Archives of Psychiatric Nursing
Volume 17, Issue 1 , Pages 3-11, February 2003

No comfort in the rural South: Women living depressed☆☆☆★

University of Virginia School of Nursing, Charlottesville, VA.

Article Outline

Abstract 

Despite the widespread notion of the bucolic life in the country, major depressive disorder (MDD) is common among impoverished women in the rural South. Women with MDD seldom get treated because of the paucity of treatment available, the inability to pay for services because of no insurance, and the distance they must travel to reach care. Even if treatment was available, impoverished rural Southern women are unlikely to seek services because of cultural and social prohibitions. These include incongruence between the biomedical model of MDD and sociocultural explanations for its causes and manifestations, stigma, and traditional viewpoints of women that keep them isolated and invisible. Innovative treatment strategies must be devised for these women that are based on local views of MDD and its treatment, and people and monetary resources available in poor rural economies. Needed research with this population include ethnographic studies to gain understanding of the cultural factors associated with MDD and its treatment and evaluation of outreach, and other novel paradigms of rural service delivery including the use of nonprofessional personnel. Although the problems of treatment and research with this population are daunting, there is an opportunity for imagination, innovation, and creativity in devising local solutions to local problems. Copyright 2003, Elsevier Science (USA). All rights reserved.

 

The literature is replete with studies of depression in women but research about the mental health of rural women is sparse (Mulder et al., 2000). Although several studies suggest that the incidence of major depressive disorder (MDD) is high among rural women (Hauenstein and Boyd, 1994, Hauenstein & Peddada, 2003; Sears, Danda, & Evans, 1999), scant mental health services and women's poverty and isolation render them difficult to access, research, and treat. Further, cultural taboos about talking about mental health problems and other rural values prevent women from expressing their mental health needs and community leaders and health professionals from identifying the scope of the need for mental health services.

This article describes MDD in women living in the rural South, the social and cultural factors that affect meanings ascribed by these women to depressive symptoms, and how these factors contribute to chronic depression in this population. Because of the limited information available on depression in rural women in the research literature, the reviewed literature is supplemented with knowledge I have gained in the field over 13 years of research with this population. Some suggestions about culturally congruent practice of psychiatric nursing with rural populations and needed research are provided.

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Depression in rural women 

Data from the National Comorbidity Study (Kessler et al., 1994) showed that the 12-month prevalence rate of MDD among women was nearly 13%, but rates in poor rural Southern Appalachian women may be considerably higher. Several studies have documented high rates of MDD in rural populations. By using the PRIME-MD (Primary Care Evaluation of Mental Disorders; Spitzer et al., 1994), a diagnostic measure of psychiatric disorder, Sears et al. (1999) found that 39% of users of rural primary care had a diagnosis of mood disorder. Of these, 35.3% had current MDD. Another study showed that 21% of women from a mixed urban-rural population had MDD (Miranda, Azocar, Komaromy, & Golding, 1998). By using a depression screener, Hauenstein and Boyd (1994) found that 41% of rural women using primary care had scores in the depressed range. A follow-up to that study showed that 67% of women drawn from the same sample and completing a computerized form of the Diagnostic Interview Schedule (Robins, Helzer, Croughan, & Ratcliff, 1981) had current MDD. In a later study with a sample drawn from the same rural primary care population, Hauenstein and Peddada (2003) estimated a current prevalence rate for MDD of 51%, documented by a diagnostic interview (Bucholz, Marion, Shayka, Marcus, & Robins, 1996).

There is evidence that rural women are disabled significantly by their psychiatric symptoms. Studies with rural samples show disablement in physical and emotional functioning among rural populations (Clayer, Bookless, Air, & McFarlane, 1998; Sears et al., 1999). Data derived from an evaluation of a depression treatment program (Hauenstein 1996a, 1996b, 1997) showed considerable emotional disability among impoverished, rural Southern women who had MDD.

The larger context of this problem is the impact depression has on individual women and the often significantly strained resources of rural communities. Many rural Southern communities are medically underserved (Beauregard, Drilea, & Vistnes, 1997; Kass, Weinick, & Monheit, 1999). The added burden of women seeking care for ill-defined symptoms further stretches the already thin medical resources. Depressed women are less likely to be employed or otherwise productive so they are unable to contribute to the often meager economy of rural communities. Although the extent to which depression-related disability influences rural communities has not been established, studies from urban settings suggest that the economic effects on resource-poor rural communities could be considerable. For example, in studies with primarily urban populations, disablement has been associated with lost wages owing to disability days (Simon et al., 2000), cognitive and social deficits in children of depressed women (Field, 1998; Goodman & Gotlib, 1999; Murray, Sinclair, Cooper, Ducournau, Turner, & Stein, 1999; NICHD Early Child Care Research Network, 1999), and marital conflict (Sayers, Kohn, Fresco, Bellack, & Sarwer, 2001).

The rural South 

The Southern region of the United States includes 12 states, with diverse topography and culture. It includes the Southern Appalachian mountain chain and the Piedmont—a flat plain extending from the Appalachians to the Atlantic Ocean. Although there are several major metropolitan areas in the South, the region is primarily rural. The economy is based on slow-growth or declining industry biased toward low-skill, low-wage activities, with fewer jobs available today than in 1969 (Report: The Adequacy of Rural Financial Markets, 2002). There are more women, children, elderly, and African Americans living in the rural South than in other regions in the country. The rural South has more poverty than any other region of the country (Economic Research Service, 2002; U.S. Department of Agriculture Economic Research Service, 2002). Almost 18% of nonmetropolitan areas are impoverished, compared with metropolitan areas of the South (12.2%) and rates nationally (11.7%) (Proctor & Dalaker, 2001). In the United States, 382 counties are considered persistently poor; 363 of these are rural counties, the vast majority in the rural South. Here, in 2000, the poverty rate for children was 24%, compared with 17.3% for Southern metropolitan children and 20.3% nationally (Procker & Dalaker). For women who are heading households, 37.2% in the rural South are impoverished. Just over 20% of Southern rural residents are uninsured (Blackwell & Tonthat, 1998).

As in other rural regions of the United States, there are few mental health providers in the South, and as a result rural residents have fewer mental health visits when compared with urban dwellers (Fortney, Rost, Zhang, & Warren, 1999; Petterson & Hauenstein, under review). Primary care agencies provide the majority of services for rural persons with depressive and anxiety disorders (Fox, Merwin, & Blank, 1995), but here, mental health problems are less likely to be detected or adequately treated (Rost, Humphrey, & Kelleher, 1994). With the scarcity of mental health providers and the extent of poverty, women in the rural South with mental health problems are unlikely to receive mental health treatment.

Explanatory models of depression 

Kleinman (1980) asserts that individual experience of illness is culturally bound. Meanings assigned to illness, beliefs about etiology, and the language of illness are informed by local values and traditions. Only a handful of studies describe how women perceive their experience of MDD. Two studies showed that the meaning attached to MDD by highly educated urban women closely coincided with the biomedical model of MDD (Gammell & Stoppard, 1999; Schreiber & Hartrick, 2002). MDD was conceptualized as loneliness in two studies (Beck, 1992; Wilkinson & Pierce, 1997). In another investigation, low-income women characterized MDD as loss of control and having conflicting feelings (Poslusny, 2000). Only one of these studies directly focused on the meaning of MDD, and all had very small samples.

Contrary to biomedical causal models of depression, impoverished rural Southern women attribute illness symptoms to other causes. Southern religion, Appalachian and poverty cultures, gender, ethnicity, language, and stigma influence the meaning assigned by these women to their depressive symptoms. Beliefs in the causes of mental illness are rooted in Southern religious traditions including Evangelical Christianity, slave religion, and derivatives of early 18th century voodoo (Morrison & Thornton, 1999). Thus, spirit possession and punishment are important attributions for the causes of mental illness by impoverished Southern rural residents.

The Appalachian subculture in the mountainous regions of the rural South has attributions for behavior commonly associated with mental illness that differ from those based on the a biomedical model. Flaskerud (1980), for example, asked Appalachians, lay non-Appalachians, and mental health professionals to respond to 8 vignettes describing men and women who had been hospitalized for mental illness. Most Appalachian respondents did not endorse behaviors in the vignettes as associated with mental illness even though they were labeled as such by mental health professionals and lay non-Appalachians. Appalachians ascribed different meanings to the same behaviors labeling them as “giving up,” “immoral,” “stupid,” “rude,” “lots of people are like that,” “bully,” “mean,” and “drinking too much.” Most Appalachians said that behavior evident in the vignettes should be punished, tolerated, or justified. Only a few thought that mental health treatment was warranted. In a more recent study of Appalachian women, severely depressed respondents did not recognize their symptoms as depression and delayed seeking treatment until they were having considerable difficulty functioning (Browning, Andrews, & Niemczura, 2000). Because impoverished rural Southern women believe that God works through the individual, they turn to family, friends, and special healers to help them recover their health (Hill & Fraser, 1995). Further, they are unlikely to see mental health or other providers as helpful in managing their symptoms (Fox et al., 1995).

The condition of “nerves” is a common meaning for depression used by women in diverse cultures (Cayleff, 1988; Finkler, 1989), and may be part of the lexicon impoverished rural Southern women use to describe their depressive symptoms. Symptoms known as nerves include tension, trembling, stomach pain and/or nausea, headaches, heart tremors, shortness of breath, chest pains, dizziness, blurred vision, “falling out,” hot flashes, lethargy, sadness, tension, insomnia, weight pressing on the chest, arms, and head, and obsessive worrying (Nations, Camino, & Walker, 1988). Nerves also are reported to cause problems with motivation, sleeplessness, and increased appetite. Affective symptoms include crying, pouting, anger, resentment, feeling like yelling, an inability to forgive and forget, poor concentration, and fear. Nations et al. found a strong association between the condition of nerves and depressive and anxiety symptoms.

Camino (1989) conducted a study of nerves in a Southern African-American community, focusing more on the meaning and attributions women made for nerves. Causal attributions for nerves included women's “weaker” nervous system and their tendency to worry, called “worriation.” Worriation caused nerves to become “broken,” “frazzled,” “torn,” “shot,” “wore out,” or “wrung out.” Women in this study reported being reluctant to talk about their nerves to others in the community because they feared that others would exploit them in their weakened conditions.

These findings suggest that the language and culture of poor Southern women differs from that of mainstream America. They are less likely to view aberrant behavior as signs of mental illness, and more likely to believe that illness and recovery is caused by the work of God or spirits. Thus, impoverished rural Southern women are unlikely to hold the biomedical model of depression as a reasonable explanation for their symptoms. Kleinman (1980) noted that incongruence between mental health providers and the recipients' explanatory models of illness impedes help seeking and increases the likelihood that treatments suggested by providers will be rejected. From this perspective supplementation of scant mental health resources in rural areas of the South, in itself, is unlikely to be effective. Instead, health services research efforts should focus on developing local strategies that are culturally congruent and acceptable to potential consumers, and that are feasible in the rural economies where they will be implemented.

Invisible women 

Mental health problems are stigmatized in all classes and regions of the United States but little is written about stigma and its effects on rural women. Although stigma is acknowledged in many studies as a problem for rural residents, typically the problem is painted in broad strokes, revealing little about its impact personally or on use of mental health services (Blank, Fox, Hargrove, & Turner, 1995; Van Hook, 1999). There is a general reluctance to speak about mental illness in rural areas because of fears of breaches of confidentiality and the stigmatizing attitudes of care providers (Fuller, Edwards, Procter, & Moss, 2000; Mulder et al., 2000; Starr, Campbell, & Herrick, 2002). The author's current work in a rural Southern Appalachian community confirms these findings. For example, our research team interviewed key informants from this community who repeatedly mentioned the unwillingness of rural residents to disclose their mental health problems as one of the major barriers to providing mental health services in the community.

Rural poverty also contributes to Southern women's invisibility and increases their risk for MDD (Brown & Moran, 1997; Bruce, Takeuchi, & Leaf, 1991; Costello, Keeler, & Angold, 2001; Kessler et al., 1994). Rural Southern women are more likely to live in persistent poverty, which has unique and often more devastating outcomes than intermittent or transient poverty. Long-term poverty has been associated with depression, developmental deficits in children, problems in activities of daily living, and decreased life expectancy (Geronimus, Bound, Waidmann, Hillemeier, & Burns, 1996; Korenman, Miller, & Sjaastad, 1995; Lynch, Kaplan, & Shema, 1997). Thus, persistent poverty has the effect of sustaining itself by limiting personal capabilities, educational achievement, and possibilities of gainful employment (Stipek & Ryan, 1997).

Several studies illustrate this point. For example, a study of women from an economically deprived area of Southern Appalachia showed that when compared with women whose poverty was transient, they were less likely to hold a high school diploma or return to school after dropping out, have fewer job opportunities, and little in the way of future plans (Duncan & Lamborghini, 1994). Rabow, Gerkman, and Kessler (1983) suggest that under conditions of persistent poverty, people experience learned helplessness, limiting their ability to take advantage of opportunities that may come their way.

Women's invisibility also was evident in data that emerged from a phenomenologic/hermeneutic study (Cohen, Kahn, & Steeves, 2000) conducted by the author to evaluate impoverished rural Southern women's experiences with MDD and responses to treatment for this disorder. By using intensive in-home interviews with 14 women who had completed a treatment program for depression, the author queried them about their experience of being depressed, in treatment, and changes they had made consequent to treatment. Two themes, no voice and no choice, emerged from the data. Women believed that they had little influence in their homes and communities and little choice about their actions. Factors that contributed to this sense of helplessness included parental abandonment, stigma, living in an abusive situation, and having few resources. Excerpts from a few narratives are illustrative. With regard to childhood adversity: “It was always from what I can remember, the sexual abuse between the years of probably 6 and 8. The verbal abuse lasted as long as my parents were alive.” The women's self-esteem was terrible. One woman interviewed never looked at the interviewer during the entire 2-hour span of the interview. She said “I've always been a kind of withdrawn person…if you have noticed, I guess you have, I have trouble looking at you in the face. I just can't believe that anybody would put up with me. I am…my voice is aggravating as hell.” Poor self-esteem also was associated with being overly willing to accept responsibility for circumstances outside of the women's control. The following excerpt shows the point. “I cowered to everybody. Hey, I'm your floor mat, walk on me. And everybody did, you know.” Some women talked about the difficulties of being a woman in rural Southern society. One said “The old South is…you are raised to be subservient, you know, and they just really—I was a dog. They made me feel like a little dog and I know I don't have to be that little dog any more.”

Invisible women cannot speak on their own behalf. Their voicelessness has led to a void in our understanding of their experience of MDD and thwarted efforts to find treatment paradigms that sustain long-term recovery. For example, extant research provides little insight about the meanings impoverished rural Southern women assign to depressive symptoms, and how these symptoms are sustained by social and cultural imperatives. Although “nerves” seems to be part of the lexicon of women in many cultures, it is not certain that it is meaningful to this population. What is known is that the meanings about depression and mental illness currently understood by this group of women are so inhospitable that speaking about illness of this type virtually is taboo. Under these conditions, applicability of known effective treatments for depression is less salient than understanding the ways these women can talk about their symptoms and experience, how they treat their symptoms and its efficacy, and what aspects of the dominant cultural narrative impede depressed women in their efforts at self-care.

Chronic depression 

Untreated, MDD results in a long-term spiral into chronic depression. In this state, the full criteria for MDD are met for 2 or more years without remittance (Hays, Krishnan, George, Pieper, Flint, & Blazer, 1997). Chronic MDD is refractory to treatment. Women caught in this spiral describe themselves as always feeling depressed for as long as they can remember. In states of chronic depression women are unlikely to view treatment as being beneficial to them because they have given up hope.

Chronic depression is a problem for impoverished rural Southern women. In previous research we have found that 91.9% of those diagnosed with depression had the recurrent form (Hauenstein and Peddada, under review). Although a major factor contributing to chronic depression is nontreatment, many factors, some rooted in rural Southern culture, contribute to rural impoverished women's inability to obtain needed treatment. First are beliefs about consumption of health care services. In the rural South there is a greater tolerance of aberrant behavior, beliefs that illnesses arise from God and must be removed by God, and the value of self-reliance. These perspectives tend to prevent obtaining treatment because treatment is viewed as not necessary. Recent studies with impoverished rural Southern residents showed that only 5.8% of 32.4% diagnosed with a psychiatric disorder sought help for their disorder even when provided with information about the disorder and how and where they could get help (Fox, Blank, Berman, & Rovnyak, 1999). Although 99.3% of respondents in this study said that they would seek mental health care if they thought mental health services would help them, the most common reason cited by the sample for not obtaining treatment when told they needed it was that they did not view it as necessary (Fox, Blank, Rovnyak, & Barnett, 2001).

Second, available treatments may not be obtained because they are incongruent with women's explanation of their depressive symptoms. How impoverished rural Southern women describe their symptoms are likely at variance with that of the biomedical model. The language of nerves or other colloquialisms for depressive symptoms may not be associated with MDD by primary care providers. Even when MDD is detected, these women may be unwilling to follow the recommended treatment because it does not fit with what they believe is the root cause of their problem. A report on the design of community-based interventions cited a recent research clinical trial with poor urban women of non-Hispanic white, Hispanic, and African-American ethnic origin (Hohmann & Shear, 2002). The African-American subjects in this trial refused to be randomized to the medication group because of their perception that depression symptoms are inevitable consequences of their social condition (poverty, crime, and abuse). In other research, even women who had biomedical explanatory models for depression thought that this explanation was limited and interfered with their taking more responsibility for aspects of their illness (Gammell & Stoppard, 1999; Schreiber & Hartrick, 2002).

A third issue is accessibility. Studies reviewed earlier show that mental health manpower shortages, poverty, being uninsured, and long distances to treatment all interfere with receiving treatment for depression (Fortney et al., 1999; Hauenstein & Petterson, under review). Finally, poor motivation interferes with treatment in impoverished rural Southern women. Attendant with MDD are impairments in motivation, concentration, and memory, and a sense of hopelessness, helplessness, and worthlessness. These impairments directly interfere with women's willingness to seek health care because they do not believe they can feel any differently, they do not feel worthy of treatment and they are unable to mobilize cognitive abilities to figure out how to get to care. Further, the culture of poverty can contribute to passivity and helplessness in these women, leaving them unmotivated to change their situation.

Culturally congruent treatment 

The new mantra in health care delivery is providing culturally congruent treatment. Without diminishing its importance, much of the discussion relative to this topic entails how we can modify existing treatments to make them more tenable in the communities in which they will be implemented. This is a fairly limited concept of cultural congruence because there are some treatments, known to be effective, that will not be acceptable to populations such as this one. For example, referring back to the earlier example of the clinical trial in which African-American women refused to enter the medication arm of the study because they did not believe that medication would change their symptoms, we find a known effective treatment, medication, which will not be effective in this specific cultural group. A commonly used strategy for this type of problem is to provide education about the biologic basis of depressive illness. Unfortunately, the biomedical model is not nearly as convincing as experiencing the feelings associated with oppression or violence.

If medication and psychotherapy are the known effective treatments for MDD but may not be acceptable to impoverished rural Southern women, what kind of treatment could be implemented that also would be effective? There are currently no models of rural mental health treatment that are appropriate for impoverished people with mental health problems. One model being advocated is the integration of mental health services into rural primary care settings. Because these services must be insurance based to be solvent this is not a model that would be applicable to most rural impoverished women. The lack of models, however, provides the opportunity to be creative and culturally relevant and apply local solutions to local problems. For example, assuming that the explanatory model rural poor Southern women have for depressive symptoms is different than the biomedical model of depression, then a first priority would be to learn what depressive symptoms they have and what they call them. Developing a shared meaning about the illness and its causes provides a point of departure for designing culturally congruent treatment. Next, it is useful to determine what women have tried to manage the symptoms they experience, and what works and does not. Because many Southerners believe that God has a role in the etiology and recovery from illness, a member of the clergy or a spiritualist may be useful in reducing depressive symptoms. Although first-line medication for depression may be unacceptable, a herbalist may prescribe remedies helpful in reducing depressive symptoms. With a good understanding of acceptable strategies for treating mental health problems in rural women, nurses can design treatment plans that are effective and culturally congruent.

Although antidepressant medication is a known, effective treatment for MDD, its use is highly stigmatized and, for some, a public recognition of their mental illness. Medication is very expensive, far outside the ability of most impoverished Southern woman's ability to pay. Further, women may need to travel some distance to fill the prescription. So, although efficacious, medication may not be not effective for this population of women. This is not to say that medication is never warranted, there are many situations in which it is. Long-term resolution of depressive symptoms in this population, however, is unlikely to occur only through the use of medication.

The other treatment known to be efficacious for treatment of depression is psychotherapy. In a population of few words, it is reasonable to question the usefulness of psychotherapy in reducing depressive symptoms. In the rural South, narrative or story is the principal means of shaping values and behaviors of the next generation, and inculcating cultural norms. Through narrative, for example, Appalachian girls learn the traditions that form women's roles including selflessness, caring for the home and family, being strong, and keeping one's place. This dominant narrative serves to shape their personal identity, which is congruent with traditional views of women.

Because story is an accepted means of communication in this environment, narrative therapy, a postmodern therapy, may be a useful approach. In narrative therapy women are asked to tell their stories, either in a life history format or the story of their illness. By using story as a format, depressed women might be queried about when they first started having symptoms and how the symptoms affected their life. When the client gains more trust in the therapist, she might be asked to tell the story of her growing up years by using a life-history approach. The therapist shapes the story through queries about how having these symptoms has affected her life, and the life of the people important to her (White & Epston, 1990). To learn what strategies might be used to reduce depressive symptoms the client is asked to recount those times and circumstances in her life when she was less affected by her symptoms. These queries help the client to tell her story in different ways and, over time, to gain greater understanding of herself and her world. In telling their illness stories, women may be freed to develop new meanings of depressive illness that are less culturally constrained and more consonant with their personal identity. Story telling is viewed as a viable means to provide holistic nursing care (Banks-Wallace, 1999) and has been used successfully in such diverse interventions as educating girls about their sexuality (Nwoga, 2000), controlling stuttering (DiLollo, Niemeyer, & Manning, 2002), treatment planning for long-term residents of nursing homes (Heliker, 1995), and treatment of oppositional defiant disorder (Smith & Celano, 2000).

Local solutions for local problems 

Our knowledge of depression and its treatment is based largely on studies of middle-class, non-Hispanic whites, or people otherwise insured. In a report to the American Psychological Association, Mulder et al. (2000) document the paucity of research on the mental health of rural women, especially those of a lower socioeconomic background. Of high import is the need for ethnographic research that establish the meaning that rural Southern poor women ascribe to depressive symptoms and what they do to manage this problem. A critical component of this research is understanding what keeps these women silent about their distress. Second, new models of service delivery must be developed that are acceptable to these women and address the important barriers to treatment. For example, rural outreach programs have been a successful model for providing basic health care and preventative services. These programs bring health care to the rural communities instead of using a centrally located health care center. Hauenstein (1996a, 1996b, 1997) has used in-home treatment for depression for rural women, and this may be another approach to mental health care. Integrating mental health services in primary care settings has been successful in urban areas, but this model has been designed and tested only on insured clients. Models must be designed so that they can be supported by the local economy, which often has few resources for establishing and maintaining human service programs.

Building on this last concept, mental health treatment must be designed to use local resources and methods of treatment. The concept of individual treatment by a mental health provider simply will not work in this resource-poor environment. Instead, mental health providers might be better used as a resource to those in the community who already provide services for women. For example, in the rural community in which the author currently practices there are a wealth of nonprofessionals who minister to people's needs. These include the clergy, the volunteer coalition, lay healers, root doctors, and the family. These established methods of informal care already are acceptable to rural women, and there are fewer barriers to receiving this type of care. Research should address how these local informal providers can be partners in treatment, and the efficacy of such treatment.

Thus, to treat rural Southern women and other poor rural residents, we must imagine new forms of treatment, in new settings, using different resources. We do that by learning local knowledge, and having obtained that, devise local solutions for mental health problems.

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☆ Supported by grant no. MH19177, National Institutes of Mental Health, Bethesda, MD.

☆☆ Address reprint requests to Emily J. Hauenstein, PhD, LCP, APRN, BC, Associate Professor of Nursing, University of Virginia School of Nursing, Box 800782, Charlottesville, VA 22908-0782. E-mail: ejh7m@virginia.edu

★ 0883-9417/03/1701-0002$30.00/0

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doi:10.1053/apnu.2003.6

Archives of Psychiatric Nursing
Volume 17, Issue 1 , Pages 3-11, February 2003

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