| This report reviews the literature on the prevalence, | | | | • Offering welfare recipients financial incentives to |
| treatment, and consequences of depression in | | | | work |
| low-income women, highlighting the relationship of | | | | Research suggests that each of these strategies may |
| depression to welfare and employment. Depression is | | | | both reduce depressive symptoms and increase |
| a debilitating illness, characterized by profound feelings | | | | self-sufficiency. |
| of sadness, low mood, and loss of interest in usual | | | | Treatment Availability |
| activities, that can have severe adverse effects, not | | | | Despite the availability of effective therapies, |
| only on the individual woman but also on her job and | | | | depression in the general population remains largely |
| family life. | | | | mistreated or altogether untreated. Moreover, income, |
| Recent changes in welfare policy in the United States, | | | | health insurance type, ethnicity, and gender affect |
| including the five-year lifetime limit on assistance and | | | | treatment rates and the type of treatment received. A |
| the requirement that recipients obtain jobs after two | | | | number of disparities are found in the literature, |
| years of continuous support, have increased concern | | | | including: |
| about depression and other problems facing many | | | | • Individuals with low incomes are less likely to |
| women on welfare. The research findings reviewed | | | | receive treatment from mental health specialists, such |
| here have a range of implications for research and for | | | | as psychiatrists and psychotherapists. |
| TANF and welfare-to-work policies and programs, | | | | • Medicaid beneficiaries are less likely to receive |
| which are outlined in this report. | | | | newer forms of antidepressants, such as Prozac. |
| Prevalence Of Depression Nationally | | | | • Medicaid beneficiaries are less likely to obtain |
| Data from large-scale national and community surveys | | | | psychotherapy than are individuals with private |
| reveal that: | | | | insurance. |
| • In any given year, approximately 4 percent to 10 | | | | Additionally, racial disparities are apparent within |
| percent of adults suffer from major depression. | | | | depressed Medicaid recipients, with nonwhite patients |
| • Rates of depression among women are 1.5 to 3 | | | | receiving less optimal treatment than white patients. |
| times that of men. | | | | Care Received Once Access has been Achieved |
| • Women from low-income groups are about twice | | | | Unfortunately, adequate treatment of depression is not |
| as likely as those from higher income groups to be | | | | guaranteed by access to health care. In fact, studies |
| depressed. | | | | consistently reveal: |
| These results suggest that low-income women and | | | | • High patient attrition rates |
| women on welfare are at particularly high risk for | | | | • Poor treatment adherence rates |
| developing depressive disorder. | | | | • Subtheraputic dosing patterns in the management |
| Prevalence of Depression in Women on Welfare | | | | of depression |
| Studies of women on public assistance that have used | | | | Many of these problems are exacerbated among |
| comparable and reliable measures of Major | | | | individuals with low incomes. |
| Depressive Disorder (MDD) to evaluate high levels of | | | | Barriers to Treatment |
| depressive symptoms find: | | | | Barriers to effective treatment for depression abound |
| • Twelve-month prevalence rates of MDD | | | | in the low-income population, including: |
| between 12 percent to 36 percent (median: 22 | | | | • High costs |
| percent). | | | | • Lack of medical insurance |
| • High levels of depressive symptoms exist in 25 | | | | • Stigma |
| percent to 57 percent of women (median: 47 percent). | | | | • Poor recognition of depression by physicians |
| While variation in rates across studies may reflect | | | | • Patient barriers, such as language barriers or |
| differences in local caseload characteristics, in timing of | | | | mistrust of strangers |
| the studies, or in assessment strategies, these levels | | | | Screening and Assessment - |
| of depression and its symptoms are quite high in | | | | Implications for TANF and Welfare-to-Work Programs |
| welfare samples, as compared to community samples. | | | | Identifying and treating those in need of mental health |
| Relationship of Employment and Depression | | | | services will require screening individuals to determine |
| Although considerations of depression among welfare | | | | whether or not they have symptoms that warrant |
| recipients generally focus on depression as an | | | | further (diagnostic) assessment. Currently, screening |
| obstacle to employment, but other explanations of the | | | | adults for depression, other mental disorders, or |
| association between depression and employment | | | | co-morbidity is not standard practice at welfare |
| have empirical support in the literature. This report | | | | agencies or in welfare-to-work programs. This raises a |
| summarizes research on the following possible causes | | | | number of issues for policymakers, including: |
| and consequences of depression: | | | | • What (if any) screening tools are available? |
| • Depression as a barrier to employment | | | | • How willing are welfare recipients to reveal |
| • Depression as limiting the capacity to retain | | | | information about depression? |
| employment | | | | • How can the confidentiality of results be insured? |
| • Depression as a consequence of poor-quality | | | | • What system changes may be required to deliver |
| jobs | | | | adequate mental health services? |
| • Depression triggered by job loss | | | | • Evaluate the adequacy of the current diagnostic |
| Because these possibilities are not mutually exclusive, it | | | | system for depression. |
| is important to better understand the conditions under | | | | • Develop longitudinal, nationally representative |
| which they emerge. | | | | samples of low-income women to study the onset, |
| Consequences of Maternal Depression for Children | | | | causes, and consequences of depression. |
| For mothers, major depression compromises their | | | | • Understand the sources of disparities in treatment. |
| ability to respond to their children and places children at | | | | • Evaluate how treatment of depressed mothers |
| considerable risk for psychopathology and | | | | affects their children. |
| developmental difficulties. The problems found in | | | | • Compare the costs and benefits of treating |
| children of depressed mothers include: increased rates | | | | depression, including savings for welfare systems. |
| of clinical diagnoses, impairments in psychological | | | | To ensure that there is timely and effective treatment |
| functioning, difficulties in meeting social and academic | | | | and preventive intervention for depression faced by |
| demands, more internalizing and externalizing behaviors, | | | | low-income women, policymakers and program |
| and substantial risk for psychiatric diagnoses later in life. | | | | administrators will want to: |
| Thus, any intervention aimed at mothers should | | | | • Ensure access to health insurance. |
| consider strategies for reaching at risk children. | | | | • Institute adequate coverage for mental health |
| Treatment Effectiveness | | | | treatment and intervention. |
| A large number of studies document the | | | | • Develop screening tools and procedures. |
| effectiveness of various treatment and prevention | | | | • Utilize multiple points of entry to identify at-risk |
| options for depression. Research findings from | | | | women and children. |
| experimental assignment to treatment show: | | | | • Ensure adequate income support. |
| • Equal effectiveness of psychopharmacological | | | | For more information about this study and the full |
| and psychotherapeutic treatments, as compared with | | | | report, as well as research citations, please refer to |
| placebo, for mild to moderately severe depression | | | | Depression and Low-Income Women: Challenges for |
| • Possibly greater effectiveness when drugs and | | | | TANF and Welfare-to-Work Policies and Programs. |
| psychotherapy are combined to treat recurrent | | | | Copies of the full publication are available on the |
| severe depression | | | | Research Forum Web site: or by writing to NCCP, 154 |
| Few studies have specifically focused on low-income | | | | Haven Avenue, New York, NY 10032; Tel: (212) |
| populations or women. While little attention has been | | | | 304-7100; Fax: (212) 544-4200 or 544-4201; |
| given to rigorous evaluations of nonmedical or | | | | E-mail: . |
| nonpsychotherapeutic interventions in this population, | | | | For more information contact Judith W. Katz-Leavy, |
| two promising approaches are reviewed: | | | | M.Ed., Center for Mental Health Services, Office of |
| • Incorporating attention to mental health problems in | | | | Policy, Planning, and Administration, at (301) 443-000. |
| job search programs | | | | |