Team-based suicide prevention: lessons learned from early adopters of collaborative care.

Suicide prevention in clinical settings requires coordination among multiple clinicians with expertise in different disciplines. We aimed to understand the benefits and challenges of a team approach to suicide prevention in primary care, with a particular focus on Veterans. The Veterans Health Administration has both a vested interest in preventing suicide and it has rapidly and systematically adopted team-based approaches for primary care interventions, including suicide prevention. We conducted eight focus groups and eight in-depth interviews with primary care providers (PCPs), behavioral health providers and nurses located in six regions within one Veterans Administration Catchment Area in the northeast of the US. Transcripts were analyzed using simultaneous deductive and inductive content analysis. Findings revealed that different clinicians were thought to have particular expertise and roles. Nurses were recognized as being well positioned to identify subtle changes in patient behavior that could put patients at risk for suicide; behavioral health providers were recognized for their skill in suicide risk assessment; and PCPs were felt to be an integral conduit between needed services and treatment. Our findings suggest that clinician role-differentiation may be an important by-product of team-based suicide prevention efforts in VHA settings. We contextualize our findings within both a processual and relational interprofessional framework and discuss implications for the implementation of team-based suicide prevention.

Depression, social support and associated factors among women living in rural China: a cross-sectional study.

BACKGROUND: Few studies have focused on depression and social support in Eastern populations, especially women in rural China. Our research investigated depression among women in rural China, and studied the relationships between social support and depression. METHODS: We recruited women ages 16 years and older from north Sichuan. Participants completed socio-demographic measures, the Center for Epidemiologic Studies Depression Scale, and the Duke Social Support Index. The analysis method included descriptive statistics and logistic regression. RESULTS: The final sample included 1,898 participants with a mean age of 48.6 years, and the prevalence of significant depressive symptoms was 12.4%. Results suggest being unemployed, having poorer perceived health/economic status, and lower social support were positively associated with depression. Younger age and greater social support were negatively associated with depression. CONCLUSIONS: This study provides insights on the psychological health of women in rural China and potential directions for future research. These issues are especially pertinent during this time of rapid economic transformation and outmigration in rural China.

The TRIBE model: How socioemotional processes fuel end-of-life treatment in the United States.

Prior interventions have repeatedly failed to decrease the prescription and receipt of treatments and procedures that confer more harm than benefit at the End-of-Life (EoL); new approaches to intervention are needed. Ideally, future interventions would be informed by a social-ecological conceptual model that explains EoL healthcare utilization patterns, but current models ignore two facts: (1) healthcare is an inherently social activity, involving clinical teams and patients' social networks, and (2) emotions influence social activity. To address these omissions, we scaffolded Terror Management Theory and Socioemotional Selectivity Theory to create the Transtheoretical Model of Irrational Biomedical Exuberance (TRIBE). Based on Terror Management Theory, TRIBE suggests that the prospect of patient death motivates healthcare teams to conform to a biomedical norm of care, even when clinicians believe that biomedical interventions will likely be unhelpful. Based on Socioemotional Selectivity Theory, TRIBE suggests that the prospect of dwindling time motivates families to prioritize emotional goals, and leads patients to consent to disease-directed treatments they know will likely be unhelpful, as moral emotions motivate deference to the perceived emotional needs of their loved ones. TRIBE is unique among models of healthcare utilization in its acknowledgement that moral emotions and processes (e.g., shame, compassion, regret-avoidance) influence healthcare delivery, patients' interactions with family members, and patients' outcomes. TRIBE is especially relevant to potentially harmful EoL care in the United States, and it also offers insights into the epidemics of overtreatment in healthcare settings worldwide. By outlining the role of socioemotional processes in the care of persons with serious conditions, TRIBE underscores the critical need for psychological innovation in interventions, health policy and research on healthcare utilization.

Negotiating depression treatment with older adults: primary care providers' perspectives.

BACKGROUND: Primary care occupies a strategic position in the evaluation and treatment of depression in late life, yet many older patients do not initiate or adhere to treatments available in primary care. AIM: To explore how primary care providers describe the process of discussing depression care with older adults. METHOD: Semi-structured interviews conducted with 15 providers involved with intervention studies of depression management for older adults. We used the constant comparative method to identify themes related to negotiating the treatment of depression with older adults. RESULTS: Providers felt that older patients often attribute depression to non-medical causes. They talked about the challenges and described the need to 'convince' them of the medical model of depression. CONCLUSION: How primary care physicians surmise patients' views of depression may influence the discussion of depression in practice. As medication is most often provided for depression treatment, some may feel compelled to convince their patients of biomedical explanations while others may avoid treating depression altogether.

A Biopsychosocial and Interprofessional Approach to the Treatment of Family and Intimate Partner Violence: It Takes a Village.

Family and intimate partner violence and abuse (FIPV) is a critical public health problem with repercussions for mental and physical health. FIPV exposure also is associated with social difficulties such as low socioeconomic status, legal issues, poor access to employment and education, housing instability, and difficulty meeting other basic needs. As a biopsychosocial problem, one discipline alone cannot adequately address FIPV. While individuals who experience FIPV traditionally seek respite, care and safety through domestic violence shelters, social services or courts, they also often present to health care settings. Building on the medical-legal partnership model with critical input from a community advisory board of individuals with lived experiences of FIPV, we implemented a person-centered approach in the health care context to cohesively integrate legal, safety, social, psychological and physical health needs and concerns. The purpose of this paper is to describe the Healing through Health, Education, Advocacy and Law (HEAL) Collaborative for individuals who have experienced psychological abuse, physical abuse, sexual abuse, or neglect related to child maltreatment, intimate partner violence, and/or elder abuse, and review our real-world challenges and successes. We describe our interprofessional team collaboration and our pragmatic biopsychosocial framework for bringing together: professional and stakeholder perspectives; psychological, medical, legal, and personal perspectives; and clinical, evidence-based, and educational perspectives. There is no doubt that creating a program with biopsychosocial components like HEAL requires professionals appreciating each other's contributions and the need to begin working from a common goal. Furthermore, such a program could not be successful without the contributions of individuals with the lived experience we seek to treat, coupled with the external health care clinicians' input. We describe lessons learned to date in an effort to ease the burden for those seeking to implement such a program. Lessons include HEAL's more recent clinical adaptions to serve patients both in-person and via telehealth in the wake of COVID-19.

"Whose Fault Is It?" How Rural Chinese Women Explain Intimate Partner Violence: A Qualitative Study.

Women are often the victims of intimate partner violence (IPV). Though China has established its first statute against domestic violence, the service developments for victims fall behind. It is important to assess community members' perceptions of what causes IPV to create interventions to prevent and address IPV. This study completed the Short Explanatory Model Interview (SEMI) among a subset sample from a large epidemiology study in rural Sichuan China. The social ecological model was applied to analyze qualitative interviews. Among 339 participants, the average age was 46.01 ± 12.42 years old. There were 31.86% of them had been educated, 14.75% of them had migrant worker partners, and 49.26% of them had experienced violence from their partners in the last year. There were 252 participants attributed IPV to individual factors, and they primarily discussed the social characteristics, behaviors, personalities or even health problems of the husband or the wife in the vignette. Under this theme, there were 86 participants blaming the victim for being anxious, social disconnectedness or lazy; and there were 166 participants blaming to the perpetrator being abusive, irresponsibility, lack of understanding, and cheating. There were 44 women believed the cause was relational, in which there were 41 participants attributed the problem to the broken relationship between the couple and three participants attributed to the lack of support. There were 28 participants believed the cause was communal and societal, such as being poor, family problems, fate, and believed IPV was a common scene. There were 15 participants could not identify the cause of IPV. These participants usually provided very brief responses and barely had insight on violent behaviors or confidence in discussing the cause. Our findings offer a direction for understanding the rural Chinese women's beliefs about the etiology of IPV to better develop interventions which must consider raising a public awareness campaign about the risk factors of IPV and focus on reducing self-blame among victims.

Implementing a New Tool to Predict the Risk of Intimate Partner Violence in Rural China.

Most of current scales for assessing intimate partner violence (IPV) were developed for Western populations. The Chinese Risk Assessment Tool for Victims (CRAT-V) was a new scale evaluating the risk of IPV, which was developed based on Chinese populations in the context of Chinese culture. To determine whether the CRAT-V could add further value to research involving IPV and violence against women in rural China, we sought to implement the CRAT-V and to explore its factor structure among a rural population in the mainland of China. This study included women from rural Sichuan Province of China, who aged 16 years and older, had been living locally for at least 2 years, and reported that they were married or in a relationship in the preceding year. A total of 670 participants completed the CRAT-V during the field survey. We utilized exploratory factor analysis to validate the fact structure of CRAT-V. The Cronbach's alpha of the CRAT-V was 0.90, indicating good reliability. The CRAT-V reported that 45.07% (302/670) of participants were in risk of IPV, and the risk was higher in women who were 16 to 29 years old, having 7 years and higher education, and living in stem families. The CRAT-V fit a 5-factor model including healthy relationship, jealous feeling, jealous reaction, stressful living condition, and sexual abuse. Our findings provided support for using the CRAT-V as a culturally sensitive measure to predict the risk of experiencing IPV in China, and lend insights into factors that may contribute to timely IPV prevention and intervention.

URMC Universal Depression Screening Initiative: Patient Reported Outcome Assessments to Promote a Person-Centered Biopsychosocial Population Health Management Strategy.

Background: Patient-reported outcomes (PROs) can promote person-centered biopsychosocial health care by measuring outcomes that matter to patients, including functioning and well-being. Data support feasibility and acceptability of PRO administration as part of routine clinical care, but less is known about its effects on population health, including detection of unmet healthcare needs. Our objectives were to examine differences in rates of clinically significant depression across sociodemographic groups and clinical settings from universal depression screens in a large health system, estimate the number of patients with untreated depression detected by screenings, and examine associations between biopsychosocial PROs-physical, psychological, and social health. Methods: We analyzed data from over 200,000 adult patients who completed depression screens-either PROMIS (Patient Reported Outcomes Measurement Information System) or PHQ-2/9-as part of routine outpatient care. Results: Depression screens were positive in 14.2% of the sample, with more positive screens among younger vs. older adults, women vs. men, non-White vs. White, and Hispanics vs. non-Hispanics. These same sociodemographic indicators, as well as completing screening in primary care (vs. specialty care) were also associated with greater likelihood of detected depression in the medical record. Discussion: Universal screening for depression symptoms throughout a large health system appears acceptable and has the potential to detect depression in diverse patient populations outside of behavioral health. Expanded delivery of PROs to include physical and social health as well as depression should be explored to develop a clinically-relevant model for addressing patients' biopsychosocial needs in an integrated fashion across the health system.

Sources of Information for Learning and Decision-Making in Men With Localized Prostate Cancer.

Information seeking is essential for effective patient-centered decision-making. However, prostate cancer patients report a gap between information needed and information received. The importance of different information sources for treatment decision remains unclear. Thus, using the Comprehensive Model of Health Information (CMIS) framework, we assessed the antecedent factors, information carrier factors, and information-seeking activities in localized prostate cancer patients. Data were collected via semistructured one-on-one, interviews and structured survey. Men with localized prostate cancer were recruited from two urban health-care centers. Following the interview, participants completed a survey about sources that were helpful in learning about prostate cancer treatment and decision-making. The interviews were audio-recorded, transcribed, and subjected to a thematic analysis using NVivo 10. Fifty localized prostate cancer survivors completed the interviews and surveys. Important antecedent factors that were observed were age, marital status, uncertainty, anxiety, caregiver burden, and out-of-pocket expenses. We identified complexity, magnitude, and reliability as information carrier characteristics. Preferred sources for information were health providers, medical websites, and pamphlets from the doctor's office. These sources were also perceived as most helpful for decision-making. Urologists, urological oncologists, and radiation/radiation oncologists were important sources of information and helpful in decision-making. Prostate cancer patients obtained information from multiple sources. Most prostate cancer patients make patient-centered choices by incorporating personal factors and medical information. By considering factors that influence patients' treatment decisions, health-care providers can enhance the patient-centeredness of care. Multiple strategies and interventions are necessary for disseminating valid, reliable, and unbiased information to prostate cancer patients to facilitate informed decisions.

Team communication within integrated primary care in the context of suicide prevention: A mixed methods preliminary examination.

Direct and indirect communication through the electronic medical record play a vital role in helping medical home primary care teams implement suicide prevention efforts. The purpose of this study is to examine how communication related to suicide prevention occurs among primary care team members working within a group of clinics in the Veterans Health Administration that has embedded integrated behavioral health providers (BHPs) and uses a shared electronic medical record. Using sequential exploratory mixed methods design, eight focus groups and 11 in-depth interviews with primary care providers (PCPs), nurses, and BHPs comprised the qualitative portion of the study, which was used to help develop an online questionnaire distributed to all primary care teams. Participants (n = 86) of the online survey included 15 BHPs, 32 PCPs, and 39 registered nurses. Qualitative data included asking a series of questions concerning how suicide prevention is accomplished in primary care. Themes concerning how providers communicate both directly and indirectly arose from the data and were used to develop questions for the survey to help further understand the data. Overall, the data suggested good team communication was occurring. However, there were opportunities to enhance communication through the use of huddles and enhancing communication from PCPs to other team members when the patient's medical status changed. Direct communication was preferred, and finding ways to increase communication may be important to help decrease potential errors that may occur via diffusion of responsibility. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Taking the Long View in an Inpatient Medical Unit: A Person-Centered, Integrated Team Approach for Patients With Severe Mental Illnesses.

OBJECTIVE: Patients with severe mental illnesses and related conditions, such as substance misuse and suicide attempts, are among the highest utilizers of acute inpatient medical services. The objective of this study was to assess the impact of a specialized medical unit that uses a comprehensive biopsychosocial model to care for patients with severe mental illnesses. METHODS: The study used administrative data to compare patients with severe mental illnesses admitted to a specialized unit with patients admitted to medically similar acute (non-intensive care) medical units in a tertiary academic medical center. With controls for sociodemographic variables, illness severity, and medical complexity, multivariate regression analyses compared utilization outcomes for patients from the specialized unit with outcomes from comparison units. RESULTS: Patients on the specialized unit (N=2,077) were younger, had more mental disorder diagnoses, and were more likely to have less severe general medical illness and less medical complexity than patients from comparison units (N=12,824). Analyses of a subsample of patients with complex behavioral health diagnoses indicated that those on the specialized unit had a shorter average stay, higher odds of discharge to home, and lower odds of 30-day readmission, compared with those on comparison units. CONCLUSIONS: Specialized units targeted to the needs of patients with serious mental illnesses can provide a moment of engagement when vulnerable patients are likely to benefit from more coordinated care. Findings suggest that a specialized unit that capitalizes on this moment of engagement and uses a biopsychosocial model of care can improve utilization outcomes.

Losing faith and using faith: older African Americans discuss spirituality, religious activities, and depression.

BACKGROUND AND OBJECTIVES: Older African Americans are often under diagnosed and under treated for depression. Given that older African Americans are more likely than whites to identify spirituality as important in depression care, we sought to understand how spirituality may play a role in the way they conceptualize and deal with depression in order to inform possible interventions aimed at improving the acceptability and effectiveness of depression treatment. DESIGN: Cross-sectional qualitative interview study of older African American primary care patients. PARTICIPANTS AND SETTING: Forty-seven older African American patients recruited from primary care practices in the Baltimore, MD area, interviewed in their homes. MEASUREMENTS: Semi-structured interviews lasting approximately 60 minutes. Interviews were transcribed and themes related to spirituality in the context of discussing depression were identified using a grounded-theory approach. MAIN RESULTS: Participants in this study held a faith-based explanatory model of depression with a particular emphasis on the cause of depression and what to do about it. Specifically, participants described depression as being due to a "loss of faith" and faith and spiritual/religious activities were thought to be empowering in the way they can work together with medical treatments to provide the strength for healing to occur. CONCLUSIONS: The older African Americans in this study described an intrinsically spiritual explanatory model of depression. Addressing spirituality in the clinical encounter may lead to improved detection of depression and treatments that are more congruent with patient's beliefs and values.

Bridging Psychiatric and Anthropological Approaches: The Case of "Nerves" in the United States.

Psychiatrists and anthropologists have taken distinct analytic approaches when confronted with differences between emic and etic models for distress: psychiatrists have translated folk models into diagnostic categories whereas anthropologists have emphasized culture-specific meanings of illness. The rift between psychiatric and anthropological research keeps "individual disease" and "culture" disconnected and thus hinders the study of interrelationships between mental health and culture. In this article we bridge psychiatric and anthropological approaches by using cultural models to explore the experience of nerves among 27 older primary care patients from Baltimore, Maryland. We suggest that cultural models of distress arise in response to personal experiences, and in turn, shape those experiences. Shifting research from a focus on comparing content of emic and etic concepts, to examining how these social realities and concepts are coconstructed, may resolve epistemological and ontological debates surrounding differences between emic and etic concepts, and improve understanding of the interrelationships between culture and health.

When chemotherapy fails: Emotionally charged experiences faced by family caregivers of patients with advanced cancer.

OBJECTIVE: To explore family caregivers' emotional experiences while caring for patients with advanced cancer and navigating distressing information, awareness of dying, and difficult decisions. METHODS: Qualitative descriptive study of semi-structured interviews with 92 bereaved caregivers of patients with advanced cancer. Interviews explored caregivers' experiences as patients transitioned out of active cancer treatment and neared the end of life. RESULTS: Included in caregivers' characterization of this transition time were three particularly emotionally charged experiences. The first occurred when caregivers felt jolted into awareness that patients were dying.They were startled to realize that patients would die sooner than expected; some expressed frustration that they had not been adequately warned. In the second, caregivers felt conflicted when involved in decisions that pitted patients' preferences against what caregivers felt patients needed, resulting in ambivalence, guilt, and grief. Thirdly, caregivers who felt they did their best for patients expressed fulfillment and gratitude. CONCLUSION: Caregivers of patients with advanced cancer face unique, emotionally charged experiences that can lead to distress and affect care at the end of life. PRACTICE IMPLICATIONS: Awareness of these situations may help oncology teams to provide sufficient guidance and support, partner with caregivers to clarify patients' needs, and deliver higher quality care.

Patient-Centered Approach to Develop the Patient's Preferences for Prostate Cancer Care (PreProCare) Tool.

Objectives. To describe the development of our Patient Preferences for Prostate Cancer Care (PreProCare) tool to aid patient-centered treatment decision among localized prostate cancer patients. Methods. We incorporated patient and provider experiences to develop a patient preference elicitation tool using adaptive conjoint analysis. Our patient-centered approach used systematic literature review, semistructured patient interviews, and provider focus groups to determine the treatment attributes most important for decision making. The resulting computer-based PreProCare tool was pilot tested in a clinical setting. Results. A systematic review of 56 articles published between 1995 and 2015 yielded survival, cancer recurrence, side effects, and complications as attributes of treatment options. We conducted one-on-one interviews with 50 prostate cancer survivors and 5 focus groups of providers. Patients reported anxiety, depression, treatment specifics, and caregiver burden as important for decision making. Providers identified clinical characteristics as important attribute. Input from stakeholders' advisory group, physicians, and researchers helped finalize 15 attributes for our PreProCare preference assessment tool. Conclusion. The PreProCare tool was developed using a patient-centered approach and may be a feasible and acceptable preference clarification intervention for localized prostate cancer patients. The PreProCare tool may translate into higher participant engagement and self-efficacy, consistent with patients' personal values.

Longitudinal Relationship Between Frailty and Cognition in Patients 50 Years and Older with Breast Cancer.

OBJECTIVES: To evaluate relationships between frailty and cognition longitudinally in adults 50 years and older with breast cancer receiving chemotherapy. DESIGN: Secondary analysis of a prospective longitudinal observational study. SETTING: University of Rochester NCI Community Oncology Research Program community oncology clinics. PARTICIPANTS: Patients with breast cancer age 50 and older receiving adjuvant/neoadjuvant chemotherapy (n = 376) and age-matched controls without cancer (n = 234). MEASUREMENTS: Frailty was assessed using a modified frailty score from self-reported assessments (weakness, exhaustion, physical activity, and gait speed). Cognition was assessed by patient report (Functional Assessment of Cancer Therapy-Cognition [FACT-Cog]) and objective measures. Frailty and cognition were measured at three time points (prechemotherapy [A1], postchemotherapy [A2], and 6 months postchemotherapy [A3]; similar time interval for controls). Linear regression models evaluated associations between frailty and cognition adjusting for covariates. RESULTS: The average age was 59 years (standard deviation = 6.4 y). At baseline, patients with cancer had a higher mean frailty score (1.21 vs .73; P < .001) and lower mean FACT-Cog score (158.4 vs 167.3; P < .001) compared with controls. Objective cognitive measures were not statistically different. Longitudinal decline in FACT-Cog between A1 and A2 (P < .05) and between A1 and A3 (P < .01) was associated with increased frailty score in patients compared with controls. Longitudinal worsening in Controlled Oral Word Association (P < .05) and Trail-Making Test (P < .01) were associated with an increase in frailty between A1 and A2 in patients compared with controls; longitudinal decline in the Delayed Match to Sample test was associated with an increase in frailty between A1 and A3 (P < .05) in patients compared with controls. This finding remained significant for a subset analysis of those aged 65 and older. CONCLUSION: In patients with breast cancer aged 50 and older, longitudinal decline in FACT-Cog and objective measures of attention and memory were associated with increased frailty during treatment and up to 6 months posttreatment. Overall, our study suggests cognition and frailty are both important factors to assess in breast cancer patients. J Am Geriatr Soc 67:928-936, 2019.

Effects of the Values and Options in Cancer Care Communication Intervention on Personal Caregiver Experiences of Cancer Care and Bereavement Outcomes.

Background: Care teams are increasingly expected to attend to the needs of patient's personal caregivers (e.g., family members). Improving communication among oncologists, patients with advanced cancer, and their personal caregivers might enhance caregivers' experiences of end-of-life (EoL) cancer care and bereavement outcomes. Objective: To explore the effects of the Values and Options in Cancer Care intervention on caregivers' experiences of EoL care and bereavement outcomes. Design: We developed a brief behavioral intervention to improve communication among oncologists, patients with advanced cancer, and their personal caregivers. The intervention was designed to help patients/caregivers ask questions, express concerns, and help oncologists respond effectively. We randomly assigned oncologists (and their patients/caregivers) to the intervention or usual care. Setting/Subjects: Medical oncologists in NY and CA; patients/personal caregivers with advanced cancer. Measurements: Two months after the patient's death, caregivers completed three instruments assessing their experiences of EoL care. Seven months after the patient's death, caregivers completed the Prolonged Grief Disorder-13 (PG-13; primary prespecified outcome), the Purpose-in-Life scale, and scales assessing mental health function, depression, and anxiety. Results: The intervention did not significantly improve caregivers' scores on the PG-13 (p = 0.21), mental health function, depression, or anxiety, but it did improve purpose-in-life scores (p = 0.018). Cohen's d (95% confidence interval) for all three experiences of EoL care outcomes were promising, ranging from 0.22 (-0.19 to 0.63) to 0.39 (-0.07 to 0.86) although none was statistically significant. Conclusion: Preliminary findings show promise that scalable interventions in cancer care settings may improve caregiver experiences with cancer care and some bereavement outcomes.

More than just a communication medium: what older adults say about television and depression.

PURPOSE: Older adults watch more television than younger people do. Television's role in mental health has been described in the general population, but less is known about how older adults think of television in the context of depression. DESIGN AND METHODS: Using a semistructured interview created to help clinicians understand how older adults conceptualize depression diagnosis and treatment, we conducted a qualitative study of 102 patients aged 65 years or older. We recruited them from primary care offices and interviewed them in their homes. During our analysis, we found that many respondents offered spontaneous thoughts about the relationship between television and depression. We extracted all television-related content from the interview transcripts and identified themes by using grounded theory. RESULTS: Participants cited television as a way to identify depression in themselves or others (either through overuse or lack of interest) or as a way to cope with depressive symptoms. Some felt that television could be harmful, particularly when content was high in negativity. A substantial number of participants discussed more than one of these themes, and a few mentioned all three. Married people were more likely to discuss television's role in identifying depression. Participants with low education more often mentioned that television could be helpful, whereas those with a history of depression treatment were more likely to discuss television's potential harm. IMPLICATIONS: Researchers should conduct further studies to help them better understand the relationship among depression, television viewing, and individual viewpoints concerning television's role in geriatric depression. An exploration of these issues may yield new approaches to help clinicians address depression in late life.

How older adults combine medical and experiential notions of depression.

Past research has suggested that patients might not accept depression treatment in part because of differences between patient and doctor understandings of depression. In this article, we use a cultural models approach to explore how older adults incorporate clinical and experiential knowledge into their model of depression. We conducted semistructured interviews about depression with 19 patients aged 65 years and older who were identified by their physicians as depressed. We found that whereas older adults viewed as helpful the doctor's ability to identify symptoms and "put it all together" into a diagnosis, they felt that this viewpoint omitted important information about the etiology and feeling of depression grounded in embodied experience and social context. Our findings suggest that more emphasis on issues related to the etiology of depression, the effect of depression on social relationships, and emotions emanating from depression might lead to more acceptable depression treatments for older adults.

Depression as seen through the eyes of rural Chinese women: Implications for help-seeking and the future of mental health care in China.

BACKGROUND: As part of a larger epidemiological study of depression among rural Chinese women, we sought to understand their explanatory models of depression. We explored how participants describe depression, to what cause they attribute depression, and what sources of treatment they would recommend. METHODS: Participants first were assessed with the Center for Epidemiological-Depression scale (CES-D), with a cut-point of 16 or greater indicative of depression. The Short Explanatory Model Interview (SEMI), a semi-structured questionnaire, was our primary tool for exploring participants' explanatory models relating to a vignette describing a rural Chinese woman with depression. RESULTS: Among the 416 women who consented and completed the SEMI, 277(66.6%) reported that the woman in the vignette had something wrong with her health. Among these, only 8(2.9%) women provided a specific psychiatric name for the condition, while 150(54.2%) provided non-specific psychiatric disease names or affective symptoms, and 78(28.2%)of the sample provided physical disease names. Participants attributed causes largely to internal factors (41.5%) or external factors (36.8%). In terms of help-seeking, 101(36.4%) said the woman in the vignette should see a doctor, 70(25.3%) indicated that she should solve the problem herself, and 42(15.2%) recommended seeking support from family members and friends. We did not find any differences in recognition, causal attribution, and help-seeking suggestions between women with a CES-D ≥ 16 and those with CES-D < 16. LIMITATIONS: The use of a vignette to prompt discussion was not the same as talking about real-life personal situations. CONCLUSION: Our results point to potential challenges and opportunities that lay ahead as China develops mental health services in its vast rural areas among women who may be at risk for developing depression. We found that our participants often attributed their symptoms to internal or external social causes, and preferred not speaking with family members and friends. Our findings suggest that rural Chinese women may be reticent to recognize or describe categorical concepts such as "depression" as a health problem, and they invite further consideration about how best to develop new health services in China's rural regions.