The goal of this proposal is to increase our understanding about why many rural people with depression do not receive treatment despite the overwhelming evidence of treatment benefits. In order to explore rural- urban and intra-rural differences, we propose to use a random telephone survey to identify a cohort of 480 rural and urban people with major depression, dysthymia, or substantial depressive symptoms. We will administer a baseline interview to this cohort to measure predictors of use and a 6-month follow-up interview to determine use of services for depression in the general medical or specialty sector. Severity of depression and indicators of general functioning will be measured at baseline, 6 months and 12 months. This research design will allow us to accomplish three specific aims. First, we will examine whether rural people are less likely than urban people to seek care and receive appropriate treatment for depression. In addition to rural-urban comparisons, this will be the first study to characterize the extent of intra-rural variation in the delivery of mental health services. Findings from the first specific aim will demonstrate the extent to which rural people are failing to receive professional help for mental health problems which can be effectively addressed. Second, using Aday and Andersen's model of access to care, we will identify policy-relevant predictors of use. Building on existing cross-sectional studies conducted primarily in urban populations, we will prospectively identify enabling factors which predict use of mental health services for depressed individuals regardless of the community in which they reside, and factors which are particularly relevant for depressed rural residents. We will also examine whether depressed people in greatest need are more likely to receive appropriate care in both rural and urban areas. Third, we will compare how outcomes change over time between rural and urban individuals who did not use services for depression. We will examine whether factors which mediate recovery from depression differ between rural and urban people, placing rural people who do not seek care at greater risk of poor outcomes than their urban counterparts. Findings from the study will provide important evidence that can be used in the design of intervention studies to improve the mental health of rural Americans.
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