, p. 7, 1999). Before a treatment plan can be created, a clinician must first review client responses to key questions. Consideration should be given to which treatment options would likely provide the best results. Suggestions for treatment is then reviewed with the client and a treatment plan defined by the client can then be written. Treatment for Depression Client readiness. Client readiness can affect the clinician’s choice regarding how to proceed with treatment. The goal of evaluating an individual's readiness for entering the psychiatric rehabilitation process with a good chance of success should be the first step in the psychiatric rehabilitation process. Cohen stressed that if the client is not ready for this first step the focus should then be directed toward helping the person move toward readiness. Readiness goals as identified by Cohen would, for example, include an exploration of goals and a definition of family expectations (Cohen & Farkas, 1992). The five areas that Cohen and Farkas consider in a readiness assessment for treatment are described as: Need for change—Does the individual perceive a need for change? This includes the influence of environmental issues. Is the individual successful in their current environment, or is the environment forcing a change? Commitment to change—This assesses client beliefs that change is necessary, positive, possible, and will be supported. Has the client taken concrete steps or actions to pursue change? Environmental awareness—This assesses the individual’s knowledge, including previous experiences, about the chosen environments in which they plan to operate. Self-awareness—This assesses the client's knowledge about him or herself, 60 and may include likes and dislikes, personal values, and strengths and weaknesses. Closeness to practitioner—This evaluates the client’s relationship with the clinician in the area of trust. A close working relationship contributes to a more effective treatment process (Cohen & Farkas, 1992). Increasing or developing individual readiness can take place in many ways. Starting the rehabilitation process itself can encourage readiness by increasing a client's self-awareness and the understanding that there are alternative points of view. New and informative efforts on the part of the client may demonstrate that recovery from a mental illness is possible, and that achieving normalized role functioning, such as being a worker, student, parent, homeowner, committee member, is attainable (Cohen, & Farkas, 1994). In the treatment of depression, some of the most effective therapeutic methods have been found to include a form of one or more of the following, Behavior Modification, Cognitive Behavior Therapy (including DBT and/or Cognitive Reframing), Interpersonal Psychotherapy, Narrative Therapy, Systems Theory, and for some clients who choose it, more simply just Medication Management. Although a client may choose a unimodal approach, for example, medication management onlywithout counseling or counseling only-without medication, a multi-modal approach appears to be most effective for a large percentage of people. In social work, where clients are considered to be the experts in their own lives, a choice of treatment options should be offered without bias. Particular treatment approaches may appeal to an individual based upon such factors as gender, age, culture, type of depressive episode or 61 disorder, and client readiness. As clinicians, we should be well prepared to offer a wide variety of quality treatment options. Medication management. Antidepressant medications, are most helpful in treating major depressive disorders, especially when connected to coinciding psychotherapy, as recent research shows antidepressants are no better than a placebo effect in the treatment of mild to moderate depression (Fournier, DeRubeis, Hollon, Dimidjian, Amsterdam, & Shelton, 2010). A psychiatrist can prescribe any number of different antidepressants as part of the treatment process for depression. These medications come from three separate classifications of to help those with depressive symptoms. The three different classes of antidepressants have different actions. These classes include Trycyclics, Selective Serotonin Reuptake Inhibitors (SSRIs), and Monoxarnine Oxidate Inhibitor (MAOIs), which include Trazadone, Nefazodone, and Buspropion (Preston, O'Neil, & Talaga, 2002, p. 169). All of these antidepressants must be taken for several weeks before the medications take a therapeutic effect. Anti-depressants have proven to be effective, but there are serious issues to consider before taking the pharmacological approach with a psychiatrist. There is the cost of the medication and the patient's history with medication to consider. In addition, there are side effects to each of the medications. Patients who are taking Trycyclics should be wary of its history of producing sedation, blurred vision, constipation, and mild confusion. SSRIs are known to have fewer side effects, but are still known to cause restlessness and headaches. The MAOIs have the most potentially serious side 62 effects. Patients must follow a specific diet in order to avoid hypertension, gastrointestinal problems, dizziness and dry mouth (Preston, et al., 2002). Cognitive Behavioral Therapy. Aaron Beck, creator of the Beck Depression Scale has been using cognitive therapy for depression since the 1960s. The Cognitive Behavior Theory maintains that human behavior is influenced by our ability to think and reason, and maintains that everyone has a cognitive “schema,” or Worldview that includes units of information about everything (Sheafor & Horejsi, 2008). Oftentimes, people can benefit from changing or accommodating their schema in order to function better. Restructuring thinking patterns often has a profound effect on a person’s ability to make positive changes. Changing the way that a depression sufferer views himself is central to resolving the difficulties related to this disruptive mental disorder. Psychotherapy can "identify negative or distorted thinking patterns that contribute to feeling of hopelessness and helplessness that accompany depression" (APA, 1998, p. 2). Identifying these negative thought patterns can help them improve and explore other thoughts and behaviors when interacting with other people. The hope is to help people regain a sense of control and find pleasure in daily life and activities. Interpersonal Psychotherapy (IPT). This form of psychotherapy is a preestablished time-limited treatment approach with a beginning, a middle, and an end. In the beginning phase, the clinician and client review client feelings about the client’s current and past relationships and interactions with significant people. Satisfactory and unsatisfactory aspects of relationships are evaluated. An assessment is taken of problem areas in relation to current depression. Focus is on changes that the client 63 wants to make in their relationships, and goals are determined. In the middle phase, problem areas such as grief, role dispute, transitions, or deficits are discussed. Focus in the middle phase is about interpersonal encounters, what the client said and how the client felt. The clinician reinforces what the client has done skillfully, and sympathizes when things go wrong, while exploring other options through role-play. In the final phase of interpersonal psychotherapy, client progress is reviewed (Weissman, Markowitz, & Klerman, 2007). Interpersonal Psychotherapy has been found to be more effective than a placebo, and it appears to be comparable to CBT in terms of outcome. This form of treatment provides the client with a relevant model of depression. This therapy is easily understood and reasonable, and contains intervening change strategies that occur in a logical sequence. IPT encourages independent use of skills to promote change, and attributes change to the individual rather than to the therapist's skill. An important component of IPT is the use of clinician interest and empathy. IPT is a superior, specific treatment for those with adjustment and reactive depressive disorders (Parker, Parker, Brotchie, & Stuart, 2006). Behavior Modification. This treatment addresses the theory that human behavior is determined through learning from the environment (Sheafor & Horejsi, 2008). Many components of depression may be learned through a person’s cultural environment. With proper assessment, diagnosis, and treatment, and given the appropriate reinforcement, punishment, or stimulus including regular reinforcement of new behaviors, that which has been learned may be unlearned. 64 Narrative Therapy. The worker is called upon to bear witness through the client’s narrative, and trust must be established in order for a true alliance to take place. When beginning narrative therapy, clients need to be reminded that they will be vulnerable when reminders of the trauma surface and new traumas arise. With narrative therapy, the time will come when the stories do not produce the same physical and psychological response, and the intensity of the emotions will become part of the client’s life continuum, resulting in the final stage, reconnection (Nehls, 1999). According to Judith Herman, 1997, upon mourning the old self that was destroyed by the trauma, reconnection can begin as the client has an opportunity to create a new future. Strength and empowerment are vital components. Narrative Therapy may include psychodynamic reenactment, and a reference to the inner-child metaphor for the learning of self-soothing techniques. Therapeutic options should include identifying the characteristics of the narrative to providing narrative coherence, closure, and interdependence. Societal and environmental influences should be dealt with, emphasizing a strengths perspective (White, 1995). Clients may need to tell their story, repeatedly if necessary, until the emotions hold less power. Systems Theory. The Systems Theory approach to treatment is used predominantly by social workers. The General Systems Theory was introduced by Bertalanffy in 1968, and the Ecological Systems Theory is an offshoot of this theory which includes the biopsychosocial perspective, emphasizing the individual as a whole system, made up of numerous elements or subsystems, and the idea exists that a system 65 will constantly strive for balance, and human behavior is influenced by how the systems both inside and outside the individual interact. The Ecological Systems Theory, within the systems theory, focuses on improving the fit between the client system and the environment. This theory ultimately led to the biopsychosocial perspective of social work (Germain & Gitterman, 1996). This theory proposes that there is a two-way interface between the client system and the environment. People affect the environment, and the environment effects people. Today, this theory includes techniques to integrate thorough biological, psychological, social, and cultural components into an encompassing assessment and intervention strategy. Intervention occurs at the micro level, which includes individuals and their families, the mezzo level, which includes for example, schoolmates, work associates, and neighbors, and the macro level, which includes communities, organizations, institutions, and society as a whole. The subcomponent of multiculturalism has been added. This subcomponent centers on human diversity and culture in the areas of race, ethnicity, gender, education, and class (Sheafor & Horejsi, 2008). The study of depression, viewed through the lens of the General Systems Theory, with an emphasis on Ecological Systems Theory and the added biopsychosocialcultural perspective of social work provides a resourceful, flexible, and adaptable approach (Germain & Gitterman, 1996). In treating clients with depression, it is important to incorporate the systems that influence their day-to-day lives. Together the clinician and the client may identify the person’s closest supporters as those who could be called upon to support the client 66 during treatment. The involvement of caring family members or close friends can be beneficial, and can add depth to the sessions; however, they may also be the source of additional pain and drama. A person may, or may not, wish to include someone else in session, or may choose to do so later (Murray-Swank, Glynn, Cohen, Sherman, Medoff, & Fang, 2007). Additional resources to consider when treating clients with depression are the self-help and peer-led support groups. These groups are often beneficial in providing social encouragement; however, they may not be for everyone, especially in the beginning (Davidson, Chinman, Sells, & Rowe, 2006). Combined therapy. Clients often respond best to combined therapy that is made up of both anti-depressants and psychotherapy. Medication may be helpful in reducing symptoms, but research shows that it may take several weeks before an antidepressant medication takes effect. The combination of both medication and psychotherapy can be particularly effective for treating symptoms of depression (Bair, Kroenke, Sutherland, McCoy, Harris, & McHorney, 2007). Initiating psychotherapy can encourage medication compliance thereby allowing the time needed for the medication to take effect and prepare clients for continued psychosocial therapy (Weerasekera, 2010). This can be an uncertain time in therapy, and a therapeutic alliance, based upon initial rapport between client and clinician, is essential. The clinician can perform many various roles to support clients, and can continually assess the client's level of functioning. In combined medication and psychosocial therapy, clinicians can address the stigma of taking medication. As therapy continues, the clinician can observe the 67 client, watching for adverse medication side effects, and can teach self-monitoring skill (Bair, et al., 2007). Multimodal treatment approach. The multimodal therapy approach developed by Arnold Lazarus, a pioneer in the field of cognitive behavioral therapy, rather than being a therapeutic method itself, provides a flexible framework that employs many different approaches. At the core of the framework are seven modalities, which take into consideration that human beings are biological and we think, act, feel, sense, imagine, and interact (Garrett, 2007). The use of a multimodal treatment approach can be effective in achieving early remission of depressive symptoms and may help to avert significant relapse. The definition of a multimodal approach is built upon the assumption that it is not enough to simply help the client gain insight and challenge irrational ideas (Lazarus, 2006). In addition, behavioral inconsistencies and negative images must be identified and resolved, and antidepressant medication should be considered. Therefore, this broadbased approach focuses not only on cognitive issues, but also on specific behaviors, sensations, images, interpersonal relationships, and other interactive effects (Palmer, 2008). The multimodal approach assumes that unless seven distinct but interactive modalities are addressed, treatment may not fully consider significant concerns. Initial interviews and the use of a Multimodal Life History Inventory (Lazarus, 2006) help to provide a preliminary overview of a client's significant behaviors, affective responses, sensory reactions, images, cognitions, interpersonal relationships, and the need for 68 drugs and other biological interventions. Individuals favor certain modalities over others, and the Multimodal Life History Inventory may be administered to assess clients in each modality, as the questionnaire considers past history, current problems, and maintaining factors. The first letters of each word produce the anagram BASIC I.D., which is easy to recall. These psychophysiological processes are connected by chains of behavior. The client, along with the clinician, determines which specific problems across the BASIC I.D. are most prominent. Psychophysiological processes are connected by chains of behavior. The client, along with the clinician, determines which specific problems across the BASIC I.D. are most prominent (Lazarus, 2006). The multimodal framework enables the practitioner to administer the necessary measures in a systematic and comprehensive manner. The seven modalities of the multimodal therapy approach are abbreviated by the acronym BASIC I.D. as follows: (Garrett, 2007). B - Behavior A - Affect S - Sensation I - Imagery C - Cognition I - Interpersonal relationships D - Drugs/biology All modalities should be addressed for effective treatment. Of these seven modalities, the first six address the fact that all humans exhibit behavior, have 69 emotional responses, retain experiences related to the five senses, invoke images, think, and interact with other people. (NIMH, 1999). Some of the procedures of a multimodal approach include desensitization of irrelevant emotional responses, cognitive reframing, assertiveness training, use of imagery as a coping strategy, focusing on enjoyable events, role-playing, family therapy, and the use of antidepressant medication (Lazarus, 2006). The multimodal therapy framework involves a complete assessment of the individual, and treatments are specifically designed for the particular client. This process encourages clinicians to adjust therapy to the client. The aim of multimodal therapy is to come up with the best methods for each client rather than force all clients to fit the same therapy. The therapist can also include strategies for the implementation of the treatment plan in order to avoid possible relapse. Experienced clinicians stress the importance of maintaining the integrity of distinct roles in performing therapy, while respecting the separate roles of other professionals as well. The National Association of Social Workers (NASW) Code of Ethics, 1999, defines the Value of Competence, with the corresponding Principles of Practicing within One’s Area of Competence, and Developing and Enhancing Professional Expertise. Medication advice is beyond the beyond scope of practice for a social worker. At the client’s request, and with the doctor’s permission, clinicians may assist clients with medication issues by offering to accompany the client to the psychiatric appointment to report any observations. Staff training and development is critical in order to ensure staff effectiveness and integrity of 70 the principles in conjunctive therapy. Through workforce education, the wellness and recovery model of the MHSA through staff training and staff development has been a crucial factor in erasing stigma through more humane treatment, and has accomplished OR produced a lot to increase self-esteem as people take an active role in their recovery. It contributes to the growth and vitality as the respective disciplines communicate to maintain the mission of providing the best therapeutic environment possible for individuals with depression in our communities (Hill-Ashford, Canchola, Palmisano, Guzman, Kurz, 2007). The likelihood of helping a client choose an appropriate treatment modality rests on the premise that the social worker understands the etiology and symptoms of a disorder. These skills should increase with the accuracy of the diagnosis. Clinical social workers have adapted to brief therapy by shifting to short-term modalities in order to provide services that are more effective. Intervention plans focus on assessing for suicidality and impulse control while discouraging any self-destructive behaviors in the form of Harm Reduction. Because of the emphasis on community-based treatment, the clinical social worker must assess the individual’s existing community support system and the level of need for continued mental health resources to determine appropriate social service referrals (Spratt, Saylor, & Macias, 2007). As anti-depressant medications typically do not take immediate effect, proactive outreach may help to prevent a relapse while stabilizing the mood of an individual who is suffering with symptoms of depression (Durlak, 1998). Therefore, in the beginning, it is up to the 71 social worker to establish rapport, and to inspire hope. With self-awareness and preplanning, a client may more successfully integrate back into the community. Psychosocial education. When treating depression, it is important to remember that clients, as well as those closest to them, may not have an accurate definition for the disorder. Many who suffer from depression experience a sense of paralyzing guilt due to an inability to adequately function, accompanied by a feeling of worthlessness. Simple, but thoughtful and individually considered written psychosocial educational information should be made available at the client’s first visit (Southwick, Friedman, & Krystal, 2008). We must also consider educating members of the public to act as gatekeepers. Gatekeepers are individuals in a community who have face-to-face contact with large numbers of community members as part of their usual routine; they may be trained to identify persons at risk for mental health problems or suicide and refer them to treatment or supporting services as appropriate (Department of Mental Health, 2010). Applying the Theoretical Framework The Cognitive Behavior Theory asserts that negative schemas and thought patterns can effect problem-solving abilities and influence behavior that could perpetuate and maintain depressive moods in an individual. The goal of cognitive therapy is to help the client learn or reactivate adaptable thinking patterns to aid them in understanding when dysfunctional beliefs occur that may expose them to depressive reactions. Cognitive theory, as it relates to the way a person stores, codes, and organizes information, also maintains that negative schemas are commonly found in those who 72 experience depressive episodes. Learned habits and problem-solving skills can affect a person's mood. Stress can activate negative schemas and reveal poor problem solving skills, as a person may become overwhelmed by external stressors thereby entering into a depression (Steinberg, Karpinski, & Alloy, 2007). The Cognitive Behavior Theory maintains that human behavior is influenced by a person’s ability to think and reason (Sheafor & Horejsi, 2008), and changing the way that a depression sufferer views oneself is central to resolving the difficulties related to this disruptive mental disorder. Research studies have indicated that cognitive therapy is as effective as pharmacotherapy (Haeffel, Gibb, Metalsky, Alloy, Abramson, & Hankin, 2008) in treating depression. One study suggested that those who responded to cognitive therapy were only half as likely to relapse or seek further treatment compared to those who were exposed to pharmacotherapy alone (Haeffel, et al., 2008). As therapy progresses, it is hoped that the client will be able to evaluate the worth and usefulness of their cognitions to make an informed choice about the possible consequences of their behavior. In order to accomplish the goals of cognitive therapy, there is a series of activities the client must go through to learn a more positive and functional belief system. The suggested activities include learning adaptive coping skills such as breaking down problems into manageable steps to promote mastery and positive experiences. Other actions include scheduled daily activities, and task assignments. Since cognitive therapy is typically carried out in eight to fourteen sessions, homework is usually asked of the client to maximize the therapy experience. Completion of homework assignments helps both the therapist and the client to assess 73 mood and symptoms, bridges information from previous sessions, and assesses feedback from the client. Strategies in the session can include psycho-education, roleplaying, imagery, and guided discovery. The completion of depression rating scales on a regular basis lends itself to the tasks associated with continual awareness and signifies client growth potential. At the end of therapy, the client should be able to evaluate and modify dysfunctional beliefs and build prevention skills to resist future depressive episodes (Cohen, Butler, Parrish, Wenze, & Beck, 2008). Proper assessment and available choices of evidence-based treatments, as well as the introduction of new therapeutic techniques found within the wellness and recovery approach, provide alternatives for improvement in the quality of well-being for those affected by the excruciating symptoms associated with this mood disorder. Summary To summarize, the history and nature of depressive mood disorders has been presented. An agreed upon definition is necessary in order to discuss the major findings about depression. The criterion for the definition of depressive disorders has been provided by the DSM-IV-TR, a diagnostic classification of mental disorders created by The American Psychiatric Association (APA). It has been determined that many experts have theories on the causes of depression. There are the biological factors, and although a specific genetic marker for depression has not yet been positively identified, there is research suggesting that depression runs in families, and is genetically related. Furthermore, brain scans show different cerebral activity in depression sufferers when compared to those who do not display symptoms of depression. Psychological 74 theories contend that attachment issues with support systems, isolation, and other issues, both internal and external, commonly lead to or exacerbate depression. Cognitive social theory examines negative thinking patterns that are typically found in individuals with depression. Negative schemas regarding self-image, and lack of hope about the future leads many individuals to believe that their actions are controlled by the external environment, which often leads to inadequate coping skills. Social theory builds upon the principles of cognitive theory and contends that a client’s social status, low educational attainment, lack of occupational resources, and limited income, often have a strong influence on their mood, causing further vulnerability to other external stressors. Learned helplessness prevents a person from being motivated toward change due to the perception that they are unable to alter their external environment. Following was a discourse on diversity issues relating to age, gender, ethnicity, culture, and spirituality, influencing individual experiences and thus the management of depressive symptoms. Also expressed was the need for clinicians to first rule out substance abuse and general medical conditions, as these disorders are commonly found in individuals with depression and often negatively affect mental health. The subsequent area of focus was in the identification and selection of an appropriate depression measurement instrument to assist in the increased accuracy of assessment. The use of the pharmacological approach in the treatment of depression was discussed. Three different classes of antidepressants medications were introduced, each with a different action to treat depressive symptoms, and each with different side 75 effects. Further dialogue regarding treatment was presented in regards to cognitive behavioral therapy (CBT), also considered "talk therapy." The focus of cognitive behavioral therapy is to educate the client that there are multiple realities and that they can learn to appreciate how this constructs their perceptions. Rather than trying to challenge a client's present thoughts and belief systems, this therapy honors the client’s history. As a result, the client may eventually become the author of their story. This approach is more empowering for the individual. Client empowerment helps to overcome cognitive deficits and teaches new coping skills during therapy (Haeffel, et al., 2008). The goal of CBT is to reframe negative schemas and inspire coping skills to overcome stress and depression. Evidence suggests that CBT is equally as effective as antidepressants. The combination of both pharmacology and psychosocial therapy to treat depression has many benefits. Cognitive Behavioral Therapy can provide support with self-esteem during the time it takes for antidepressant medications to bring about the necessary curative outcomes. The final area of discussion was in regards to the theme of effective depression treatment strategies leading to a targeted choice of therapeutic options for selection by the client. In addition to CBT, other valid treatment options were also presented, and included Behavior Modification, Interpersonal Psychotherapy, Narrative Therapy, and Systems Theory. This study explores the topic of depression, and identifies some of the medical model and wellness and recovery approaches used by clinicians while identifying the predominant depression measurement instruments employed. The researcher examines 76 the possible correlation between individualization of assessment and diagnostic instruments in the proper identification, intervention, and treatment of depression. The study discusses treatment practices within rural communities. The researcher seeks to present best practice options for the treatment of depressive symptoms and hopes to add to the knowledge base for identifying a universal approach to the assessment and treatment of depression. Prevention and early intervention are important factors in inhibiting unnecessary prolonged emotional hardship, where extended periods of distress often cause an increase in suffering. Inconsistent assessment techniques may lead to improper diagnosis and ineffective treatment, which correlates to the inability of the sufferer to heal from the various aspects of physical, cognitive, and affective indications. The use of depression measurement instruments is important in assisting practitioners in the increased accuracy of assessing and treating depression. The purpose of this study is to explore the topic of depression, and to identify medical model and wellness and recovery instruments used by clinicians to assess, diagnose, and treat depression in adults. The study aims to advance the professional knowledge base of these aspects of depression in a rural community, and to identify the predominant medical model, and wellness and recovery instruments employed by professionals. The instruments used by clinicians are central to the development of a universal approach to assessment, diagnosis, and treatment of depression within rural populations. 77 Chapter 3 METHODOLOGY Introduction This exploratory study presents five specific areas that may enhance our understanding of depression measurement instruments used by mental health professionals: (1) the extent to which diagnostic instruments are being used in the assessment of depression; (2) the severity of unipolar depressive disorders most often treated; (3) the diversity issues which effect the selection of depression rating instruments; (4) the internal and external factors measured by diagnostic instruments; and (5) the association of the identification of instruments used with an effective form of treatment. Study Design This is an exploratory study of the association between the utilization of depression measurement instruments in determining the selection of an appropriate treatment model. The design is appropriate in exploring the outcomes, but is not experimental, as participants have not been chosen randomly (Royse, Thyer, & Padgett, 2009, p. 245). This project focuses on diversity issues, as well as internal and external factors associated with depression, and the ability of depression measurement instruments to assess these factors. The study utilizes a descriptive design to describe the association of diagnostic instruments to the selection of a treatment approach. Descriptive research can provide much needed information for establishing and developing social programs and can use both qualitative and quantitative approaches 78 (Marlow, 2005, p. 227-233). This research applies both of these approaches with written surveys and face-to-face interviews. This is a quantitative study with an element of qualitative analysis for the open-ended questions. In the use of a deductive approach, research begins with an abstract, but logical relationship among concepts, then moves toward concrete empirical evidence (Neuman, 2007, p. 29). Content analysis will be used to analyze the transcripts for emergent themes. A theory will then be formulated to determine whether such diversity issues such as gender, age, and culture create enough of a difference in the experience of depression to justify new, more targeted depression measurement instruments. As well, this research focuses on a possible association between the utilization of measurement instruments in determining the treatment approaches to be considered. This study focuses on the use of depression measurement instruments. Themes include issues of diversity, external and internal factors commonly associated with depression, client readiness, treatment approaches, and use of self-help groups and psychosocial education, as well as selection of an appropriate treatment model. Study Questions In an effort to select appropriate therapeutic approaches, the study identifies various ways in which professionals assess depression. This researcher believes that the selection of an appropriate depression measurement instrument can help to increase the validity of selected treatment modalities. The following questions represent the main purpose of the study. Are practitioners who apply the wellness and recovery or hybrid approach more or less likely to use diagnostic instruments compared to those who use a 79 medical model for treatment? Is the type of Depressive Disorder associated with a practitioner’s use of assessment instruments? Does the use of diagnostic instruments assist the clinician in determining the specific theoretical approaches they select to treat depression? This study examines the use of depression measurement instruments to determine a diverse presentation of depressive symptoms. For example, gender specific expression of emotional responses that occur simultaneously with depression, age and how this relates to differences in the appearance of depressive symptoms, and the impact of the environment as well as the distinctive differences in the expression of depression due to cultural differences. Population and Sampling Procedures The study population and sample consisted of thirty (N=30) self-identified mental health clinicians from rural areas within the Northern California Sierra Foothills. Participants for inclusion in this study encompassed both licensed mental health professionals and mental health professionals who are currently collecting clinical hours through the Board of Behavioral Sciences of California. To qualify; these professionals had to have clinical experience in the diagnosis and treatment of adults with significant mood disorders, and had to have an awareness of various depression measurement instruments. For the purposes of this study, adults are defined as persons ages 18 and older. Non-probability sampling methods were used to recruit participants for the interview process. The researcher first acquired permission from the director of the Amador County Behavioral Health Department to conduct the interviews. Upon 80 approval, the researcher began by asking interested colleagues to participate in the study, and requested that colleagues refer others who might be willing to take part and who meet the participant criteria (see Appendix B). Taken as a whole, with direct and indirect links, all participants were within an interconnected web of linkages in that they are all mental health professionals in rural communities. This type of nonprobability sampling method, referred to as convenience sampling, recruited nine participants. Through use of the snowball sampling technique, twenty-one additional participants were recruited for the study. No inducements were offered, and in order to avoid any conflict of interest, the researcher had no prior supervision or supervisory relationship with any of the participants, nor did the researcher have any knowledge of case/client specific information. Participants were informed that they could request a copy of the thesis upon completion. Protection of Human Subjects Protocol for the Protection of Human Subjects was submitted and approved by the Division of Social work as a no-risk research project. The number that has been assigned to this project is 09-10-072. This study poses “no risk” to its participants because it deals directly with clinicians who are operating within their scope of practice and the information provided does not put these professionals at risk in any way. No physical procedures have been used in this study and professionals have not been subjected to any physical or emotional harm when participating in the interview process. Before completing questionnaires and conducting interviews, participants were briefed about the voluntary nature of this study through the informed consent 81 procedure, as explained in the informed consent document (see Appendix B). In order to provide comfort and security, interviews took place at an appropriate location of the participant’s choosing. All appropriate precautions were made to ensure the protection of the participants. Although the study was not anonymous, the participant’s identity and information remained confidential by providing each participant with an alias identifier, which was used for all related data and documents. All participants were treated in accordance with the National Association of Social Work code of ethics. Prior to interviewing participants, this researcher requested permission and verbal consent when utilizing an audio recorder. Participants were encouraged to discontinue participation in the interview process if they wished to do so at any time. Audio recordings of the interviews were quickly transcribed using a computer. No other equipment or instruments, nor any drugs or pharmaceuticals were used in this study. All recordings, transcripts, interview notes, and documents have been stored in a locked cabinet in the home of the researcher. Consent forms have been stored in a locked cabinet separate from audiotapes, transcripts, and data. All data including audio recordings and transcripts will be destroyed upon approval of this thesis. Data Collection and Instrumentation Tools Upon verbal approval from the directors of the Amador County Behavioral Health Services Department, the Behavioral Health Services Department of Calaveras County, and the Mariposa County Behavioral Health and Recovery Services 82 Department, this researcher disbursed thirty questionnaires and conducted thirty interviews from January 2010 to May 2010. The questionnaire consists of twenty-three questions (see Appendix C) and follow-up interviews with the participants were conducted. Both open-ended and close-ended questions were used (see Appendix C), and this researcher encouraged participants to clarify or elaborate on their answers in order to discern expertise as shared in the interviews. Interview times varied and were approximately thirty to sixty minutes each, depending upon the interviewee. All interviews took place in an appropriate setting as selected by the participant in an attempt to increase their comfort level. This researcher reviewed the form entitled Informed Consent to Participate as a Research Subject (see Appendix B) with all participants prior to conducting interviews. Participants also gave oral consent on the audio recorder before this researcher began interviewing. All data collected was kept confidential in accordance with the CSUS Human Subjects Committee of the Division of Social Work. The researcher designed this survey so that each person completing it would be able to add their own insight, reflections, and experiences using their own words based on working with individuals experiencing depression, as well as their use of diagnostic instruments in the assessment of depression severity. The design utilized quantitative data with an element of qualitative analysis for the open-ended questions. Each of the participants was asked to address matters related to depression and the use of depression measurement instruments. 83 Sources of Data The interviews centered on the use of depression measurement instruments and how various mental health professionals utilize these instruments in their practice. Information regarding diversity and internal and external factors were reviewed, along with a variety of diagnostic instruments as relates to various factors. In addition, the discussion included observations on whether diagnostic instruments are being used on a continual basis and if they are being used to assist in the selection of appropriate treatment approaches. Data Analysis The goal of this quantitative analysis was to search for the cause of incidents that exist when depression occurs within diverse groups of people. Additionally, this researcher wished to explore the possibility of whether the use of the medical model, a wellness and recovery approach, or a hybrid method that includes both is beginning to call for new and/or revised instruments for those who suffer from depressive disorders, and if this is being addressed within the mental health community. Furthermore, this researcher explored whether diagnostic instruments were being used on a continual basis in the monitoring of depressive symptoms. All questionnaires and interviews have been thoroughly reviewed by this researcher to identify the role of depression measurement instruments in the selection of appropriate treatment models. Themes have been identified, and similarities and differences in responses are discussed in relation to the research problem. Quotes were 84 utilized in the data analysis giving evidence to common themes. Upon collection of all data, Cross Tabulations utilizing Pearson Chi-Square Test of Association were run to determine significance. 85 Chapter 4 FINDINGS Introduction The information for this study was gathered from a questionnaire consisting of twenty-three questions (see Appendix C) and follow-up interviews with the participants. The researcher designed this survey so that each person completing it would be able to add their own insight, reflections, and experiences using their own words based on working with individuals experiencing depression, as well as their use of diagnostic instruments in the assessment of depression severity. The design utilized quantitative data with an element of qualitative analysis for the open-ended questions. Each of the participants was asked to address matters related to depression and the use of depression measurement instruments. Themes included issues of diversity, external and internal factors commonly associated with depression, client readiness, treatment approaches, and use of self-help groups and psychosocial education. Additionally, these thirty respondents were separated into two categories, those who are social workers and those who are not social workers. Survey data was compiled and analyzed in a variety of methods in relation to the research question. This chapter presents analysis of study findings organized by 1) demographics; 2) descriptive information on client assessment and treatment approaches; and 3) tests of association. Although results of these analyses did not disclose the type of impressive data hoped for, some interesting patterns were nevertheless revealed. 86 Demographic Information For this study thirty (N=30) self-identified rural mental health clinicians were selected (see Table 1). These clinicians were either licensed or currently collecting clinical hours through the Board of Behavioral Sciences of California. Of the thirty professionals interviewed, seven were male and twenty-three were female. Sixteen participants were social workers, eight were marriage and family therapists, three were psychologists, and three were psychiatrists. In addition, of these thirty professionals, nine participants received their highest degree between less than one year ago and up to but not including six years ago, eleven received their highest degree between six years ago and up to but not including 11 years ago, and ten received their highest degree between 11 years ago and beyond. Additionally, eleven have worked with adults diagnosed with depression for between less than one year and up to but not including six years, ten have worked with adults diagnosed with depression for between six years and up to but not including 11 years ago, and nine have worked with adults diagnosed with depression for between 11 years and beyond. Descriptive Information on Client Assessment Tools and Treatment Approaches 87 Table 1 Professional Demographics Of the thirty professionals interviewed, nineteen assess and treat clients in the 18-49 age range, ten participants see clients in the 50-65+ age range, and fifteen clinicians meet with all age groups. All clinicians interviewed see both male and female clients in their practice settings. Within the ratio of men to women who seek treatment with the three agencies involved in this study, nineteen professionals said that females seek treatment more often than males and eleven said that there is no gender difference in seeking treatment. Fifteen clinicians stated that females present with a higher rate of depression, and fifteen feel that there is not a gender difference. The primary participants of this rural study were from Amador, Calaveras, and Madera Counties. These and many other rural counties of the Northern California Sierra Foothills consist of a majority of Caucasian residents. Within a population of 88 37,876 in Amador County, 90 percent of individuals were listed as Caucasian. Within a population of 148,632 in Madera County, 87 percent indicated a Caucasian ethnicity. Within a population of 46,731 in Calaveras County, nearly 93 percent identified as Caucasian (U.S. Census Bureau, 2008). Consequently, sixteen of the study participants indicated that they do not have any immigrants on their caseload. Of the fourteen who indicated they do have immigrant clients only one said they have several, the other thirteen said they have very few. Only four of the participants feel that immigrants experience a higher rate of depression, just two feel that immigrants experience a lower rate of depression, and the remaining eight feel that there is no recognizable difference between immigrants and U.S. born clients in the rate of depression experienced. Some of the respondents stated that depressive symptoms are typically due to reasons that are unique such as language barriers, a lack of resources, and a lack of knowledge regarding resources. Cultural differences toward awareness of symptoms, or regarding outward expression of such symptoms may also create barriers. For example, Mexican immigrants often express depressive symptoms in a somatic manner. Therefore, depression may be overlooked when treating these clients. Descriptive Information on Client Assessment Tools and Treatment Approaches/Models Of the thirty professionals who were interviewed no one selected the unimodal medical model of assessment, diagnosis, and treatment for depression in adults (n=0). Six stated that they prefer a Wellness and Recovery Approach (n=6, 20%), and twenty-four participants reported that they prefer to utilize a hybrid method, which 89 includes components of the medical model, as well as a wellness and recovery approach (n=24, 80%) (see Table 2). Table 2 Treatment Approaches Concerning an affirmative answer regarding the question of use of depression measurement instruments, nearly three-fourths (n=22, 73.3%) said they do use one of the identified scales, and just over one-fourth (n=8, 26.7%) said that they do not utilize one of these instruments. Of the twenty-two participants who do use diagnostic instruments, no one uses the Zung Self-Rating Depression Scale (ZSRD). Fourteen have used the Beck Depression Inventory (BDI), nine have utilized the revised Burns Depression Checklist (Burns-D), two have used the Edinburgh Postnatal Depression Scale (EPDS), six have used the Geriatric Depression Scale (GDS), and two have utilized the Hamilton Depression Ration Scale (HAM-D), which is the only scale 90 administered by clinical professionals, the other aforementioned instruments are by selfreport. Eight participants report that they commonly use a scale other than one of those listed. Some of the other scales used included the Personal Health Questionnaire Depression Scale (PHQ-9) (Kroenke, Spitzer, Williams, 2001), a generic depression/anxiety checklist with no name indicated, the Mood Disorder Questionnaire (Hirschfeld, Williams, Spitzer, Calabrese, Flynn, Keck, Flynn, Keck, Lewis, McElroy, Post, Rapport, Russell, Sachs, Zajecka, 2000), two adolescent scales, the Reynolds Adolescent Depression Scale, (RADS) for clients up to age 20 (Reynolds, 1986), and the Millon Adolescent Clinical Inventory (MACI), for clients up to age 19 (Millon, 1993), and two unnamed depression scales by insurance companies Pacific Care and United Behavioral Health (see Table 3). Table 3 Instruments Used by Professionals 91 Seventy percent (n=21) of the participants in this study state that they rule out substance use disorders and general medical conditions by use of a request for medical examination, including laboratory testing. Sixty-six percent (n=20) of the participants use personal observation. Just over eighty-six percent (n=26) utilize client-reported history. Twenty percent (n=6) percent use family members or friends as informants. Concerning diversity and a choice of depression measurement instrument, twelve of the thirty participants said that age is an important issue. Only five of the thirty indicated that gender is an important consideration. Eight participants stated that culture is an important factor to examine in their choice of an instrument. Eight others indicated that reasons other than those listed are important factors to weigh in the selection of a diagnostic instrument. These factors included: I always use a Bio Psycho Social Assessment; the client’s situation determines the choice of instrument; the client’s socioeconomic status determines selection; determined by clinical interview; conversation with client and information regarding stressors at home and at work; the need to examine depression severity level, or to measure progress of treatment over time; I use client symptoms to determine the choice of instrument; I use a clientcentered approach to determination. Eleven participants stated that this question does not apply, as they do not use depression measurement instruments, or they always use the same instrument (see Table 4). 92 Table 4 Client Diversity Issues Affecting Choice of Depression Instrument In determining desired treatment approaches, eleven of the thirty participants said that age is an important issue. Eight of the thirty indicated that gender is an important consideration. Eleven participants stated that culture is an important factor to examine in their choice of treatment approaches; one participant added that clients of some cultures might be less likely to use medications. Nineteen of the thirty respondents said that the type of depressive disorder is important in determining the selection of treatment approaches. Twenty-five respondents feel that it is important to allow the client to determine the treatment approach, while five respondents gave additional answers. For example, two respondents said that they use an eclectic approach, two said they use a client-centered approach, one said family history and substance use influences choice of treatment, one said client’s developmental status is 93 an important factor, one said risk factors for safety of client, pacing with client for readiness improves success. Only one participant said that the question does not apply, and that they always use the same treatment approach when prescribing therapy for depression. The depressive disorders include: Major Depressive Episode Depressive Disorder NOS Dysthymic Disorder Major Depressive Disorder (Single Episode) Major Depressive Disorder (Recurrent) Major Depressive Disorder (Most Recent Episode with Atypical, Catatonic, Melancholic Features, and Postpartum Onset) Of these disorders, Major Depressive Disorder is the most commonly diagnosed at 90 percent (n=27). Major Depressive Disorder, Recurrent was also highly indicated (n=25, 83%). Of the five areas of client readiness for treatment success: Need for Change, Commitment to Change, Environment Awareness, Self-Awareness, and Closeness to Practitioner, answers varied widely among participants; however, the top two responses were Need for Change (n=16, 53.3%) and Commitment to Change (n=15, 50%) (see Table 5). 94 Table 5 Client Diversity Issues Affecting Choice of Treatment Model Most participants indicated that they consider the following eleven external factors as frequently presenting with a depressive episode, Abuse-domestic, physical, and sexual; General Medical Conditions; Grief; Isolation; Lack of Basic Resources; Lack of a Functional Social System; Oppression; Relationship Issues; and Substance Use (including alcohol). Very few answered always to one or more of these factors, and very few answered occasionally to one or more of these factors. None of the respondents answered rarely or never. Regarding the treatment of depression, question number 17 asked whether clinicians prefer to use a Unimodal or a Multi-Modal Approach, or whether the selected approach depends upon the client’s choice of treatment, or upon indicated external 95 factors. Twenty of the respondents stated that they prefer to use a Multi-Modal Approach, nine respondents said that they prefer to base treatment upon either age, gender, culture, type of depressive disorder, or client readiness, as they deem appropriate, and only one respondent said that they prefer to leave the treatment approach completely up to the client. None of the participants said that they prefer to use a Unimodal Approach (see Table 6). Table 6 Preferred Treatment Modality The model most used by these clinicians to treat depression is Cognitive Behavior Therapy, followed closely by use of Medication Therapy. Quite often, these treatments are prescribed together (see Table 7). 96 Table 7 Treatment Model Used Additionally, twenty-six participants (87%) refer clients diagnosed with depression to self-help and/or peer-led support groups. Twenty-three participants involve family members in client treatment sessions (77%) and seven said they do not see family members at all (23%). Of the respondents who report seeing family members, they do so only upon the request of the client. Twenty-eight of the respondents provide psychosocial educational information to the client (93%), and twenty-two (73%) provide psychosocial educational information to family members (see Table 8). 97 Table 8 Use of Psychoeducational Material and Referral to Self-Help Groups Tests of Association Frequency tables were used as a first step in organizing the variables. Of the thirty professionals interviewed, twenty-two utilize depression measurement instruments and eight do not. To determine the significance associated with the use of depression measurement instruments and a variety of collected research data, several Chi Square Analyses were performed. These analyses included use of diagnostic instruments and the following: professional identity specified as social workers and non-social workers; gender of professional; type of depressive disorder; identified treatment approach; selection of treatment model; and distribution of psychoeducational material. 98 Of the thirty professionals interviewed, sixteen participants were social workers and fourteen were non-social work professionals. Of the sixteen social workers, eleven utilize depression scales and five do not. Of the fourteen non-social work professionals, eleven use depression scales and three do not (see Table 9). Table 9 Use of Depression Measurement Instruments and Social Work or Non-Social Work Professional Social Workers Non-Social Work Professionals Use of Scales 11 (36.67%) 11 (36.67%) 22 Does Not Use Scales 5 (16.67%) 3 (10%) 8 Total 16 14 30 Total n = 30 (2 = .426, df = 1, p-value > .05) Using cross tabulation with Pearson Chi-Square Test, the association between the use of depression measurement instruments and professional identity specified as social workers and non-social workers, was found to be non-significant. Of the thirty professionals interviewed, seven were male and twenty-three were female. Five of the seven male participants utilize depression scales and the other two do not. Seventeen of the twenty-three female practitioners use depression scales and the other six do not (see Table 10). 99 Table 10 Use of Depression Measurement Instruments and Gender of Professional Male Female Total Use of Scales 5 (16.67%) 17 (56.67%) 22 Does Not Use Scales 2 (6.67%) 6 (20%) 8 Total 7 23 30 n = 30 (2 = .623, df = 1, p-value > .05) Utilizing cross tabulation, Pearson Chi-Square Test, the association of the use of depression measurement instruments and gender of professional was found to be nonsignificant. Of the thirty professionals interviewed, three participants who utilize depression measurement instruments use a wellness and recovery only approach. Nineteen professionals who utilize depression measurement instruments use a hybrid method that includes both a medical model and a wellness and recovery approach. Three of the participants who do not utilize depression instruments use a wellness and recovery only approach, and five use a hybrid method (see Table 11). 100 Table 11 Use of Depression Measurement Instruments and Choice of Treatment Approach Wellness & Recovery Approach Hybrid Method Total Use of Scales 3 (10%) 19 (63.33%) 22 Does Not Use Scales 3 (10%) 5 (16.67%) 8 Total 6 24 30 n = 30 (2 = .175, df = 1, p-value > .05) A cross tabulation, Pearson Chi-Square Test, was run and the association of the use of depression measurement instruments and choice of a treatment approach was found to be non-significant. Of the thirty professionals surveyed, seven commonly diagnose Major Depressive Episode and twenty-three do not. Twelve commonly diagnose Depressive Disorder, Not Otherwise Specified and eighteen do not. Nine commonly diagnose Dysthymic Disorder and twenty-one do not. Nine commonly diagnose Major Depressive Disorder, Single Episode and twenty-one do not. Twenty-five commonly diagnose Major Depressive Disorder, Recurrent and five do not. Regarding the use of depression measurement instruments and the common diagnosis of Major Depressive Episode (with answer equal to yes or no), of the thirty respondents surveyed, twenty-three do not commonly diagnose Major Depressive 101 Episode and seven do commonly diagnose Major Depressive Episode. Of the seven who do commonly diagnose Major Depressive Episode, five use scales, and two do not. Regarding the use of depression measurement instruments and the common diagnosis of Depressive Disorder, NOS (with answer equal to yes or no), of the thirty respondents surveyed, eighteen do not commonly diagnose Depressive Disorder, NOS and twelve do commonly diagnose Depressive Disorder. Of the twelve who do commonly diagnose Depressive Disorder, NOS, nine use scales, and three do not. Regarding the use of depression measurement instruments and the common diagnosis of Dysthymic Disorder, NOS (with answer equal to yes or no), of the thirty respondents surveyed, twenty-one do not commonly diagnose Dysthymic Disorder and nine do commonly diagnose Dysthymic Disorder. Of the nine who do commonly diagnose Dysthymic Disorder, seven use scales, and two do not. Regarding the use of depression measurement instruments and the common diagnosis of Major Depressive Disorder, Single Episode (with answer equal to yes or no), of the thirty respondents surveyed, twenty-one do not commonly diagnose Major Depressive Disorder, Single Episode and nine do commonly diagnose Major Depressive Disorder, Single Episode. Of the nine who do commonly diagnose Major Depressive Disorder, Single Episode, seven use scales, and two do not. Regarding the use of depression measurement instruments and the common diagnosis of Major Depressive Disorder, Recurrent (with answer equal to yes or no), of the thirty respondents surveyed, five do not commonly diagnose Major Depressive Disorder, Recurrent and twenty-five do commonly diagnose Major Depressive 102 Disorder, Recurrent. Of the twenty-five who do commonly diagnose Major Depressive Disorder, Recurrent, nineteen use scales, and six do not (see Table 12). Table 12 Use of Depression Measurement Instruments and Type of Depressive Disorder Major Depressive Episode Depressive Disorder, NOS Dysthymic Disorder Major Depressive Disorder, Single Episode Major Depressive Disorder, Recurrent Not Commonly Diagnosed 23 18 21 21 Commonly Diagnosed Use of Scales Does Not Use Scales 7 12 9 9 5 9 7 7 2 3 2 2 5 25 19 6 This researcher hoped to show a significant association between the use of depression measurement instruments and the type of depressive disorder. However, a cross tabulation test of association was conducted, and results indicated that there is no significance between use of depression scales and the common diagnosis of particular depressive disorders. Of the thirty professionals surveyed, seventeen do not utilize Behavior Modification and thirteen do. One does not utilize Cognitive Behavior Therapy and twenty-nine do. Eighteen do not utilize Interpersonal Psychotherapy and twelve do. Twenty-two do not utilize Narrative Therapy and eight do. Nineteen do not utilize Systems Theory and eleven do. Six do not utilize Medication Management and twentyfour do (see Table 13). 103 Regarding the use of depression measurement instruments and use of Behavior Modification (with answer equal to yes or no), of the thirty respondents surveyed, seventeen do not utilize Behavior Modification and thirteen do utilize this model. Of the thirteen who do utilize Behavior Modification, eleven use depression measurement scales, and two do not. Regarding the use of use of depression measurement instruments and use of Cognitive Behavior Therapy Model (with answer equal to yes or no), of the thirty respondents surveyed, one does not utilize a Cognitive Behavior Therapy model of treatment and twenty-nine do utilize this model. Of the twenty-nine who do utilize this model, twenty-one do use depression scales, and eight do not. Regarding the use of use of depression measurement instruments and use of Interpersonal Psychotherapy Model (with answer equal to yes or no), of the thirty respondents surveyed, eighteen do not utilize an Interpersonal Psychotherapy model of treatment and twelve do utilize this model. Of the twelve who do utilize an Interpersonal Psychotherapy model of treatment, nine do use depression scales, and three do not. Regarding the use of use of depression measurement instruments and use of the Narrative Therapy Model (with answer equal to yes or no), of the thirty respondents surveyed, twenty-two do not utilize a Narrative Therapy model of treatment and eight do utilize this model. Of the eight who do utilize a Narrative Therapy model of treatment, five do use depression scales, and three do not. 104 Regarding the use of use of depression measurement instruments and use of the Systems Theory Model (with answer equal to yes or no), of the thirty respondents surveyed, nineteen do not utilize a Systems Theory model of treatment and eleven do utilize this model. Of the eleven who do utilize a Systems Theory model of treatment, eight do use depression scales, and three do not. Regarding the use of use of depression measurement instruments and use of Medication Management Model (with answer equal to yes or no), of the thirty respondents surveyed, six do not utilize a Medication Management model of treatment and twenty-four do utilize this model. Of the twenty-four who do utilize a Medication Management model of treatment, eighteen do use depression scales, and six do not. Table 13 Use of Depression Measurement Instruments and Use of Treatment Model Behavior Modification Cognitive Behavior Therapy Interpersonal Psychotherapy Narrative Therapy Systems Theory Medication Management Does Not Use Model 17 1 18 22 19 6 Use of Model 13 29 12 8 11 24 Use of Scales 11 21 9 5 8 18 Does Not Use Scales 2 8 3 3 3 6 This researcher hoped to show a significant association between the use of depression measurement instruments and the choice of appropriate treatment approaches. To determine whether the use of depression scales was associated with the selection of a treatment model, a cross tabulation test of association was conducted. Results indicated that there is no significance between use of depression scales and 105 selection of treatment model. The most popular choice for the treatment of depression, regardless of the type of diagnosed disorder, was Cognitive Behavior Therapy. Of the thirty professionals interviewed, twenty-eight provide psychoeducational material to clients and two do not. Of the twenty-eight who do provide psychoeducational material to clients, twenty use depression scales and eight do not. Of the two professionals who do not provide psychoeducational material, both do use depression scales (see Table 14). Table 14 Use of Depression Measurement Instruments and Use of Psychoeducational Material Provide Does Not Use Psychoeducational Psychoeducational Material Material Total Use of Scales 20 (66.67%) 2 (6.67%) 22 Does Not Use Scales 8 (26.67%) 0 (0%) 8 Total 28 2 30 n = 30 (2 = .531, df = 1, p-value > .05) This researcher hoped to show a significant association between the use of depression measurement instruments and the distribution of psychoeducational material to the client. Using cross tabulation with Pearson Chi-Square Test, the association between the use of depression scales and the distribution of psychoeducational material was found to be nonsignificant. 106 Chapter 5 CONCLUSIONS Summary This project explored the use of depression measurement instruments and how utilization of such instruments may be associated with diversity issues, internal and external factors, use of treatment approach and selection of treatment models for use by practitioners, as well as the utilization of self-help and peer-led support groups, and the distribution of psychoeducational material. The findings of this project were based on thirty interviews conducted over a period of four months. Each interview consisted of twenty-three foundation questions in which this researcher asked clinical mental health professionals for clarification and elaboration as needed. Several themes emerged based upon the interview questions. Within each theme, comments were given by the participants interviewed. Limitations The small sample size of this project was limited and may not be easily generalized to the larger population. This project took place in a rural setting, which limited the diversity of the sample. This project also pulled from a limited group of interview questions that could have been better written to acquire more specific and relevant information. It may be helpful in further related research to create a more precise group of questions to utilize during the interview process. The study questions evaluated by this researcher related to the exploration of an association between the use of depression measurement instruments and the choice of 107 treatment approach, as well as a possible association with selection of treatment model. Upon completion of data analysis, it became clear that there are other influential factors that determine the selection of a treatment model, which should be included in the research questions. For a more thorough analysis, it is recommended that future related research include other such factors. Conclusions, Implications, and Recommendations Micro level. The information acquired by the use of diagnostic instruments can provide insight into the etiology of a client’s depression as well as ascertain the internal and external factors that influence a client’s depression. For example, the Burns Depression Checklist, revised (Burns-D-R) measures the severity of depression across domains that include thoughts and feelings, activities and personal relationships, physical symptoms, and suicidal urges. Scores are assigned according to indications of severity from mild to severe impairment and provide a quantitative assessment that is useful in following the course of the mental illness and/or possible responses to therapy (Burns, 1999, p. 729). Cognitive Behavior Therapy was the treatment of choice by the professionals surveyed in this study. If a client’s depression is related to thoughts, Cognitive Behavior Therapy may be the best choice of treatment; however, if a client’s depression is not thoughts-based, but is instead based upon physical factors, Cognitive Behavior Therapy may not be the best choice of treatment and perhaps Behavior Modification or Medication Management would be a better treatment model choice. Mezzo-level. This study was unable to show a significant association between the use of diagnostic scales and practitioners’ selection of treatment models, which was 108 the main focus of this study. The literature review shows that, although a lot of research has been done on the topic of depression and several studies have been performed on the use of diagnostic scales, there is a lack of empirical research concerning the use of depression measurement instruments by clinicians as relates to the selection of particular treatment models. This researcher wished to determine if practitioners who apply the wellness and recovery or hybrid approach versus medical model were more or less likely to use diagnostic instruments compared to those who use a medical model for treatment. Although a significant association could not be determined, it was established that most practitioners currently utilize a hybrid approach to treatment that includes both the medical model and a wellness and recovery approach to treatment. This was true across professions and it is interesting to note that even the psychiatrists who participated in this study utilize a hybrid approach. Another study question was concerning whether or not the type of Depressive Disorder is associated with a practitioner’s use of assessment instruments. Although, once again, a significant association was not determined, the research did indicate that the depressive disorder most commonly treated is Major Depressive Disorder, Recurrent, and that the majority of practitioners do utilize depression measurement instruments. The design of this project required professionals to review their use or non-use of depression measurement instruments in possible relation to their selection of an appropriate treatment model, which is an important component of social work practice. 109 Prior research reveals that there are many internal and external factors that are related to the onset of, experience of, and treatment for a depressive episode (Dumais, Lesage, Phil, Alda, Rouleau, Chawky, Roy, Mann, Benkelfat, & Turecki, 2005). Previous research indicates that several depression measurement instruments offer reliability in assessing symptoms of severity and responses to treatment (Reynolds, Dew, Pollock, Mulsant, Frank, & Miller, 2006). Macro-level. Exploring both influences and causes of depression, and how these present in clients with depressive disorders, can add further benefit in the area of targeted treatment. Continuing research may assist clinical professionals in further utilizing diagnostic instruments as a resource for the selection of appropriate treatment models. This may help individuals fit back into their communities, thereby benefitting society through fewer workdays lost, lower healthcare costs, a lower usage of disability benefits, increasingly involved parents, and fewer depressed and more active community. Depression measurement instruments do not appear to be widely used as an ongoing assessment tool and are typically used instead as a one-time diagnostic device. However, the continuous use of these instruments at regular intervals could provide valuable information in future research. If clients were provided scales at weekly intervals, patterns could be detected. Clients might begin to see that a particular time of month influences a person’s mood, or perhaps that depression increases before, during, or after holidays or anniversaries of significant events in their life. Individuals might find that particular types of events cause depressive responses in various categories. 110 For example, one might find that having a dispute with a co-worker causes more severe depressive thoughts and feelings, and may cause the individual to believe that they cannot go to work, as they are sick with a headache or stomachache. A client may find that relationship difficulties cause a spike in suicidal urges, and so forth. As people begin to see patterns in their expression of depression, they may use preliminary measures to offset their normal response pattern. Clients may find that if they take special care of themselves at the onset of a depressive episode with the use of pre-established self-care techniques, such as refraining from over-scheduling, getting plenty of rest, and eating nutritional foods, they might alleviate some of the longer lasting results of depression. Acceptance and self-care can remove feelings of guilt and allow depressive episodes to resolve more quickly. New diagnostic scales are constantly being created as needs change, and as more knowledge about mental illness is gained. For example, Mental Health America, Los Angeles (2005) created the Milestones of Recovery Scale (MORS), which is a recent diagnostic tool that measures indicators of recovery. This scale classifies consumers in particular clusters according to their needs in a way that would enable the providers of services to be held accountable for the outcomes of their services. The five domains of this scale include Risk of Involuntary Treatment, Activities of Daily Living/Independent Living Skills (ADL/ILS) Functioning Capacity, Employment/Role Performance, Symptom Distress, and Living Arrangements. Consumers are assigned to groups based on their level of risk, their level of coping skills, and their level of engagement with the mental health system. Just the movement from one group to 111 another could be viewed as an outcome. It also seems that such movement can be seen as a description of the recovery process. The three Components of Recovery are Level of Risk, Level of Engagement, and Level of Skills and Supports. The eight Milestones of Recovery are Extreme Risk, High Risk/Unengaged, High Risk/Engaged, Poorly Coping/Unengaged, Poorly Coping/Engaged, Coping/Rehabilitating, Early Recovery, and Advanced Recovery. The validity of this scale is r = .86, 95% CI = .80, .90. The diagnostic and therapeutic techniques new scales have to offer, their validity, their usefulness, and the needs they fulfill will determine whether they gain in popularity. Depression measurement instruments are being utilized, although perhaps under-utilized in comparison to the numerous ways in which they can be used. Older scales are being revised, and new diagnostic tools are being introduced. Further review of how these instruments can compliment professional practice is up to the clinicians. 112 113 APPENDICES 114 APPENDIX A Approval by the Committee for the Protection of Human Subjects by the Division of Social Work CALIFORNIA STATE UNIVERSITY, SACRAMENTO DIVISION OF SOCIAL WORK TO: Diana G. Peck Date: December 10, 2009 FROM: Committee for the Protection of Human Subjects RE: YOUR RECENT HUMAN SUBJECTS APPLICATION We are writing on behalf of the Committee for the Protection of Human Subjects from the Division of Social Work. Your proposed study, “Professional Perspectives of instruments Used to Assess, Diagnose, and Treat Depression in Adults.” __X_ approved as _ _ _EXEMPT _ X__ NO RISK ____ MINIMAL RISK. Your human subjects approval number is: 09-10-072. Please use this number in all official correspondence and written materials relative to your study. Your approval expires one year from this date. Approval carries with it that you will inform the Committee promptly should an adverse reaction occur, and that you will make no modification in the protocol without prior approval of the Committee. The committee wishes you the best in your research. Professors: Teiahsha Bankhead, Chrys Barranti, Andy Bein, Joyce Burris, Maria Dinis, Susan Eggman, Serge Lee, Kisun Nam, Sue Taylor Cc: Dr. Sue Taylor 115 APPENDIX B Informed Consent to Participate as a Research Subject I hereby agree to participate in a study entitled, “Professional Perspectives of Instruments Used to Assess, Diagnose, and Treat Depression in Adults,” and I understand that the participation in the study involves the following: Why is this study being conducted? This study is conducted by Diana G. Peck, a graduate-level MSW student at California State University, Sacramento, as the researcher’s thesis project. The study explores professionals’ perspectives associated with the diagnoses of depression, as well as the prominent clinical diagnostic instruments used to assess, diagnose, and treat adults with depression. Identification of this information is expected to add to the best-practice information available in Amador County related to professional practice with adults experiencing clinical depression. What will you be asked to do? You will be one of 10 mental health professionals in the Amador County area who will be asked to participate in a face-to-face interview with the researcher. The interview will take approximately one hour, and will take place in an appropriate county location of your choosing. The interview will be tape recorded and transcribed. You can request that the audio taping be stopped at any time in the interview without any negative consequence. The tape recording and transcripts will be destroyed upon completion of this study, and no later than July, 2010. Is this voluntary? Yes. You are under no obligation to participate. When you agree to participate, you can ask the interviewer to skip any questions that you would rather not answer. You are also free to stop the interview at any time. What are the advantages of participating? Participating in this study will assist in the development of knowledge of best practices utilized by professionals in identifying the etiological factors that lead to depression in adulthood, and the tools used to assess, diagnose, and treat adults with depression. Is this confidential? Yes. The study will remove identifying information from the interview form completed by the interviewer. All records will be identified only by a number, and any information between that number and the name of the professional will be kept in a locked file 116 cabinet that is available only to the principal investigator. At the completion of the study all identifying information, as well as the tape recording and transcripts, will be destroyed. Any reports or other published data based on the study will appear only in the form of summary statistics or a condensed account, and will not include the names or other identifying information of the participants. What risks do I face if I participate? There are no risks expected as the researcher is trained to ask the questions in a way that ensures the dignity and privacy of the participant. Each participant has the right to answer or not answer any question during the interview. Who do I contact if I have questions about this research? If you have any questions about this research project, or would like to inquire about the findings from this study, you may contact Diana G. Peck at email@example.com, or at (209) 296-7325; or you may contact the researcher’s thesis advisor, Dr. Susan Taylor in the Division of Social Work at firstname.lastname@example.org, or at (916) 278-7176. My signature below indicates that I consent to be interviewed, that I have read and understand the consent form, and that I have been provided with a copy. ___________________________________ Signature of Interviewee ____________________ Date Diana G. Peck Name of Interviewer ____________________ Date 117 APPENDIX C Survey and Interview Questionnaire I. Demographics: 1. Gender of Professional? M F 2. Professional Identity (type of clinical degree)? ___ LCSW ___ LMFT ___ ASW ___ IMF ___ Licensed Psychologist ___ Psychiatrist ___ Content Specific Degree ___ Other (please specify): _______________________ 3. Number of years since highest educational degree awarded? ___ <1 year ___ 1-5 years ___ 6-10 years ___ 11-15 years ___ >15 years 4. Years in clinical practice? ___ <1 year ___ 1-5 years ___ 6-10 year ___ 11-15 year ___ >15 years 5. Over the course of your clinical practice, how many years have you worked with adults diagnosed with depression? ___ <1 year ___ 1-5 years ___ 6-10 year ___ 11-15 years ___ >15 years II. Practice: 1. In the assessment, diagnosis, and treatment of depression in adults, do you prefer to use: ___ The Medical Model? ___ A Wellness and Recovery Approach? ___ A Hybrid Method that includes components of the Medical Model, as well as a Wellness and Recovery Approach? 2. Please check the following scales you have used in the past year to assess depression. (If you did not use a particular scale, please leave blank.) ___ Beck Depression Inventory (BDI), self-report ___ Burns Depression Checklist, (Burns-D) or revised, Burns-D-R, selfreport ___ Edinburgh Postnatal Depression Scale (EPDS), self-report ___ Geriatric Depression Scale (GDS), self-report ___ Zung Self-Rating Depression Scale, self-report ___ Hamilton Depression Rating Scale (HAM-D, HDRS), administered by clinical professional 118 ___ Other (please specify): _______________________________________ 3. Substance use disorders, as well as general medical conditions, are highly correlated with depression. How do you rule out for Substance-Induced Mood Disorder due to alcohol or other drugs, or rule out for Physiological Effects of a General Medical Condition? ___ Request Medical Exam (including laboratory testing) ___ Observation ___ Client-Reported History ___ Use of Informants close to the client Comments: ____________________________________________________ 4. Which factors, if any, most determine the instruments you use to assess depression? ___ Age ___ Gender ___ Culture Other: ________________________ ___ Does not apply, I always use the same assessment instrument. 5. If one or more of the factors in the previous question most affects your choice of depression assessment instrument, how does it affect your choice? Comments: ____________________________________________________ 6. Which client age group do you primarily assess and treat for depression? ___ 18-29 ___ 30-39 ___ 40-49 ___ 50-59 ___ 60-64 ___ 65+ 7. Do you assess and treat both males and females in your practice? ___ Yes ___ No If yes, does one gender tend to seek treatment at this clinic more often than the other, and if so, which one? ___ Male ___ Female ___ No Difference 8. Within the ratio of men to women who seek treatment at this clinic, does one gender appear to experience a higher rate of depression, and if so, which one? ___ Male ___ Female ___ No Difference Comments: ____________________________________________________ 119 9. Do you have any immigrants on your caseload assessed with symptoms of depression? ___ Yes ___ No If yes, how many are assessed with symptoms of depression? ___ None ___ Very Few ___ Several ___ Most 10. If the answer to the previous question is yes, do immigrants appear to experience a higher or lower rate of depression than clients who were born in the United States? ___ Higher ___ Lower ___ No Difference Comments: ____________________________________________________ 11. Which factors, if any, most determine the approach you use to treat depression? ___ Age ___ Gender ___ Culture ___ Type of Depressive Episode/Disorder ___ Client Readiness ___ Other: ____________________ ___ Does not apply, I always use the same treatment approach. 12. If one or more of the factors in the previous question most affects your choice of depression treatment approach(es), how does it affect your choice? Comments: ____________________________________________________ 13. Which type(s) of Depressive Episode/Disorder(s) do you most commonly diagnose? ___ Major Depressive Episode ___ Depressive Disorder Not Otherwise Specified ___ Dysthymic Disorder ___ Major Depressive Disorder ___ Single Episode ___ Recurrent ___ with Full Interepisode Recovery ___ without Full Interepisode Recovery ___ with Seasonal Pattern ___ Major Depressive Disorder, Most Recent Episode ___ with Atypical Features ___ with Catatonic Features ___ with Melancholic Features 120 ___ with Postpartum Onset 14. In entering the rehabilitation process, which of the following areas of client readiness do you find most increase the chance of treatment success? (Please number, in order from 1 to 5, with 1 being most important.) ___ Need for change ___ Commitment to change ___ Environment awareness ___ Self awareness ___ Closeness to practitioner 15. In your practice with adults diagnosed with depression, which of the following events do you feel are associated with the development/ recurrence of depression? Always Frequently Occasionally Rarely Never Abuse – Domestic 5 4 3 2 1 Abuse - Physical 5 4 3 2 1 Abuse - Sexual 5 4 3 2 1 General Medical Condition 5 4 3 2 1 Grief 5 4 3 2 1 Isolation 5 4 3 2 1 Lack of Basic Resources 5 4 3 2 1 Lack of Functional Social System 5 4 3 2 1 Oppression 5 4 3 2 1 Relationship Issues 5 4 3 2 1 Substance Use (incl. alcohol) 5 4 3 2 1 16. In your client population, are there additional factors that appear to contribute to depression that are not listed in the previous question? Comments: ____________________________________________________ 17. In treating depression, do you typically use: ___ A Uni-Modal Approach ___ A Multi-Modal Approach ___ It Depends Upon the Client’s Choice of Treatment ___ It Depends Upon Factors Indicated in Question Number 11 121 18. Please check the therapeutic approach(es) you find most effective in treating depression. ___ Behavior Modification ___ Cognitive Behavior Therapy (including DBT and Cognitive Reframing) ___ Interpersonal Psychotherapy ___ Narrative Therapy ___ Systems Theory ___ Medication Management 19. Do you refer clients diagnosed with depression to self-help and/or peer-led support groups? ___ Yes ___ No 20. When treating depression in adults, do you involve family members in sessions? ___ Yes ___ No If yes, do you ever meet with family members alone? ___ Yes ___ No 21. 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