Journal of Evidence-Informed Social Work

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Depression Literacy Among American Indian Older Adults Soonhee Roh, Kathleen Brown-Rice, Natalie D. Pope, Kyoung Hag Lee, YeonShim Lee & Lisa A. Newland To cite this article: Soonhee Roh, Kathleen Brown-Rice, Natalie D. Pope, Kyoung Hag Lee, YeonShim Lee & Lisa A. Newland (2015): Depression Literacy Among American Indian Older Adults, Journal of Evidence-Informed Social Work, DOI: 10.1080/15433714.2014.983284 To link to this article: http://dx.doi.org/10.1080/15433714.2014.983284

Published online: 29 Apr 2015.

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Date: 06 November 2015, At: 06:52

Journal of Evidence-Informed Social Work, 00:1–14, 2015 Copyright q Taylor & Francis Group, LLC ISSN: 2376-1407 print/2376-1415 online DOI: 10.1080/15433714.2014.983284

Depression Literacy Among American Indian Older Adults Soonhee Roh School of Social Work, University of South Dakota, Sioux Falls, South Dakota, USA

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Kathleen Brown-Rice Division of Counseling and Psychology in Education, University of South Dakota, Vermillion, South Dakota, USA

Natalie D. Pope School of Social Work, University of Kentucky, Lexington, Kentucky, USA

Kyoung Hag Lee School of Social Work, Wichita State University, Wichita, Kansas, USA

Yeon-Shim Lee School of Social Work, San Francisco State University, San Francisco, California, USA

Lisa A. Newland Division of Counseling and Psychology in Education, University of South Dakota, Vermillion, South Dakota, USA

Older American Indians experience high rates of depression and other psychological disorders, yet little research exist on the depression literacy of this group. Depression literacy is fundamental for individuals seeking help for depression in a timely and appropriate manner. In the present study the authors examine levels and predictors of knowledge of depression symptoms in a sample of rural older American Indians (N ¼ 227) living in the Midwestern United States. Data from self-administered questionnaires indicate limited knowledge of depression and negative attitudes toward seeking help for mental health problems. Additional findings and implications for social work practice and policy are discussed. Keywords: Depression literacy, functional disability, mental health services, depression, American Indian older adults

The American Indian and Alaska Native (AI/AN) population is a diverse and growing population; however, it is among the least studied racial and ethnic minority groups in the United States. This is especially true of research on mental health issues (Echo-Hawk, 2011) and studies focused on older adults within this population (NIMH, 2001). Given that the number of AI/ANs aged 60 years and older is predicted to increase 280% between 2010 and 2050 from 629,000 to 1,766,000 (U.S. Census Bureau, 2009), it is important for practitioners to have an understanding of the American Indian older adult population and their health status. While there is great resiliency in this Address correspondence to Soonhee Roh, School of Social Work, University of South Dakota, 1400 West 22nd Street, Sioux Falls, SD 57105, USA. E-mail: [email protected]

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population (Roh et al., 2014), previous limited research has found that American Indian older adults are at greater risk of physical health conditions (i.e., diabetes, cardiovascular disease, cancer), mental health issues (i.e., depression, posttraumatic stress disorder), and disability rates than their White counterparts (Chapleski, Kaczynski, Gerbi, & Lichtenberg, 2004; Sutherland & Tulkin, 2012; Weaver, 2010). Further, evidence suggests that older American Indians have greater affective and/or probable depressive symptoms when compared to their peers of other racial and ethnic groups (Goins, Moss, Buchwald, & Guralnik, 2007; Goins & Pilkerton, 2010; Kim, Bryant, & Parmelee, 2011; Satter, Wallace, Garcia, & Smith, 2010; Sutherland & Tulkin, 2012). In fact, Miller-Cribbs, Byers, and Moxley (2009) find “depression as a critical mental health issue for Native American elders” (p. 266). Very little is known about specific factors related to depression with this population (Brave Heart, Chase, Elkins, & Altschul, 2011). This could be due to the fact that traditional dominant culture assessments may not be valid in capturing the experiences of depression in the older American Indian population (Miller-Cribbs et al., 2009; Struthers & Lowe, 2003). In that, researchers and clinicians may not be considering the cultural manifestation of depressive symptoms and the historical relationship between the dominant European culture and AI/AN people in the United States. The theory of historical trauma was developed by Brave Heart and DeBruyn (1998) to explain how current problems in many AI/AN communities are a direct result of past brutalities suffered by the AI/AN people. This population was subjected to numerous traumas by the White dominant culture (i.e., genocide of people, taking of land, disruption of families, robbing of culture) and these traumas resulted in a cross-generational transmission of maladaptive functioning that continue today in many AI/AN communities (Brave Heart et al., 2011; BrownRice, 2013; Whitbeck, Adams, Hoyt, & Chen, 2004). Specifically, “the psychological, socialenvironmental, and physiological concerns that plague many Native people are signs and symptoms of a communal reaction to generations of persecution, discrimination, and oppression” (BrownRice, 2013, p. 125). This collective response is very different from the Eurocentric perception of illness which assesses distress in terms of individual causes and solutions (Goodkind, Hess, Gorman, & Parker, 2012). Given the possible different cultural perceptions and stigmas related to depression, it is important that researchers study depression literacy in this population. However, no previous study has examined older American Indians’ mental health literacy. This is problematic because, for early diagnosis to occur, the mental health literacy of a population must be determined (Lee, Tang, Leung, Yu, & Cheung, 2009). Given the lack of knowledge of American Indian older adults’ mental health literacy, the purpose of the authors in the current study was to explore the levels and predictors of knowledge of depression among older American Indians.

REVIEW OF THE LITERATURE American Indian Older Adults and Attitudes Toward Mental Health An extensive literature search to identify research published between 1990 and 2010 dedicated to treatment of depression for older adults according to race/ethnicity found no articles related to older American Indians (Fuentes & Aranda, 2012). Possible reasons for the scant literature on American Indian older adults could be the different cultural views of depression and social stigma surrounding individualistic health issues. In fact, “different cultures have different beliefs about the etiology of their problems which may affect the manifestations of mental illness” (Curyto et al., 1998, p. 22). For example, it has been found that older American Indians are less likely to disclose emotional symptoms such as sadness, anxiety, or hopelessness (Bird & Parslow, 2002; Fiske, Wetherell, & Gatz, 2009). Moss (2005) suggests that many American Indian older adults tolerate illness,

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meaning that they report their health as good or excellent, even when they are functioning poorly. Traditional cultural perceptions with this population provide that the needs of family and community take priority over an individual’s needs (Smyer & Stenvig, 2007). Therefore, older American Indians may ignore their own health problems, neglect to report symptoms, or forego seeking treatment if they perceive it could negatively impact their family/community (Gallant, Spitze, & Grove, 2010). It seems there is a stigma for individuals to seek assistance for a personal need if it is perceived to negatively impact the family/community. Another rationale as to why this population might have negative attitudes toward mainstream mental health care could be related to the dysfunctional relationship between the federal government and the AI/AN people. A qualitative study of AI/ANs found respondents associated mainstream health care with abuses by the U.S. government which suggests a significant relationship between the experience of discrimination and the underutilization of Western healthcare (Fu et al., 2007). Burgess, Ding, Hargreaves, van Ryn, and Phelan (2008) also found a significant correlation between AI/AN patients underutilizing mental health services and having frequent experiences of discrimination. Therefore, experiences of racism, discrimination, and prejudice could impact older American Indians’ attitude about reporting mental health concerns to practitioners, especially those of the dominant White culture. American Indian Older Adults and Depressive Symptomology There is limited research on depressive symptomology being present in the older American Indian population (NIMH, 2001). Satter and colleagues (2010) completed a detailed study of the health risks, health status, and health services use of American Indian older adults in California. These researchers found that when compared to all other races (i.e., non-Latino White, Latino non-AI/AN, non-Latino African American, non-Latino Asian), older American Indians of both genders selfreported a higher need for assistance with mental health problems. It has also been found that American Indian older adults had the highest occurrence in the past year of experiencing serious emotional distress compared to their White, African American, Latino American, and Asian American counterparts (Kim et al., 2012). In another study, Lagana` and Sosa (2004) investigated 228 non-institutionalized women (60 years of age or older) from diverse ethnic and racial backgrounds and found being AI/AN was a risk factor for having depressive symptoms. Due to the prevalence of chronic illnesses as AI/AN adults age, it is important to note that empirical research also provides evidence of a significant correlation between chronic illness and depression with AI/ANs (Calhoun et al., 2010), specifically with older American Indians (Singh et al., 2004). John, Kerby, and Hennessy (2003) investigated 1,039 rural community-resident older American Indians (60 years or older) and found 57% reported three or more of 11 chronic conditions with a four-cluster comorbidity structure which included cardiopulmonary, sensory-motor, depression, and arthritis. When looking at other demographic variables (i.e., living alone, level of education) related to depressive symptoms with American Indian older adults, extensive search of the literature found limited studies that have examined these relationships. One study was located related to older American Indians living alone and having depressive symptoms. In this study, living alone was a significant predictor for depression symptomatology for this population (Roh et al., 2014). When looking at level of education, only one study found that depressive symptoms were associated with lower levels of formal education with American Indian older adults (Bell et al., 2010). American Indian Older Adults and Depression Literacy Increasing health literacy is seen as a way to improve health outcomes within a population (Mika, Kelly, Price, Franquiz, & Villarreal 2005). Mental health literacy includes a person’s knowledge and beliefs about mental disorders that assist in recognition, management, or prevention of these

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disorders and is a factor in help-seeking behaviors and utilization of mental health services (Jorm et al., 1997). As AI/AN adults underutilize mental health services (Greer, 2004) and are at a greater risk than any other racial group of experiencing psychological distress and having poorer overall mental health (Barnes, Adams, & Powell-Griner, 2010), it would seem especially prudent to examine the mental health literacy of this population. In particular, more needs to be learned about how mental health literacy relates to depression, especially given that American Indian older adults are overrepresented in experiencing affective disorders (Kim et al., 2012; SAMHSA, 2012) and previous findings that a relationship exists between older American Indians having a chronic illness and depressive symptoms (Calhoun et al., 2010; John et al., 2003). Depression literacy is associated with an individual having a specific understanding about depression: (a) how to recognize depressive symptoms, (b) beliefs about the etiology of depression, (c) knowledge of treatments and interventions, and (d) attitudes regarding receiving treatments (Gabriel & Violato, 2010). Improvement in depression literacy facilitates changes in attitude regarding this illness and helpseeking behaviors (Lauber, Nordt, Falcato, & Rossler, 2003). The authors of this current study would be the first to look specifically at depression literacy among older American Indians and examine the predicting variables of living alone, education, and gender. This seems especially important given the positive correlation between mental health literacy and attitudes toward seeking psychiatric assistance (Mika et al., 2005) and the prevalence of mental health concerns with this population (Barnes et al., 2010). Research Questions Through the present study the authors added to the dearth in mental health research regarding older American Indians. In particular, they aimed to explore knowledge about depression and the factors that predict that knowledge in a sample of American Indian older adults. The following research questions were examined: (1) What is the current knowledge level of American Indian older adults regarding depression? and (2) What are the salient predictors of knowledge of depression among American Indian older adults? METHODS Sample and Data Collection With approval from the institutional review board at the principal investigator’s Midwestern university, data were collected from a convenience sample of rural American Indian older adults, ages 50 and older, from January to May 2013. Being drawn from populations with fewer than 50,000 people (U.S. Census Bureau, 2009), the sample was composed of rural and off-reservation older American Indian participants. The cut-off age of 50 was selected because of the reduced life expectancy of American Indian older adults in comparison with the general population (Indian Health Service, 2013). Participants were recruited through a variety of off-reservation locations including American Indian churches, social service centers, other religious organizations, senior housing facilities, senior centers, and three powwows in two Midwestern states. A total of 235 American Indian older adults participated in the study. To help ensure more accurate analyses, data from eight participants were excluded because they did not complete the entire questionnaire; more than 10% of their responses were missing. Therefore, the final sample consisted of 227 participants. In addition, for the analysis of variables with small numbers of missing values, which were typically non-random, this study used pairwise deletion to keep as many cases as possible (Hair, Anderson, Tatham, & Black, 1998). While questionnaires were designed to be self-administered, trained American Indian interviewers were available to assist participants who might need assistance. Two individuals

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completed the questionnaire with help from the interviewers. Before administering the survey, interviewers explained the study purpose, the procedures, and the scope of questions that would be asked, confidentiality precautions, the right to withdraw at any time or to refuse to answer any questions, and the overall voluntary nature of participation, as well as the benefits and risks of the study. All participants gave informed written consent prior to data collection. The questionnaire took approximately 30 minutes to complete, and participants were offered $10 for their time. Measures Depression literacy. The Depression in Late Life Quiz (Pratt, Wilson, Benthin, & Schmall, 1992) was used to assess individuals’ knowledge of depression. This scale consists of 12 items that ask about depression literacy. Items include: “It is normal for older people to feel depressed a good part of the time,” “There is a higher suicide rate among the elderly than among younger adults,” and “Health professionals often have difficulty diagnosing depression in the older person.” Although the original response format is “True,” “False,” and “I don’t know,” the present study used a simple true/false response because a majority of the American Indian elders endorsed the “I don’t know” response for many of the items during pilot testing. At .60, the internal consistency was relatively low, but this reflects the broad content area as well as variations in the difficulty of the items. The total number of correct answers was used in the analysis, with scores potentially ranging from 0 –12. Depressive symptoms. The Geriatric Depression Scale– Short Form (GDS-SF; Sheikh & Yesavage, 1986) was used to assess depressive symptoms. With a yes/no response format, the scale included five positive items (e.g., “Are you satisfied with your life?” and “Do you feel happy?”) and 10 negative items (e.g., “Do you feel that your life is empty?” and “Do you feel helpless?”). The total score was calculated by counting the number of affirmative responses to negative items, and scores for positive items were reversed. Scores on the GDS-SF ranged from 0 (no depressive symptoms) to 15 (severe depressive symptoms). A score of 5 and above is suggested as indicative of a probable depression (Sheikh & Yesavage, 1986). Internal consistency of the GDS-SF was .81 in the present sample. Functional disability. Functional disability was assessed with a composite measure of the physical activities of daily living (Fillenbaum, 1988), instrumental activities of daily living (Fillenbaum, 1988), the Physical Performance Scale (Nagi, 1976), and the Functional Health Scale (Rosow & Breslau, 1966). The 20 items covered a wide range of activities including eating, dressing, traveling, managing money, carrying a bag of groceries, and ability to reach above the head with one’s arms. Participants were asked whether they could perform each activity, and responses were coded as 0 (without help), 1 (with some help), or 2 (unable to do). The total scores range from 0 (no disability) to 40 (severe disability). Internal consistency was .94 in the current study. Attitudes toward mental health services. A 10-item version of the Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS-SF; Fischer & Farina, 1995) was adopted to assess individuals’ propensity to use mental health services. The scale includes five positive statements (e.g., “If I believed I was having a mental breakdown, my first inclination would be to get professional attention,” “A person with an emotional problem is not likely to solve it alone; he or she is likely to solve it with professional help”) and five negative statements (e.g., “The idea of talking about problems with a psychologist strikes me as a poor way to get rid of emotional conflicts,” “A person should work out his or her own problems; getting psychological counseling would be a last resort”). Individuals were asked to rate each statement using a 4-point scale ranging from 0 (disagree) to 3 (agree). Responses to the negative statements were reverse coded. Internal consistency was .68 in this study.

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Demographic variables. This study used four demographic factors: age, gender, education, and living alone. The variable “age” was a continuous variable. Dichotomous variables: “female” and “living alone” were coded as 1; otherwise, coded as 0. The “education” was an ordinal variable ranging from 1 (graduated from elementary school) to 5 (graduated from graduate school).

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Data Analysis This study employed a hierarchical regression analysis to examine the predictors of knowledge of depression among American Indian older adults, which is a continuous variable. Sets of predictors were: (1) demographic variables (age, female, education, and living alone); (2) functional disability; (3) attitudes toward mental health services; and (4) depressive symptoms. In addition, this study identified the specific amounts of variance in the knowledge of depression, which were accounted for by the sets of different predictors. No multicollinearity problems were observed because VIF scores were all greater than 1.028 (Mertler & Vannatta, 2009). For some variables with skewedness such as age, functional disability, and depressive symptoms, square root transformations were used.

RESULTS Demographic Characteristics and Main Variables Table 1 shows demographic characteristics and main scale variables’ range, mean, and standard deviation. Average age of respondents was 60.7 years, ranging from 50– 95 years old. Over 54% were female, and most participants had received a high school education/GED or more. About 26% lived alone but about 74% lived with someone. The mean score 6.96 of knowledge of depression (SD ¼ 1.7) in this study ranged from 3– 10, which was slightly higher than the 5.48 of Korean immigrant elders (Jang, Gum, & Chiriboga, 2010). The mean score of attitudes toward mental health services was 18.6, compared with 23.49, the mean score of medical outpatients (Elhai, Schweinle, & Anderson, 2008). The mean score of functional disability was 1.92 (SD ¼ 4.64) out of 40, indicating few respondents had physical functioning problems for daily activities. Scores of attitudes toward mental health services averaged 18.63 out of 30, which were lower than the mean score 23.49 of medical patients who used services in past six months (Elhai et al., 2008). Scores of depressive symptoms averaged 2.28 (SD ¼ 2.77) out of 15, which was slightly higher than the mean score 2.1 of African American women elders (Pedraza, Dotson, Willis, Graff-Radford, & Lucas, 2009). TABLE 1 Demographic Characteristics Among Older American Indians (N ¼ 227) Age, M (SD) Gender, n (%) Education, n (%)

Living arrangement, n (%) Knowledge of depression, M (SD) Functional disability, M (SD) Attitude toward mental health services, M (SD) Depressive symptoms, M (SD)

Range: 50 to 95 years Female Male Lower than high school diploma/GED High school diploma/GED Greater than high school diploma/GED Living alone Living with someone Ranged from 3–11 Ranged from 0–25 Ranged from 0–30 Ranged from 0–13

60.7 125 105 19 96 112 60 171 6.96 1.92 18.63 2.28

(8.4) (54.3) (45.7) (8.3) (42.3) (49.4) (26.0) (74.0) (1.7) (4.6) (5.6) (2.8)

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Descriptive Information for Depression Literacy

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Table 2 shows the percentages of incorrect answers on the 12 items of the Depression in Late Life Quiz. The percentages of incorrect answers ranged from 30.2%–84.5%. For 8 out of the 12 items, more than 50% of respondents had incorrect responses, indicating a lack of knowledge of depression. Item 8 (“It is common for older people to talk about potential suicide”) had the highest percentage (84.5%) of incorrect answers. The lowest percentage of incorrect responses (30.2%) was for Item 12 (“Depression among the elderly can be effectively treated with medication”), revealing that the majority of American Indian older adults were aware of the role of depression medications. However, over 51% of the respondents answered that health professionals have difficulty in diagnosing depression.

Correlations Among Variables Table 3 presents the correlations among variables. Correlation results revealed that there were significant relationships between knowledge of depression and attitudes toward mental health services, age, being female, and education. Additionally, being female was related to more positive attitudes toward mental health services and education. Functional disability was significantly associated with higher levels of depressive symptoms and age.

Predictors of Depression Literacy Table 4 summarizes the results of the hierarchical regression analysis to examine the predictors of knowledge of depression. Demographic variables in step one explained 5.8% of the variances (R2) in knowledge of depression among American Indian older adults. In step one, while the model was significant, none of the demographic predictors were not significant. In step two, demographics and

TABLE 2 Descriptive Information on the Depression in Late Life Quiz (N ¼ 227)

12 items (correct answer) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

It is normal for older people to feel depressed a good part of the time (F). Memory problems may be a sign of depression (T). Depression is easy to recognize in an older person who is physically ill (F). Older people are more likely than younger people to say, “I am depressed” (F). A complete medical evaluation is needed to rule out physical reasons for depression (T). Family and friends can usually help the depressed older person by telling him or her to “count your blessings” or “look at the bright side” (F). There is a higher suicide rate among the elderly than among younger adults (T). It is common for older people to talk about potential suicide (F). Most older persons who talk about committing suicide are not serious (F). Health professionals often have difficulty diagnosing depression in the older person (T). If depression is severe, there is little the depressed person can do to help him or herself (T). Depression among the elderly can be effectively treated with medication (T). Note. T ¼ true; F ¼ false.

Incorrect answers 69.80% 44.30% 49.60% 63.20% 32.50% 68.00% 84.10% 84.50% 75.10% 51.10% 78.40% 30.20%

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TABLE 3 Bivariate Correlations Among Main Variables (N ¼ 227)

1. Knowledge of depression 2. Attitude toward mental health services 3. Functional disability 4. Depressive symptoms 5. Age 6. Female 7. Education 8. Living alone

1

2

3

4

5

6

7

– .26*** 2.08 .04 2.15* .15* .21** 2.08

– .00 .06 2.07 .19** .09 2.05

– .40*** .24*** .02 .02 2.04

– .11 .00 2.13 .04

– 2.06 2.06 .08

– .13* .06

– 2.05

*p # .05. **p # .01. ***p # .001

functional disability accounted for 6.8% of the variances (R2), which was an increase of 1.1% from step one. In step two, only attitudes toward mental health services were a significant predictor In step three, demographics, functional disability, and attitudes toward mental health services accounted for 14.3% of the variances (R2), which was the increase of 7.5% from step two. In the final step, demographics, functional disability, attitudes toward mental health services, and depressive symptoms explained 18.2 % of the variances (R2), which was an increase of 3.9 % from step three. In step three, several significant predictors, including education and functional disability, were not previously significant. Higher levels of depressive symptoms were significantly associated with higher levels of knowledge of depression (b ¼ .387, p # .01). More positive attitudes toward mental health services were significantly related to higher levels of knowledge of depression (b ¼ .088, p # .001). Higher levels of functional disability were significantly related to lower levels of TABLE 4 Coefficients of Hierarchical Regression for the Predictors of Knowledge of Depression Among Older American Indians (N ¼ 227) Knowledge of Depression Ba (SEb) Step 1 Age Female Education Living alone R2 Functional disability Attitude toward mental health services Increment to R2 at this step Depressive symptoms Increment to R2 at this step F test R2 total Adjusted R2 total Note. a Standardized Beta coefficients. *p # .05. *** p # .001.

2.029 (.017) .329 (.271) .296 (.160) 2.187 (.335) .058

Step 2 2.020 (.017) .229 (.262) .263 (.154) 2.111 (.325)

2.017 (.016) .221 (.259) .303 (.153)* 2.300 (.333)

2.036 (.028) .084 (.023)*** .084

2.066 (.031)* .088 (.023)***

2.491* .058 .035 b

Step 3

Standard errors.

4.391*** .142 .110

.110 (.051)* .025 4.512*** .167 .130

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knowledge of depression (b ¼ 2 .066, p # .05). In addition, higher levels of education were significantly associated with higher levels of knowledge of depression (b ¼ .310, p # .05). However, age, being female, and living alone were not significant predictors of knowledge of depression in the sample of this study.

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DISCUSSION Scholars have given limited attention to engaging in research with the older American Indian populations (NIMH, 2001). This is troubling given that American Indian older adults report a higher need for assistance with emotional/mental health problems (Satter et al., 2010) and often experience serious psychological distress (Kim et al., 2012). The current study was the first to investigate the level of depression literacy among this population and to extend these findings to determine the relationship with specific independent variables (i.e., demographic characteristics, functional disability, attitudes toward mental health services, and depressive symptoms). When looking at the current knowledge level of older American Indians regarding depression, the results indicate the average number of correct responses was only 7 out of 12 possible. Across all the items, 30% –85% of participants answered them incorrectly, with an average of about 50% of participants having incorrect responses on the Depression in Late Life Quiz. This suggests a limited knowledge of depression. It is interesting that most respondents (84.5%) missed the question related to older individuals talking about suicidal ideation and did not see increased age as a risk factor for suicide. Depression is the most commonly reported psychiatric disorder and the single most important risk factor for suicide among older adults (Van Orden et al., 2013). In addition, older U.S. adults and AI/ANs are disproportionately more likely to complete suicide (CDC, 2012). Also noteworthy was 51% of respondents reported that health professionals have a difficult time diagnosing depression. It is possible that this could be related to participants’ previous experiences with mental health providers and their level of acculturation. As it has been found that AI/AN ethnicity correlated with negative ratings for medical practitioners (e.g., felt respected, provider was empathetic, good rapport); conversely, high scores on White ethnicity were associated with positive ratings for practitioners (Garroutte, Sarkisian, & Karamnov, 2012). Further, practitioners should not negate the continual impact of the past atrocities perpetrated on the AI/AN people. Older American Indians may be reluctant to trust White clinicians (Fu et al., 2007) and Western medicine to adequately understand them and their suffering. Given that previous experiences of discrimination impact patient compliance (Burgess et al., 2008), practitioners must be willing to broach the subject of race with patients in cross-cultural situations. Clinicians are ethically bound to understand the nature of diversity and oppression (ACA, 2014; NASW, 2008) and should be willing to acknowledge the existence of discrimination and oppression that has impacted the AI/AN people (Brave Heart et al., 2011). It is important to remember that older American Indians’ attitudes toward and compliance with treatment may be challenging “to engage in without validation of not only the past atrocities that occurred . . . but acknowledgment of the current discriminatory environment that many Native people still endure” (Brown-Rice, 2013, p. 127). When examining predictive variables related to American Indian older adults’ depression literacy, higher levels of self-reported depressive symptoms and positive attitudes toward mental health services were significantly associated with higher levels of depression literacy. These findings substantiate previous research that suggests depression literacy increases an individual’s ability to recognize depressive symptoms and relates to a more positive attitude regarding receipt of treatment (Gabriel & Violato, 2010; Lauber et al., 2003). It is noteworthy that the respondents in this present study scored 18.63 in their attitudes toward receiving mental health services. These results fall within the mid-range, given the scores range from 0 – 30, with higher scores indicating

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more positive treatment attitudes (Elhai et al., 2008). Therefore, clinicians should be aware that when working with American Indian older adults there may be a tendency for patients to have less positive attitudes regarding receiving mental health treatment. For this reason, older American Indians may be unlikely to discuss a negative emotional state with practitioners (Bird & Parslow, 2002; Fiske et al., 2009) due to the belief the illness must be tolerated (Moss, 2005) or that their distress would negatively affect the family/community (Gallant et al., 2010). Again, clinicians should not discount that effects of historical trauma when present. American Indian older adult may be reluctant to discuss their symptoms with non-AI/AN practitioners. For participants in this study, functional disability was significantly related to lower levels of depression literacy. Generally, this finding is consistent with previous studies (Calhoun et al., 2010; John et al., 2003; Singh et al., 2004). This information is noteworthy given that American Indian older adults are permanently disabled at six times the rate of non-Latino Whites (Satter et al., 2010) and research indicates a relationship between disability and depression with older American Indians (Denny, Holtzman, Goins, & Croft, 2005; Goins & Pilkerton, 2010). This current study provides important information to bridge the gap in literature on depression literacy and predictors of knowledge of depression in American Indian older adults. While few respondents reported having physical functioning problems for daily activities and high depressive symptoms, it was found that: (a) higher levels of depressive symptoms and more positive attitudes toward mental health services were significantly associated with higher levels of knowledge of depression; (b) higher levels of functional disability were significantly related to lower levels of knowledge of depression; and (c) higher levels of education were significantly associated with higher levels of knowledge of depression. However, the AI/AN population is diverse with 566 federally recognized tribes located in 35 states (Indian Health Services, 2013); practitioners need to consider the vast within group differences in this population. Researchers must also be careful in making generalities with the AI/AN people. One of the most noteworthy findings of this study is that 51% of the participants perceived that health professionals have difficulty diagnosing depression. This may explain the low levels of depressive symptomology reported by these same participants. It has been suggested that depressive symptomology for AI/AN should be reframed as a collective response to the past atrocities that have been perpetrated on the AI/AN people (Brave Heart & DeBruyn, 1998). As the historical traumas were systematic in nature, the responses to these traumas need to be understood as collective (Brave Heart et al., 2011; Brave Heart & DeBruyn, 1998; Brown-Rice, 2013; Whitbeck et al., 2004) and pervading all facets of existence (e.g., personal identity, interpersonal relationships, collective memory, cultural and spiritual worldviews; Weisband, 2009). While the measure utilized in this study was reliable, it is worth exploring additional instruments that measure depressive symptoms related to historical trauma.

IMPLICATIONS FOR SOCIAL WORK PRACTICE This study has several implications for social workers working with American Indian older adults. Depression literacy of minority groups, and American Indian older adults in particular, have received little attention, and diagnosis approached from a medical model rarely considers cultural factors. This can often result in healthcare consequences that differ across target populations (Skaer, Sclar, Robison, & Galin, 2000). Social workers and other allied health professionals should consider the role that culture may play in the helping process and at a minimum seek basic information about AI/AN. Such information that is easily accessible online is the Culture Card—a brief guide on AI/AN culture, highlighting topics such as cultural identity, historical distrust, and myths and facts about this population (available for free download at www.SAMHSA.gov/shin).

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Although medical social workers often underestimate the value of education as an intervention (Rabow, Hauser, & Adams, 2004), the “effective exchange of reliable information promotes client empowerment and self-determination” (Cagle & Kovacs, 2009, p.17) which are essential elements of social work practice. However, simply providing information to clients about depression does not guarantee comprehension and an ability to make an informed decision about diagnosis and treatment. The effectiveness of educational interventions, such as information provided by social workers on symptoms of depression, pharmacological treatments, and prevention strategies, depends upon many factors, including depression literacy of clients (Vahabi, 2007). This study suggests that American Indian older adults lack knowledge of depression and hold unfavorable attitudes toward seeking mental health services. Therefore, social workers and other allied health professionals should consider the social work axiom —“starting where the client is”—in terms of providing information about the diagnosis of depression and treatment options. Through the use of neutral, open-ended questions, practitioners could get a sense of what clients know about depression and then provide education based on what the clients already know about mental illness. In light of study findings, we offer suggestions for future research on this important topic. Studies with more representative samples of American Indian older adults generally and also across different tribes and rural/urban contexts will provide a fuller picture of physical and mental health effects. In addition, further refinement of the Depression in Late Life Quiz is needed. The relatively low estimate of internal consistency was not anticipated. Differences in the samples likely account for the divergent estimates of internal consistency, especially differences in age and level of education. Given cultural differences in the conceptualization and manifestation of probable depression, qualitative approaches may provide needed perspectives on how to improve this scale. Finally, while the results of the present study provide needed information to mental health care providers regarding the depression literacy of older American Indians, future researchers can add to the literature by examining the relationship between within group differences (e.g., acculturation level, tribal affiliation, reservation, and urban living) and mental health literacy. Also, an examination of the potential cultural differences in the understanding and development of depression should be undertaken. Further, the findings of this study suggest a strong need for future research focusing on the relationship between the effectiveness of preventative efforts and treatment outcomes and clients’ mental health literacy.

LIMITATIONS Several limitations of the current study should be noted. The use of a convenience sampling method to recruit older American Indians in two Midwestern states limits the generalizability of the findings to older American Indians in other settings or states. The cross-sectional design of the current study is not appropriate for exploring causal relationships between the variables. A longitudinal design that utilizes a random sample would better elucidate how depressive symptoms, functional disability, and attitudes toward mental health services influence levels of depression literacy. All of the study’s data are based on self-report, and participants could have provided answers they considered to be socially desirable. Also, data on tribal membership were not collected. Selection biases might have affected the findings in several ways. Participants who chose to participate in the study might have been more willing to discuss depressive symptoms, more positive views about mental health services, and they might have had fewer emotional or psychological problems than those who did not choose to participate. The level of depressive symptoms among older American Indians who are homebound or institutionalized might be different than those who are actively involved in senior centers and powwows who participated in this study.

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