Increasing Depression Awareness in Vulnerable Women: An Evidence Based Educational Intervention

������

Winston-Salem State University, Winston Salem, North Carolina, USA

Corresponding Author:

Daphne Kaye Sharpe
Winston-Salem State University
Winston Salem, North Carolina, USA
E-mail: daphnesha3@gmail.com

Visit for more related articles at International Journal of Emergency Mental Health and Human Resilience

Introduction

This evidence-based educational intervention aims to inform the nurses, providers, and staff at a public health department family planning clinic of the importance of screening women seen in their clinic for depressive symptoms. In the United States, depression affects twice as many women as men and depression is prevalent primarily during a woman’s reproductive years (Burt, 2009; Lee et al., 2005; Rich-Edwards et al., 2006; Waite & Killian, 2008; Weisman et al., 1996). Women who seek treatment in federally-funded family planning clinics are often at greater risk for depression because they may be uninsured, undereducated, low-income, single parents, and/ or without a regular source of healthcare (Sherbourne et al., 2001). Educating nurses and staff at public health family planning clinics about depression in women can help improve the overall health of the women who receive care at these clinics.

Background

Eighteen million Americans are affected each year by depression (National Institute of Mental Health [NIMH], 1999). Depression is a serious public health problem and is a leading cause of disability for 15-44 year old Americans (National Institute of Mental Health [NIMH], 1999). Family Planning (FP) clinics funded by federal Title X programs often serve as the main source of healthcare for the women who utilize these services (National Family Planning and Reproductive Health Association, 2005), and in 2004 federal family planning clinics served over 5 million patients.

Steps to improve recognition and treatment of depression have been in place for several years. The MacArthur Initiative on Depression and Primary Care was established in 1995 to provide a process for family practice providers to increase recognition and treatment of depression for their clients. This initiative provided tool kits available online to any provider who wished to implement a practice change to improve the recognition and treatment of depression. In 1999, the United States Surgeon General reported on the national disparities that exist in the diagnoses and treatment of depression in minority populations and women. Many national initiatives were undertaken after the report, one of which was the city of New York’s campaign to address this widespread disparity (Medical News Today, 2006). The Executive Deputy Commissioner of Mental Hygiene sanctioned the campaign, which encouraged all New Yorkers to ask their doctor about depression, and visited 1,500 primary care providers and clinical staff in the city. The providers and staff were encouraged to make depression screening routine and provided them with Patient Health Questionnaire (PHQ) screening tools. The campaign displayed posters about depression, sadness, difficulty concentrating, and sleep problems in English and Spanish on subways, buses, and community check cashing locations.

The US Surgeon General’s Report on Mental Health (1999) and the supplemental report, Mental Health: Culture, Race, and Ethnicity (2001), continue to influence initiatives to improve recognition of depressive symptoms. The reports delineate the significant societal complexities caused by depression and the gap that exists in diagnosing and treating depression in women and minorities. The United States Preventative Services Task Force (USPTF) 2002, has also made a recommendation related to depression. The charge is for healthcare to address the unmet need for depression care by screening for depression in primary health care settings and any setting equipped to screen and treat depressive symptoms.

Significance

The Forsyth County Department of Public Health provides family planning services to women of childbearing age who reside in the county. Many of the women seen in the FP clinic are uninsured, underinsured, single parents, unemployed, living below the poverty level, teenagers, victims of domestic violence, and at high risk for sexually transmitted diseases. The aforementioned factors place the women at great risk for depression. Because the FP clinic serves as the primary source of healthcare for many of the women, it is an appropriate place for the women to receive depression screening. Women are often unaware that some symptoms they may be experiencing physically and emotionally are directly related to depression. Providing evidence based education to the nurses, providers, and staff about the importance of depression screening supports future possibilities for establishing a practice change within the FP clinic. A depression screening process will not only make the nurses, providers, and staff aware that the patient may be experiencing depression, but also makes the women more knowledgeable. Once the woman is aware she may be experiencing depression she may become empowered in participating in her own health.

Question Guiding Inquiry

Focused questions are important to formulate to be sure you find the right evidence to answer the question. Melynyk and Fineout- Overholt (2005), emphasis using the PICO format. The acronym stands for: P-patient population of interest; I- intervention of interests; C- comparison of interest; O-outcome of interest. The PICO question is for nurses, providers, and staff employed in Public Health Department (PHD) family planning (FP) clinics, does an evidence based educational intervention on depression and depression screening versus current knowledge on depression screening increase understanding of importance of screening women seen in the FP clinic for depression?

Conclusion

The large body of evidence recommends initiating depression screening in primary care settings and any medical setting that is equipped to offer depression screening, referrals, or treatments. The family planning clinic at Forsyth County Department of Public Health often serves as the only source of medical care for the women who attend the clinic. By educating the nurses, providers and staff about the importance of depression screening, steps can be made to improve the overall health of the women who receive care at this clinic.

Review of the Literature and Evidence

In evidence based practice, review and appraisal of the literature is vital in guiding practice decisions. Melnyk and Fineout-Overholt (2005), reminds clinicians of the consistent need for using current information in healthcare. The authors recommend frequent review of bibliographic and full-text databases that hold the latest studies reported in medical journals to find relevant evidence to answer compelling clinical questions.

Methodology

A preliminary search of the literature was performed to identify keywords for a more complete search of the literature. The following keywords were utilized: African, American, women, minorities, awareness, screening, family planning, depression, treatment, cultural relevance, cultural, racial disparities, and mental health. Databases used included: PSYCHINFO, MEDLINE, CINAHL, COCHRANE, and PUB-MED with year restrictions of 1966 to 2009. Multiple searches were run from January 10, 2009 to May 30, 2010 with a variety of the above mentioned search terms combined in MeSH. The articles selected had to be from population-based studies, using adults, and must be in English. In all more than 1200 potential articles were found in the multiple searches. This integrative review decided on 7 articles that fit the above-mentioned criteria to discuss in this chapter. Because many vulnerable women who attend family planning clinics have no other source of healthcare, findings for primary care and depression are used in this literature review.

Findings

Throughout the review of the literature a compelling number of researchers referenced the 1999 Surgeon General’s Report on Mental Health reported by the United States Department of Health and Human services. The supplement report, Mental Health: Culture, Race, and Ethnicity(2002), was referenced equally as often. These reports provide a most profound insight into the significance of not only understanding the significant impact of mental health disorders on the nation as it impacts all of our citizens. The reports exposed the vital need for more screening in healthcare to achieve the best outcomes for those in need of diagnosis and treatment of mental health disorders such as depression (US Department of Health and Human Services, 2001).

Lee et al. (2005) examined three public health department family planning clinics in North Carolina regarding recognition and treatment of depressive symptoms. The study included 588 women who were screened for depressive symptoms. Of those screened 271 women identified with depressive symptoms. One hundred twenty six women were lost to follow up, 76 did not complete referrals, and 56 did complete referrals. Of the 56 that completed referrals 47 needed treatment. From that 47, 16 women did not obtain treatment and 31 began treatment. The multiple barriers that exist once the client is identified with depressive symptoms is an indication that more educational information should be provided to the client while the nurse and provider has her in the family planning clinic setting. The beginning of the process to attempt treatment and care is the screening process. The findings of the study uncovered barriers to treatment, however understanding there is a problem with depressive symptoms is paramount to the patient beginning the treatment process.

Vulnerable women who are patients at federally funded family planning clinics frequently have limited access to care, are uninsured or underinsured, often are young, unemployed, and single parents (Sherbourne et al., 2001) which place them at greater risk for depression. Sherbourne et al., 2001, used data found from the Common wealth Fund 1998 Survey of Women’s Health to describe the characteristic of women in need of mental health services for anxiety and depression. Only 42% of women with high psychological risk had been informed in the past five years they had depression or anxiety. Other characteristics of related to need for care included prior domestic abuse, violence, divorced, and widowed.

The fourth article reviewed Miranda et al. (2006) evaluated one year outcomes of treating depression in low income minority women. The findings indicated of that of the women diagnosed, only 36% assigned to therapy completed six or more sessions. Multiple variable were identified as barriers to treatment. Those include trust in providers, not feeling respected, medication side effects, and lack of understanding of depression. Among several recommendations from the one year evaluation of the clinical trials were adding standard depression screening questions into healthcare visits for this population of women.

O’Malley, Forrest, and Miranda (2003) identified a based sample of women residing in Washington, DC census tract where at least 30% of households’ income was 200% below the 1999 poverty level. Use of a professional sampling system was employed to develop a list that included their inclusion criteria and subsequently were called for an interview. Interviews were conducted January through March 2000 with a response rate of 85%.

The study examined if specific attributes of a primary care setting was associated with depression care. Women who perceived their primary care providers as respectful and had sustained relationships with their providers had a higher odd of being asked about and treated for depression. The study concluded that not only counseling aspects of comprehensiveness, but also the non-counseling aspects such as weight, height, and blood pressure screening were associated with care of depression. Depression care is thus concluded as one element of the overall comprehensiveness of primary care practices.

Kristofco, Stewart, and Vega (2007) did original research on perspectives on disparities in depression care. By doing a search of the medical literature, the article identified the disparities in depression care, possible reasons they exist, and the role professions education may play in the improvement of depression care provided to minority populations. The authors emphasized the Surgeon General’s report that ethnic and racial minorities in the United States face a social and economic environment of inequality that includes greater exposure to racism, discrimination, violence, and poverty. The report also states that living in poverty is the most measurable effect on the rates of mental illness. The article concludes that education can be an effective component of efforts to improve mental health care in minorities. Nurse assessment of patients, provider training, patient education and support resources are valuable methods to employ in an effort to improve mental health in minority populations.

Healthy People 2010 support two goals related to mental health which include increasing the number of people seen in primary care health settings to receive mental health screening and assessment. The general medical and primary care sector consists of health care professionals such as internists, , and nurse practitioners in office-based practice, clinics, acute medical and surgical hospitals, and nursing homes. Close to 6 percent of the adult U.S. population use the general medical sector for mental health care, with an average of about 4 mental health visits per year which is far lower than the average of 14 visits per year found in the specialty medical sector. The general medical sector has been identified as the initial point of contact for many adults with mental disorders; for some, these providers may be their only source of mental health services. More attention to mental state in primary care can promote early detection and intervention for mental health problems by implementing basics like screenings.

Limitations

Limitations of the literature review were the small number of nursing journals that fit the search criteria. Though there were findings that addressed depression screening and treatment, few nursing journals specifically addressed vulnerable women. The disciplines of social work, psychiatry, and public health did however address vulnerable women specifically.

Conclusion

Low detection rates of depression in primary care have been frequently documented in the literature. Often primary care clinicians do not recognize depression in their patients. Improving healthcare providers educational level on the importance of depression detection is an important first step to improving depression diagnosis and treatment. Depression is the most pervasive psychiatric problem observed in primary care settings (Gary & Yarandi, 2004) warranting changes in practice to improve this nationwide problem.

Theory Guiding Practice Change

Introduction

Peplaus’s theory of interpersonal relations was chosen as a guiding theory for this project. Needing a theory to address the phenomena that is affected the United States with unrecognized and undiagnosed depression was important. There are casual theories of depression that are used across all populations. Though no one theory specifically addressed undiagnosed and untreated depression in vulnerable women, Peplau’s psychodynamic nursing works were applicable to some of the desired outcomes of the project. The contextual depression theory was also reviewed however because of the focus it incorporates on the neurochemical, genetic perspectives, the impact of loss, stress, and control/coping strategies of psychosocial theory; the impact of political, social, and economic perspectives were combined which all affect the psychosocial development of the vulnerable women. Nonetheless, a primary belief in Peplau’s theory is that nursing is a significant therapeutic interpersonal process (Fawcett, 2005). Specifically, “nursing action and process are beneficial to human beings” (Fawcett, 2005). Nursing as a profession is charged with providing patients and their families with as high a level of comfort as possible. Physical, social and psychosocial services are required to provide such comfort. By using this theory to help guide the project, reinforcement of the therapeutic interpersonal process occurs with the use of the depression screening tools and the nurse’s evaluation of the tools with the patient.

Organizational Framework

Peplau built her theory on clinical work with psychiatric patients. The theory has a multidimensional concept of the nurse-patient relationship. The nurse-patient relationship as defined by Peplau is “an interpsonal process made up of four components: two persons, the professional expertise of the nurse, the clients problem, or need for which expert nursing services are being sought.” (Fawcett, 2005). Patients may enter into the family planning clinic for a variety of reason aside from birth control. The expertise of the nurse and the presenting problem of the patient must be considered in its entirety. The expertise of the nurse could establish that the client is in need of more than what may seem initially apparent.

Conclusion

Peplau’s theory is widely recognized and accepted as beneficial to patient outcomes. The theory is used extensively in real life nursing practice. Implementing protocol changes that reflect the theory is evidenced by reports of practice in nursing that use the Theory of Interpersonal Relations. Understanding the importance of depression screening in the family planning clinic is imperative to nurses and staff in order to improve overall patient outcomes. Nurses must be able to have control over the signals because the nurse’s behavior can evoke behavioral changes in the patient. Depression screening serves as additional evidence based nursing act that will demonstrate concern of the patient holistic well being and potentially strengthening the nurse-patient relationship.

Project Design

Introduction

The project was designed to increase the knowledge of the importance of depression screening in the family planning clinic at a public health department. The project assessed the knowledge of the staff in the family planning clinic on depression and the importance of depression screening. Finally the staff was evaluated on their satisfaction of the evidence based educational intervention and if they felt more educational interventions should be provided to healthcare providers concerning the importance of depression screening.

Methodology

The project was approved by Chatham University Institutional Review Board as an exempt status project (Appendix A), Dr. Timothy Monroe Public Health Director, Jackie Boggs, RN, Director of Nursing, and Carolyn Marcus, PA, Manager of Family Planning Clinic (Appendix B). Pre and post knowledge questionnaires were developed and reviewed for knowledge level about depression and depression screening. The eight-question tool used “yes”, “no”, and “don’t know” answer options (Appendix C). The one-hour educational intervention was developed based on current evidence that recommends nationwide to improve depression screening in healthcare settings that can adequately provide the service. A participant satisfaction survey was developed (Appendix D) and administered at the end of the educational intervention.

Participants and Setting

The participants in the educational intervention consisted of the staff of the family planning clinic, the Director of Nursing, and the clinic director. The public health department serves Forsyth County, North Carolina residents. Three midlevel providers, four registered nurses, three health educators, one clerical staff, and one phlebotomist staff the family planning clinic.

Evaluation of Project

The project surveys were developed with basic knowledge questions guiding the process. The pre and post-knowledge survey consisted of eight questions that asked about knowledge of depression and depression screening. The response to the questions were true, false, or don’t know. Questions from the survey were modeled after sample surveys in the literature that provided educational interventions. The participant satisfaction survey was developed with the standard corporate education surveys utilized at the facility. Participants were asked to express their satisfaction with the one hour educational intervention and asked if they thought the same educational intervention should be provided to other healthcare facilities that provided health care to women.

The surveys were screened by two instructors from a four year nursing program. The instructors deemed the surveys to be adequate to glean the desired information of weather the objectives of the educational intervention were obtained. The directness of the questions were reported to be excellent as well as the clear writing style.

Conclusion

The project is a one hour educational intervention to improve awareness of depression by educating the nurses, providers, and staff of the importance of depression screening in the family planning clinic. The project was designed to assess the knowledge of depression and depression screening before and after the educational intervention. A pre and post knowledge survey was administered and a participant satisfaction survey. The project meets the needs of education that is offered monthly at the Forsyth County Public Health Department.

References

1. Bender, E. (2007). Depression Education Must Address Needs of Black Women. Psychiatric News, 42(22), 2-11
2. Berg, A. O., Allan, J. D., Frame, P. S., Homer, C. J., Johnson, M. S., Klein, J. D., et al. (2002). Screening for depression.Annals of internal medicine, 136(10), 760-764
3. Brown, C., Abe-Kim, J. S., & Barrio, C. (2003). Depression in ethnically diverse women: implications for treatment in primary care settings. Professional Psychology: Research and Practice, 34(1), 10
4. Buus, N. (2007). The Legacy of Peplau's Interpersonal Relationships in Nursing.Danish Journal of Nursing, 21(2), 58-67
5. Callaghan, P. (2004). Exercise: a neglected intervention in mental health care?.Journal of psychiatric and mental health nursing, 11(4), 476-483
6. Chung, B., Jones, L., Jones, A., Corbett, C. E., Booker, T., Wells, K. B., & Collins, B. (2009).Using Community Arts Events to Enhance Collective Efficacy and Community Engagement toAddress Depression in an African American Community.American journal of public health, 99(2), 237-244
7. Curphey, S. (2003). Black women mental-health needs unmet. Retrieved January, 15, 2004
8. Donnelly, T. T. (2002). CONTEXTUAL ANALYSIS OF COPING: IMPLICATIONS FOR IMMIGRANTS'MENTAL HEALTH CARE. Issues in Mental Health Nursing, 23(7), 715-732
9. Douglass, J. L., Sowell, R. L., & Phillips, K. D. (2003). Using Peplau's theory to examine the psychosocial factors associated with HIV-infected women's difficulty in taking their medications. Journal of Theory Construction and Testing, 7(1), 10-18
10. Farced, A. (1994).A philosophical analysis of the concept of reassurance and its effect on coping.Journal of advanced nursing, 20(5), 870-873
11. Fawcett, J. (2005). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (.) FA Davis Company. Philadelphia, PA
12. Frydenberg, E. (2004). Coping competencies: What to teach and when. Theory into practice, 43(1), 14-22
13. Frydenberg, E., & Lewis, R. (1996). A replication study of the structure of the adolescent coping scale: Multiple forms and applications of a self-report inventory in a counselling and research context. European Journal of Psychological Assessment, 12(3), 224
14. Gary, F. A., &Yarandi, H. N. (2004). Depression among southern rural African American women: A factor analysis of the Beck Depression Inventory-II. Nursing Research, 53(4), 251-259
15. Gramling, L. F., Lambert, V. A., &PursleyCrotteau, S. (1998). Coping in young women: Theoretical retroduction.Journal of advanced nursing, 28(5), 1082-1091
16. Greenglass, E., Fiksenbaum, L., & Eaton, J. (2006).The relationship between coping, social support, functional disability and depression in the elderly.Anxiety, Stress, and Coping, 19(1), 15-31
17. Greenglass, E., Schwarzer, R., Jakubiec, D., Fiksenbaum, L., &Taubert, S. (1999). The proactive coping inventory (PCI): A multidimensional research instrument. In 20th International Conference of the Stress and Anxiety Research Society (STAR), Cracow, Poland
18. Grote, N. K., Bledsoe, S. E., Swartz, H. A., & Frank, E. (2004).Culturally relevant psychotherapy for perinatal depression in low-income ob/gyn patients.Clinical Social Work Journal, 32(3), 327-347
19. Jones, H. L., Cross Jr, W. E., &DeFour, D. C. (2007). Race-related stress, racial identity attitudes, and mental health among Black women. Journal of Black Psychology, 33(2), 208-231
20. Jones, L. V., & Ford, B. (2008). Depression in African American women: Application of a psychosocial competence practice framework. Affilia, 23(2), 134-143
21. Jones, L. V. (2007). Preventing depression: Culturally relevant group work with Black women.Research on Social Work Practice
22. Keil, R. M. (2004). Coping and stress: a conceptual analysis. Journal of advanced nursing, 45(6), 659-665
23. Kristofco, R. E., Stewart, A. J., & Vega, W. (2007). Perspectives on disparities in depression care. Journal of Continuing Education in the Health Professions, 27(S1), 18-25
24. Laughon, K., Gielen, A. C., Campbell, J. C., Burke, J., McDonnell, K., &O'campo, P. (2007).The relationships among sexually transmitted infection, depression, and lifetime violence in a sample of predominantly African American women.Research in nursing & health, 30(4), 413-428
25. Lee, L. C., Casanueva, C. E., & Martin, S. L. (2005). Depression among female family planning patients: prevalence, risk factors, and use of mental health services. Journal of Women's Health, 14(3), 225-232
26. McNaughton, D. B. (2005).A naturalistic test of Peplau's theory in home visiting.Public Health Nursing, 22(5), 429-438
27. Meinert, J. A., Blehar, M. C., Peindl, K. S., Neal-Barnett, A., & Wisner, K. L. (2003).Bridging the gap.Academic Psychiatry, 27(1), 21
28. Miranda, J., Green, B. L., Krupnick, J. L., Chung, J., Siddique, J., Belin, T., et al. (2006).One-year outcomes of a randomized clinical trial treating depression in low-income minority women.Journal of consulting and clinical psychology, 74(1), 99
29. Moreland, A. D., & Dumas, J. E. (2008).Evaluating child coping competence: Theory and measurement.Journal of Child and Family Studies, 17(3), 437-454
30. NAMI Multicultural Action Center Unity Through Diversity. [African American Community Mental Health Fact Sheet]. (January 24, 2009). Retrieved January 24, 2009, from www.nami.org
32. National Institute of Health. (January 31, 2010). Protecting Human Research Participants. Message posted to http://phrp.nihtraining.com
34. Nolan, P., & Badger, F. (2005).Aspects of the relationship between doctors and depressed patients that enhance satisfaction with primary care.Journal of psychiatric and mental health nursing, 12(2), 146-153
35. O’Malley, A. S., Forrest, C. B., & Miranda, J. (2003). Primary care attributes and care for depression among low-income African American women. American journal of public health, 93(8), 1328-1334
36. Overstreet, K. M., Moore Jr, D. E., Kristofco, R. E., & Like, R. C. (2007). Addressing disparities in diagnosing and treating depression: a promising role for continuing medical education.Journal of Continuing Education in the Health Professions, 27, 5-8
37. Peplau, H. E. (1994). Quality of life: an interpersonal perspective. Nursing Science Quarterly, 7(1), 10-15
38. Pfeil, M., Gray, R., & Lindsay, B. (2009). Depression and stroke: a common but often unrecognized combination. British Journal of Nursing, 18(6), 365-369
39. Puskar, K. R., & Bernardo, L. (2002). Trends in mental health: implications for advanced practice nurses. Journal of the American Association of Nurse Practitioners, 14(5), 214-218
40. Resnick, B. (2007). The Honor of Protecting Participants While Conducting Research or Clinical Projects.Geriatric Nursing, 28(5), 271-273
41. Rich-Edwards, J. W., Kleinman, K., Abrams, A., Harlow, B. L., McLaughlin, T. J., Joffe, H., et al. (2006).Sociodemographic predictors of antenatal and postpartum depressive symptoms among women in a medical group practice. Journal of epidemiology and community health, 60(3), 221-227
42. Ritchie, J. A. (1999). Coping with What, When, Where, How-and So What?.Canadian Journal of Nursing Research Archive, 30(4)
43. Robinson, R. (2004). Stroke and Depression: Frequently Asked Questions. University of Iowa Hospitals & Clinics Health Topics. Screening for depression: Recommendations and rationale. (2002). U.S. Preventative Services Task Force
44. Simpson, S. M., Krishnan, L. L., Kunik, M. E., & Ruiz, P. (2007). Racial disparities in diagnosis and treatment of depression: a literature review. Psychiatric Quarterly, 78(1), 3-14
45. Sinclair, V. G., &Wallston, K. A. (2004).The development and psychometric evaluation of the Brief Resilient Coping Scale.Assessment, 11(1), 94-101
46. Snowden, L. R. (2003). Bias in mental health assessment and intervention: Theory and evidence. American Journal of Public Health, 93(2), 239-243
47. Steinbrook, R. (2002). Protecting research subjects—the crisis at Johns Hopkins. The New England Journal of Medicine, 346(9), 716-20
48. US Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. Rockville, Maryland: U.S. Department of Helath and Human Services, Substance Abuse, and Mental Health Services Administration, Center for Mental Health Services
49. US Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity- A supplement to MenatlHeatlh: a Report of the Surgeion General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General
50. Van Den Berg, S., Shapiro, D. A., Bickerstaffe, D., & Cavanagh, K. (2004). Computerized cognitive–behaviour therapy for anxiety and depression: a practical solution to the shortage of trained therapists. Journal of psychiatric and mental health nursing, 11(5), 508-513
51. Waite, R., & Killian, P. (2008).Health beliefs about depression among African American women.Perspectives in Psychiatric Care, 44(3), 185-195
52. Ward, E. C. (2007). Examining differential treatment effects for depression in racial and ethnic minority women: a qualitative systematic review.Journal of the National Medical Association, 99(3), 265
53. Webster's New Collegiate Dictionary. (1980). Springfield, Massachusetts: G & C Merriam Company
54. Weissman, M. M., Bland, R. C., Canino, G. J., Faravelli, C., Greenwald, S., Hwu, H. G., et al. (1996).Cross-national epidemiology of major depression and bipolar disorder.Jama, 276(4), 293-299
55. Whooley, M. A., Avins, A. L., Miranda, J., & Browner, W. S. (1997). Case�?�finding instruments for depression. Journal of general internal medicine, 12(7), 439-445
56. Wicks, M. N., Bolden, L., Mynatt, S., Rice, M. C., &Acchiardo, S. R. (2007). INSIGHT potentially prevents and treats depressive and anxiety symptoms in black women caring for chronic hemodialysis recipients. Nephrology Nursing Journal, 34(6), 623.