Factors related to help-seeking by depressed symptomatic volunteers and clinic patients

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Title:
Factors related to help-seeking by depressed symptomatic volunteers and clinic patients
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vii, 136 leaves : ;
Language:
English
Creator:
Amori, Geraldine Heller, 1951-
Publication Date:

Subjects

Subjects / Keywords:
Depression, Mental -- Treatment   ( lcsh )
Help-seeking behavior   ( lcsh )
Community mental health services   ( lcsh )
Genre:
bibliography   ( marcgt )
theses   ( marcgt )
non-fiction   ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 1987.
Bibliography:
Includes bibliographical references (leaves 129-135).
Statement of Responsibility:
by Geraldine Heller Amori.
General Note:
Typescript.
General Note:
Vita.

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Source Institution:
University of Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 001030268
notis - AFB2386
oclc - 18130754
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AA00002150:00001

Full Text














FACTORS RELATED TO HELP-SEEKING BY
SYMPTOMATIC VOLUNTEERS AND CLINIC


GERALDINE


DEPRESSED
PATIENTS


HELLER AMORI


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY


UNIVERSITY


OF FLORIDA















ACKNOWLEDGEMENTS


It i


rare


to have


opportunity


express


formal


appreciation


so many


individuals


whose


support,


both


formal


informal


was


given


with


no consideration


potential


gratitude


or repayment.


Moreover,


difficult


to effectively


express


depth


of gratitude


without


sounding


trite.


Neverthel


ess


, it


true


that


without


these


special


people,


research


could


have


taken


place.


heartfelt


appreciation


extended


husband,


John


, and


stepchildren,


Betsey


and


Nathaniel,


their


love


patience


throughout


process.


In addition


, special


thanks


employer,


who


has


been


patient,


encouraging,


facilitating


appropriately


critical


support,


education


would


like


thank


committee

committee,


chair


, Larry


Margaret


Fon


Loesch,

g-Beyett


as wel

e and


as the


Robert


members


Lenox.


Finally,


I would


like


to thank


. Lelon


Weaver


support


friends


encouragement,


their


as well


never-ending


as all


supply


my colleagues


of positive


statements.




















TABLE OF CONTENTS


Page


ACKNOWLEDGEMENTS


ABSTRACT


a ....... a a a a a a .sat a a a a


.. a.. a. a a a at a a a a .......* a* a e *


CHAPTERS


INTRODUCTION


Need for the Study ..
Purpose of the Study
Research Questions ..
Definition of Terms .
Overview of the Paper


a.... a . . . . 1


...... .... e.aa. t.... a a
*.a...a.....ataa....a.a..a.a
*.a..at..... a.a...a.te .....

*...a......a.......aa..a ...
a a a a C bca o t a a a.1 a a a a
1 0 0 0 0 0 0 0 o 0 o
I 0 I Q 0 0 0 D 0
0 0 0 0 0 0 0 0
0 0 0 0 Q0 0 0


II RELATED LITERATURE AND INSTRUMENTATION


Depression .................................
Treatment-Seeking Behavior .................
Research Volunteers ......................aa
Symptomatic Volunteers (SVs) ...............
Personality Theories .......................
Instruments ...........................****
Summary. ............. .. ... .. .. .. *******


III METHODOLOGY


a a. a a a *t a a a a a...* a ta *


Population and Samplin'
Sampling Procedures ..
Variables/Instruments
Hypotheses ...........
Analyses of Data .....
Limitations ..........


IV RESULTS


a ...a.a.. a. a.. a.. a.. ...a

a.a............*..a.aa.a..a.
a...a.a..cc.......ttttaaa


a...a.a.. a .a.ee...... tata
o oo oo oo Do o) oo oo oo oo
) OI 1D )) (Q )) ) O O OO O O
)))()))1()))(11)111())

0 0 0 0 0 0 o 0


* a a....a.aa .a... a......*t .t...**t* see.


Evaluation of Hypotheses ...................
Summary ......... ..... ... ..... .... ... ....









Implications ...
Recommendations
Summary ........


S. .......................... 118
. .......................... 119
............................ 121


APPENDICES


DEMOGRAPHICS/REASONS FOR TREATMENT
MODE SELECTION QUESTIONNAIRE .....


COVER

COVER


LETTER

LETTER


TO SYMPTOMATIC


TO CLINIC


VOLUNTEERS


PATIENTS


REFERENCES


BIOGRAPHICAL


SKETCH













Abstract


of Dissertation


Presented


the


Graduate


School


of the


University


of Florida


in Partial


Fulfillment


Requirements


the


Degree


of Doctor


of Philosophy


FACTORS


RELATED


SYMPTOMATIC


TO HELP-SEEKING


VOLUNTEERS


AND


BY DEPRESSED


CLINIC


PATIENTS


Geraldine


Heller


Amori


December,


1987


Chairman
Major De


The


: Larry
apartment


availability


. Loesch
Counselor


Education


of volunteers


research


antidepressant

similarities b


medications


between


raised


symptomatic


questions


volunteers


about


, persons


requesting


treatment


through


drug


research


programs)


clini


patients


, persons


requesting


counseling


servi


ces


depression)


Symptomatic


volunteers


and


clini


patients


have


been


shown


to have


some


similarities


regard


to depressive


symptoms


responses


to treatment


However


was


unknown


whether


they


differed


regard


to other


factors


related


to help-seeking-behavior


Therefore


, the


purpose


of thi


study


was


to investigate


possible


differences


patients


reasons


between


regard


seeking


symptomatic


to their


help;


volunteers


demographic


depressive


clinic


characterist


symptomatology,









perceptions


of psychosocial


stress


as measured


the


Million


Behavioral


Health


Inventory


(MBHI).


Respondents


newspaper


advertisements


symptomatic


volunteers


new


(depressed)


clinic


patients


university-based,


outpatient


counseling


facility


received


packets


containing


BDI,


MBHI,


and


a questionnaire


developed


study.


Basic


criterion


inclusion


study


was


a BDI


score


. The


first


30 respondents


each


group


meeting


this


criterion


constituted


sample.


No significant


differences


.05)


between


the


groups


were


found


regard


age,


gender,


educational


level,


marital


status,


coping


styles


with


help


givers,


perceptions


of psychosocial


stress,


or overall


depression


severity.


However,


symptomatic


volunteers


were


found


to be sadder,


more


discouraged,


less


interested


others,


to have


greater


difficulty


decision


making


than


clinic


patients.


Symptomatic


volunteers


also


more


frequently


reported


financial


concerns


as an important


factor


the


decision


about

they


method


reported


the


of seeking


desire


help


to find


depression.


effective


treatme


However,

nt as the


primary


factor


decision.


Clinic


patients


cited


"being


referred"


as primary


method


seeking-help


decision,


with


desire


effective


treatment


being


secondary.


- A -l. -


-4--- -.3.-


SLt, a


--1 aIL~ *~ n AaCa


A .. a









counseling


services


similar


symptomatology.


They


.also


suggest


that


financial


concerns


are


an important


factor


method


of help-seeking


selected.















CHAPTER


INTRODUCTION


The


difference


emotional


between


problems


individuals


those


who


who


avoid


seek


such


treatment


help


interest


to counseling


administrators


(Brown,


practitioners


1978;


and


Jellinek,


to service


1978;


program


Robinson


Young,


1982


Veroff,


1981;


Yokopenic,


Clark,


Aneshensel,


1983)


Although


these


factors


have


been


fairly


well


delineated


literature,


there


a subgroup


help-seekers


about


whom


little


known.


This


group


composed


individuals


who


seek


help


emotional


problems


through


structure


of clinical


research


programs.


Although


these


individuals


are


seeking


help,


they


are


doing


so through


traditional


means


They


are


responding


efforts


of researchers


through


recruitment


tactics


such


as newspaper


advertisements,


brochures,


stories


newspapers


newsletters.


This


segment


of the


treatment-seeking


population


unique


their


concurrent


lack


of affiliation


self-identified


need


with

for


treatment

help. Of


providers


particular


their


interest


here


are


those


individuals


who


volunteer


depression


treatment









Depression


psychological


been


disorder


identified


one


as the


top


most


three


common


health


problems


United


States,


having


a frequency


occurance

Frazier,


about

1978;


equal tc

Freedman,


hyperten


1984;


sion


Kline,


(Cole,

1976).


Schatzberg,

Further,


approximately


of all


suicide


victims


are


found


have


characteristics


which


might


indicate


presence


serious


depression


at the


time


of the


suicidal


act.


About


of all


serious


depressions


eventually


terminate


suicide


(Goodman


Guze,


1984;


Roy,


1983)


The


term


depression


correctly


applied


an entire


disorder


continuum.


According


to lay


terminology,


depression


can


refer


to a continuum


of distress


from


"symptom"

transient

(Goodwin,


presence


"feeling


depressive

1982). Tr


one


depressed,


states


ansient


more


to the


or down"


affective


depression,


symptoms


through

disorder


the


depression,


defined


of major


appears


to be prevalent


society


with


some


symptoms,


such


as sleep


disturbance


difficulty


concentrating,


having


great


a prevalence


rate


as 46%


(Craig


Van


Natta,


1979).


Major


depressive


disorder


defined


Diagnostic


Statistical


Manual


Mental


Disorders


(DSM-III)


as a


prolonged


mood


disturbance


which


the


prominent


mood


sad,


down,


depressed,


or irritable.


In addition,


at least









feelings


guilt


or worthlessness,


difficulties


thinking


concentration,


frequent


thoughts


of death


or suicide,


fatigability


or heaviness


limbs,


either


being


physically


slowed


down


or agitated


(American


Psychiatric


Association,


1980,


210-215).


somatic


complaints


associated


with


depression


can


contribute


to confusion


about


appropriate


treatment


masking


underlying


condition.


For


example,


depression


can


present


somatic


concerns


such


as sleep


disorders,


fatigue,


or gastrointestinal


disturbance.


individual


may


even


attribute


anhedonia,


a major


feature


depression,


to fatigue.


This


may


lead


individual


to the


family


that


physician


may


with


be difficult


a description


to diagnose


physical


mood


symptoms


disturbance


attributed


to the


physical


symptoms


or if


patient


fails


to recognize


or admit


presence


of the


dysphoric


condition


(Moore,


Silimperi,


Bobula,


1978;


Widmer


Cadoret,


-1983).


Many


individuals


who


do not


meet


the


diagnostic


criteria


major


depressive


episode


are,


nonetheless,


experiencing


depressive


symptoms.


These


individuals


may


reacting


to a life


event


or they


may


be experiencing


psychological


or physical


problem


with


depression


as a


symptom.


If these


symptoms


persist


or interfere


with


*(d)









Surprisingly,


even


face


of psychic


discomfort,


people


needed.


that


necessarily


Yokopenic,


approximately


seek


Clark,


one-third


treatment


simply


Aneshensel


people


because


(1983)


their


found


sample


had


serious


depressive


symptoms


either


"denied"


their


concerns


or were


"unwilling"


to label


their


concerns


depre


sslon.


Of the


remaining


two-thirds


, only


about


one-third


that


sought


knowledge


treatment.


of available


Although

treatment


might


would


be argued


be imperative


treatment-seeking


occur,


even


knowledge


always


sufficient.


A follow-up


study


of referral


from


psychiatric


individual


emergency


given


room


specific


showed


that


referrals


the


follow


through


with


either


a call


or a vi


to the


referral


agency


(Jellinek,


1978) .


This


one


major


indication


that


treatment-seeking


behavior


complex


related


more


than


the


availability


of treatment


providers


community.


Differences


treatment-seeking


have


been


positively


associated


gender,


with


higher


increased

educational


caucasian


level,


race,


increased


female


severity


depression


(Brown,


1978;


Jellinek,


1978;


Yokopenic,


Clark,


Aneshensel,


1983)


In addition,


appears


to be related


positive


expectations


about


efficacy


of help


(Veroff,









(Jellinek,


a sense


1978;


Yokopenic,


of self-reliance


with


Clark,


regard


Aneshensel,


to solving


1983),


personal


problems


(Brown,


1978;


Yokopenic,


Clark,


& Aneshensel,


1983).


Although


differences


between


those


who


seek


treatment


those


who


do not


are


important,


there


is a


third


group


to be considered.


This


group


composed


those


who


do not


seek


treatment


through


"usual"


channels


of a clinical


setting,


but


who,


instead,


use


a more


indirect


approach


such


as responding


to recruitment


efforts


researchers


participate


looking


depression


symptomatic


medication


volunteers


research.


Depression


drug


research


one


form


of research


being


conducted


under


New


Drug


ADolication


process


used


pharmaceutical


industry


efforts


to develop


new


antidepressant


medications.


New


Drucr


Application


process,


which


delineated


the


United


States


Code


Federal


Regulations,


procedure


which


new


medications


become


approved


marketing


United


States


Food


Drug


Administration


(u.S.


Code


of Federal


Regulations,


Part


.1) .


There


are


types


of volunteers


medical


research:


normal


volunteers


symptomatic


volunteers.


Normal


volunteers


are


healthy


individuals


who


agree


to participate









research


on the


effects


new


drug


or procedural


treatments.


Both


normal


and


symptomatic


volunteers


are


widely


used


testing


new


medications.


and


regulation,


United


States


Food


and


Drug


Administration


requires


that


drugs


go through


four


levels


of investigation


before


being


approved


use


public.


Phase


One


studies


are


pre-clinical


trial


studies


designed


applications


investigate


adverse


drug


initial


effects


drug


healthy


dose


humans


normal


volunteers).


Phase


Two


studies


are


designed


to test


proposed


primary


new


efficacy,


medications


tolerance,


on a strictly


dose


controlled


levels


clinical


population


so that


the


drug


effects


can


be discriminated


much


as possible.


Phase


Three


and


Phase


Four


studies


are


designed


determine


efficacy


compared


to standard


treatments


as well


as the


long-term


effects


of the


proposed


treatment.


Phase


Three


Phase


Four


studies


also


adhere


to strict


protocols


procedures,


but


involve


use


individual


with


disorder


to be


treated


a less


restricted


clinical


population


than


earlier


phase


studies.


use


New


volunteers


Drua AoDlication


four


process


phases


. Code


is required


of Federal


Regulations,


Part


, p.


Symptomatic


volunteers


are


accepted


studies


based


& #7









conditions.


criteria


include


diagnostic


standards


exclude


potential


subjects


who


may


have


medical


conditions


that


could


mimic


disorder


or interfere


with


treatment.


Accordingly,


symptomatic


volunteers


are


important


study


new


drugs


treatment


of depression.


It is


common


practice


to recruit


symptomatic


volunteers


through


newspaper


adverti


sing,


brochures


public


service


announcements


persons


because


to participate


number


of available,


depression


research


appropriate


limited


clinic


populations.


Clinic


populations


are


generally


inaccessible


research


because


individuals


are


currently


involved


ongoing


treatment


or may


have


concurrent


medical


conditions


which


make


them


inappropriate


clinical


trials


(Hersen,


Bellack,


& Himmelhoch,


1981).


Typically,


many


more


people


than


meet


strict


protocol


volunteers


acceptance


(Barrett,


criteria


1981;


respond


Brauzer


to calls


Goldstein,


research


1973;


Hersen,


Bellack,


& Himmelhoch,


1981;


Thase,


Last,


Hersen,


Bellack,


& Himmelhoch,


1984).


Thus,


process


recruitment


typically


identifies


many


individuals


who


are


willing


to be treated


and


who


are


seeking


treatment


through


traditional


means.


Individuals


who


seek


help


through


depression


medication


studies


have


been


shown


to be


similar


to clinic









demographically


similar


on the


variables


of gender,


age,


educational


level


(Brauzer


& Goldstein,


1973;


Thase


et al.,


1984).


Regarding


psychological


factors,


Hersen,


Bellack,


Himmelhoch


(1981)


found


no significant


differences


between


45 female


clinic


patients


and


female


depressed


symptomatic


volunteers


on measures


social


adjustment


assertiveness.


However,


Parker


and


Blignault


(1983)


found


that


symptomatic


volunteers


were


slightly


less


extroverted


on the


Eysenck


Personality


Inventory


than


a comparable


clinic


population.


Furthermore,


symptomatic


volunteers


appear


more


likely


to be married


to have


slightly


lower


depression


scores


longer


episodes


of depression


prior


seeking


treatment


(Parker


Blignault,


1983;


Thase


et al.,


1984).


Given


the


similarities


of symptomatic


volunteers


clinic


populations


availability


of traditional


forms


of treatment,


can


only


be conjectured


what


might


lead


depressed


individuals


seek


treatment


through


research


programs.


Finances,


social


acceptability


of participation


research,


desires


the


newest


treatment


available


may


play


a role


deci


sion


to seek


help


non-traditional


manner.


Basic


coping


styles


and


attitudes


towards


psychosocial


stressors


coping


styles


which


may


impact


on the


individual'


style


of interaction


with


a


L


11


*









On the


other


hand,


there


are


factors


which


lead


individuals


factors


to seek


might


treatment


only


from


be belief


therapists.


of treatment


These


efficacy


lack


of fear


of dependency


suggested


Veroff,


1981),


they


also


may


relate


to styles


interaction


with


health


care


givers


that


render


individuals


willing


to seek


help


through


traditional


channels.


differences


coping


styles


between


symptomatic


volunteers


depression


research


clinic


patients


was


unknown.


A professional


bias


was


that


individuals


who


are


depressed


should


seek


treatment.


The


fact


that


there


are


many


willing


volunteers


depression


research


who


are


treatment


may


indicate


important


differences


within


population


of people


who


need


treatment.


Need


Study


If the


differences


between


symptomatic


volunteers


clinic


patients


were


known,


then


statements


could


be made


about


current


theories


of help-seeking


behavior.


For


example,


knowing


there


are


differences


between


groups


on the


variables


measured,


then


there


could


established


better


direction


research


into


complex


aspects


emerge,


of treatment


research


-seeking


into


behavior.


differential


no differences


choice









Counselors


counselor


educators


could


benefit


from


knowing


whether


differences


exist


between


the


groups


treatment


seekers


with


regard


to coping


styles


attitudes


towards

impact


psychosocial


directly


stressors


on individual


because these

approaches and


variables

abilities


follow


groups


through


might


with


imply


treatment


that


. No


differences


identified


variables


between


are


issue


do not


require


a change


on the


part


counselor


practitioners


however,


differences


between


groups


might


suggest


need


changes


the


presentation


provision


of counseling


serve


ices


depressed


individuals


order


to attract


greatest


number


those


who


could


benefit


from


treatment.


Purpose


Study


The


clinic


patient


volunteer


a research


study


have


chosen


different


ways


to seek


help.


The


purpose


of this


study


was


to explore


how


depressed


(symptomatic)


volunteers


seek


help


participation


a research


project


depressed


clinic


patients


may


vary.


More


specifically,


this


study


was


designed


to determine


there


were


differences


between


symptomatic


volunteers


clinic


patients


in terms


of demographics,


levels


of depression,


reasons


choice


of treatment


setting,


basic


coping









Research


Questions


research


there


questions


differences


study


between


were


symptomatic


volunteers


variables


clinic


age,


patients


gender,


on the


educational


demographic


level,


marital


status,


or income?


Are


there


differences


between


symptomatic


volunteers'


clinic


patients'


level


depression?


Are


there


volunteers'


differences


clinic


between


patients'


symptomatic

stated


(self


-reported)


reasons


choice


of treatment


mode?


Are


there


differences


between


symptomatic


volunteers'


clinic


patients'


basi


coping


styl


Are


there


differences


between


symptomatic


volunteers'


clinic


patients'


attitudes


towards


psychosocial


stressors?


Definition


of Terms


purpo


ses


study,


key


words


and


terms


were


defined


as follows:


- a


-


1









style,


type


of environmental


interpersonal


reinforcements


sought,


actions


used


achieve


those


reinforcements.


Introversive


coping


style--


A style


interacting


with


health


care


givers


characterized


a lack


initiative


autonomy.


It is


thought


to be


personality


characteristic,


operationalized


measurement


on the


This

Million


study


Behavioral


Health


Inventory.


Inhibited


coping


style--


A style


interacting


with


health


care


givers


character


people


a shy


need


approach


encouragement.


thought


to be a personality


characteristic,


operationalized


this


study


measurement


on the


Million


Behavioral


Health


Inventory.


Cooperative


coping


style--


A style


interacting


with


health


care


givers


character


dependency


a tendency


on professionals


to develop


a need


specific


instruction.


It is


thought









measurement


on the


Million


Behavioral


Health


Inventory.


Sociable


coping


style--


A style


interacting


with


health


care


givers


characterized


therapeutic


early


process


compliance


which


with


diminishes


over


course


treatment.


It is


thought


to be a personality


characteristic,


operationalized


measurement


on the


Million


Behavioral


Health


Inventory.


Confident


coping


style--


A style


interacting


with


health


care


givers


characterized


calm,


confident


behavior w

underlying


which


concern


thought

about


to mask

the


individual'


well-being.


It i


thought


to be a personality


characteristic,


operationalized


measurement


on the


Million


Behavioral


Health


Inventory


Forceful


coping


style--


A style


interacting


with


health


care


givers,


characterized


need


direct,


strong


guidance


direction


ensure


treatment









operationalized


measurement


on the


Million

. Respectfu


Behavioral

1 coping s


Health


tyle--


Inventory.


A style


interacting


with


health


care


givers


character


a tendency


individual


to deny


symptoms


problems


while


complying


with


treatment


procedures.


It is


thought


to be


personality


characteristic,


operationalized


measurement


on the


Million

Sensitive


Behavioral

coping st


Health


yle--


Inventory


A style


interacting


with


health


care


givers


characterized


variable


unpredictable


compliance


with


treatment


recommendations


thought


or prescriptions.


to be a personality


character


stic,


operationalized


measurement


on the


Million


Behavioral


Health


Inventory.


Clinic


Patient--


An individual


who


seeks


help


psychological


stress


(depres


sion)


traditional


setting


(i.e.,


clinic


or specific


m A


1 r









volunteered


a research


study


who


experiencing


a depression.


Depression--


A mood


disturbance


accompanied


at least


one


symptom


serious


depression,


and


purposes


of thi


study,


a score


of at least


Beck


Depression


Inventory.


Depression


Study


(aka,


Drug


Treatment


Study,


Clinical


Trial)--


A term


used


to refer


to UpJohn


Protocol


R-6331,


a clinical


study


a new


antidepressant


medication.


Educational


level--


A term


used


to describe


the


individual'


number


of completed


years


of formal


education.


Income--


A term


used


to describe


estimated


income


family


unit


to the


nearest


$1,000.


Marital


status--


A term


used


to describe


nature


of the


individual'


living


situation


.e.,


single-


never


married,


married,


divorced,


remarried,


cohabitating,


widowed)


Perceptions


of psychosocial


stre


SS---


A term


used


describe

influence


a style


of perceiving


presence


stress


illness


thought


in an


individual.


Chronic


tension--


A style


of perceiving


which


a


-1


1 .









operational ized


measurement


Million


Behavioral


Health


Inventory


SRecent


stress--


A style


of perceiving


which


individual


attributes


significance


recent


events.


It i


operationalized


measurement


Million


Behavioral


Health


Inventory.


. Social


alienation--


A style


of perceiving


which


individual


ability


to rely


experiences

on social


little

support


systems


It is operationalized


measurement


Million


Behavioral


Health


Inventory.


. Somatic


anxiety--


A style


of perceiving


in which


health


problems


which


may


take


on an


overwhelming


focus


of attention


and


concern


individual


It i


operationalized


measurement


Million


Behavioral


Health


Inventory


Reason


treatment


individual'


deci


mode


sion


selection--


to seek


Stated


treatment


reasons


the


University

participate


Associates


Psychiatry


depression


or to


study


a S


-


* J


A i-









life.


symptoms


must


be persistent,


last


least


weeks,


must


include


at least


three


following


interest


: loss


usual


energy,


activities,


fatigue,


OSS


loss


interest


sex,


sleep


disturbances,


appetite


changes,


thoughts


of death


or suicide,


feelings


of guilt


worthlessness,


difficulty


thinking


concentrating


diagnostic


. (This


criteria


definition


major


based


upon


depressive


disorder


as delineated


Diagnostic


Statistical


Manual-III.)


Symptomatic


volunteer


(sv)--


An individual


with


a disorder


who


agrees


to participate


in research


to test


proposed


treatment


or medication.


Overview


Paner


Chapter


was


an introduction


an unknown


associated


with


widespread


use


of symptomatic


volunteers


depression


research.


Symptomatic


volunteers


appear


to be


individuals


with


unmet


treatment


needs


who


enter


treatment


will


system


contain


through


a review


research


of the


protocols.


literature


Chapter


related


depress on,


treatment-seeking


behavior,


symptomatic


volunteers,


instruments


used.


The


details


of the





-


-- -


I


m









implications,


and


recommendations


will


be discussed


Chapter
















CHAPTER


RELATED


LITERATURE


AND


INSTRUMENTATION


impetus


treatment-seeking


behavior


more


complex


than


just


problem


recognition.


Although


researchers


have


indicated


that


differences


in demographic


characteristics


(Asser,


1978;


sler,


Brown,


& Broman


1981)


and


treatment


outcome


beli


(Cash,


Kerr


, & Sal


zbach,


1978;

help,


Veroff

these


1981)


factors


are p

alone


ivota

are


deci


insuffi


cient


sion


to seek


to explain


phenomenon


of the


symptomatic


volunteer.


Symptomatic


volunteers


are


help-seekers


who


enter


treatment


system


as research


volunteers.


They


are


unique


that


they


are


treatment,


subjectively


identify


having


a problem


needing


treatment,


voluntarily


seek


help


response


to recruitment


advertising.


Of particular


interest


are


depressed


persons


volunteer


treatment


studies.


view


seriousness


of depression,


these


individuals


defy


clinical


expectation


that


they


would


seek


treatment


through


usual


channel


of a clinic


setting


review


of literature


will


include


what


known


about


depression,


characteristics


treatment-seeking









volunteers


(SVs


as compared


to clinic


populations.


addition,


instruments


used


this


study


will


discussed.


Depression


Definition


Clinical


Features


term


"depression"


was


first


coined


as a diagnostic


entity


about


1906


Adolph


Meyer


an attempt


to provide


classification


a disorder


which


had


dysphoria


as the


prominent


mood


(Kline,


1976;


Rippere,


1977)


Although


helpful


to be able


to classify


a disorder,


use


of the


term


depression


leads


to confusion


among


the


public


professionals,


turn


leading


to a profusion


theories


proposed


treatments.


The te

a symptom,


depression


a transient


can


mood,


be applied c

or a serious


orrectly


either


complex


disorder.


Modern


terminology


views


depression


along


spectrum


ranging


from


transient,


"normal"


depression


severe


affective


disorder


(Goodwin,


1982) .


purposes


this


discussion,


focus


on the


subjective


experience


of depression.


The


maj or


depre


ssive


disorder


involves


a biological


malfunctioning


associated


with


a complex


response


organism


to the


environment


stressors


(Goodwin,









classified


can


separately


be severely


from


emotionally


other


classifications.


depressed


without


person


biological


involvement.


same


token,


a person


can


have


biological


involvement


with


presence


of a 1


ess


intense


dysphoric


mood.


Using


multiaxial


approach


classification


proposed


Zung,


most


commonly


accepted


agreed


upon


signs


symptoms


of depression


as a


syndrome


include


pervasive


affective


disturbance,


physiologic


disturbance,


psychomotor


disturbance,


psychological


disturbance.


Although


these


factors


are


part


of the


diagnostic


criteria


a major


depression


as required


clinical


trial


(Upjohn


protocol


R-6331),


purposes


of this


study


subjective


experience


depression


was


that


was


required.


EPidemiolouv


Psychologists


agree


that


depression


a serious


problem


society


Nevertheless,


prevalence


rates


are


based


upon


definition


of depress


used


any


particular


investigation.


It is


difficult


to ascertain


exactly


how


much


depression


there


population


based


solely


upon


identified


risk


factors.


Craig


Van


Natta


(1979)


conducted


a survey


of the


general


population


of Washington


County,


Maryland


from


1971









and


related


symptomatology


investigators


examined


responses


prevalence


persistence


of depressive


symptomatology


results


indicated


that


prevalence


the


16 major


indicative


depressive


of a high


rate


symptoms


transient


the

depr


population

session. S


was


ome


symptoms,


such


as sleep


disturbance


difficulty


concentrating,


prevalence


showed


point


of depres


sive


prevalence


symptoms


rates


also


as high


had


as 46%


a significant


correlation


with


age,


differed


gender,


and


was


negatively


correlated


with


educational


level


Cooke


(1982)


addressed


issue


of disparity


among


epidemiological


studi


conducting


a study


considering


specific

eight ra


types


ndomly


of depre

selected


ssive


syndromes.


individuals


were


Four h

given


hundred an

the Zung


Self-Rating


Depression


Scale


Kellner-Sheffield


Self-Rating


Scale


. Using


a principal


components


factor


analysis,


Cooke


arrived


at four


types


of depressive


syndromes


"vegetative


depression"


: "anxiety


depression"


Cooke'


depression"


, and


multiple


"cognitive


assic-


depression"


endogenous


regression


analysis


demographic


variable


showed


that


relationships


were


similar


both


sexes


on all


"cognitive


depre


ssion"


Femal


tended


to show


climacterium


increased


years


level


according


of depr


to Cooke'


session

study)


at the

and









significantly


higher


level


depression


than


those


employed.


Marital


status


femal


was


associ


ated


with


differences


"anxiety"


, "cognitive"


and


"vegetative"


depression.


Married


females


reported


higher


eve


Is of


"anxiety"


depres


sion


than


single


femal


es.


Divorced


femal


reported


significantly


higher


levels


of "anxiety


depres


sion"


than


other


groups.


Divorced


femal


also reported


higher


level


of "cognitive


ress


ion"


than


single


married


women,


but


widowed


women.


Single


men


reported


significantly


higher


level


of "cognitive


depression"


than


either


widowed


or married


men.


There


was


no clear


relationship


between


"cognitive


depression"


total


sample.


However,


"vegetative


ress


ion"


was


positively


correlated


with


while


ass


endogenous


depression"


was


negatively


correlated


with


age.


Cooke


suggested


that


general


decline


vegetative


system


leads


to increased


vegetative


symptoms


with


age.


With


regard

more "


to marital


cognitive


status


depression"


, single


than


men


showed


married


significantly


or widowed


men,


whereas


divorced


women


had


significantly


higher


level


"cognitive"


"anxiety"


depre


ssion


than


either


married


single


women.


Married


women


had


higher


level


of "anxiety"


depression


Cooke


concluded


that


age,


sex


, marital


status,


employment


status,


social


ass


were


related


- a ~-1 a -


I


L


I


I









As part


of the


procedures


Center


Epidemiological


Studies


, Myers


et al. (1984)


reported


on the


6-month


prevalence


rates


psychiatric


disorders


based


upon


a random


sampling


of all


housing


units


New


Haven,


Connecticut;


Baltimore,


Maryland;


. Loui


, Missouri,


from


1980


to 1982


Data


were


gathered


using


Diagnostic


Interview


Schedule


to collect


information


a diagnosis


orders


experienced


during


previous


6 months.


The


most


common


disorders


both


men


women


were


phobias,


substance


abuse


or dependence,


dysthymia,


major


depression.


three


communities


had


similar


and


sex


differences


rate


of disorders.


Most


common


women


were


major


depression


phobias


whereas


men


substance


abuse


disorders


were


most


prevalent.


These


findings


were


similar


to findings


a previous,


similar


study


conducted


1975-76


New


Haven.


Based


Orvaschel,


upon


same


Gruenberg


data,


, Burke


Robins


, and


Regier


, Helzer,


(1984)


Weissman,


reported


lifetime


prevalence


of the


common


disorders


identified.


Overall,


one


adult


was


found


to have


suffered


at least


one


major


depressive


episode


In general,


the


25-44


group


significantly


exceeded


next


older


group


(ages


45-65

depre


) with

ssive


respect

episode,


to drug

manic e


abuse


episodes,


dependence


antis


, major


social


II


r r rl I


II









Differences


between


blacks


whites


were


modest


consistent


across


sites.


The

depression


prevalence


negative

n was co


study


correlation


nfirmed


of depres


Blazer


sion


with


(198


elderly,


presence


In a point


he indicated


that

the


the

rate


overall


rate

other


was 8.2%.

stage in


This


was


life


no greater


cycle.


What


than

was


different


was


that


elderly


no difference


occurence


rate


existed


between


sexes.


Also,


although


incidence


symptomatology


increased


with


age,


occurrences


major


depressive


disorder


were


of shorter


duration.


Freedman


(1984)


combined


data


collected


1980


Center


Epidemiological


Study


previously


cited


with


same


data


collected


North


Carolina


Angeles


provide


included


some


epidemiologic


17,000


community


trends.


residents


The


who


total


were


sample


given


Diagnostic


Interview


Schedule


reinterviewed


one


year


preliminary


findings


indicated


that


17-23%


of adults


at least


least


one


5-6%


of the


suffering


13 major


from


psychiatric


affective


disorders


disorders.


with


highest


rates


disorders


were


in the


to 44


year


old


group.


high


rate


of prevalence


of depre


ssion


does


not,


however,


make


identification


of the


sorder


simpler


* C -h


i


1 1 _









family


practitioner'


office.


Often


patients


do not


tell


physicians


of the


experience


dysphoria


thereby


make


or other


psychological


depression


difficult


recognize


(Moore,


Silimperi,


Bobula,


1978;


Widmer


Cadoret,


1983).


Depression


also


been


the


most


common


psychiatric


sorder


seen


family


medicine


practitioners


(Justin,

Mallory,


1976;


Moore,


& Harris,


Silimperi,


1976;


Widmer


& Bobula,


Cadoret,


1978; W

1983).


Ferkman,

Given


subtlety


of the


disorder


somatic


concommitants


of depression,


surprising


that


some


individuals


find


the


diagnostic


criteria


presented


as part


recruitment


information


studies


a valuable


tool


identification


of a possible


depressive


disorder.


case


may


be built


a disorder


that


can


affect


person


age,


sex,


or soc


io-economic


background;


however,


is most


frequently


erved


women


between


44 who


are


of lower


educational


or soc


io-economic


status.


Most


depressives


first


seek


treatment


from


the


family


practitioner,


help


sought


at all.


Freedman


(1984)


observed


that


unique


feature


of this


disorder


low


percentage


treatment


high


frequency


with


which


non-psychiatric


depression an

indicate that


anxiety


physician


disorders.


approximately


initially


In fact,


of depression


encounters


estimates

ns remain









remit


time,


usually


to 12 months,


or longer


(Cole,


Schatzberg,


& Frazier,


1978,


p.4).


With


wide


range


of symptom


severity


and


duration


encompassed


use


term


"depression,


" it


understandable


that


a variety


etiological


theories


have


evolved


to describe


phenomenon.


Theories


Depression


Freud


suggested


that


depres


sion


guilt


result


from


anxiety


about


morals


fear


conscience


when


ideas


or actions


run


counter


to internalized


moral


beliefs.


Depression


thus


evolves


from


conflicts


within


personality


structure,


acting


as "an


open


wound,


drawing


energy


to itself


totally


(translated,


from


depleted"


1981)


sides,


(Wetzel,


further


draining


1984,


stated


19).


that


until


Miller


depression


narcissistic


disturbance


in which


individual'


desired


belief


self


worth


"shaken"


through


external


circumstances.


Therefore,


psychoanalytic


theory


can


linked


to moral


beliefs


about


causes


of depression.


Biochemical


theories


of depression


include


genetic


theories


linking


depression


with


recessive


genes,


and


biogenic


amine


theories.


According


to biogenic


amine


theorists,


depletion


of norepinephrine


catecholaminee


a a- -


I J -


J *


i i


-


L









time


depression


developed


the


stage


where


neurovegetative


signs


are


a strong


component


of the


symptomatology,


autonomou


however,


At that


depression


point,


becomes


depression


biologically


relatively


resistent


psychological


interventions


until


medical


treatment


alleviates


symptoms


or until


the


episode


run


course


(Wetzel,


1984).


The


most


popular


cognitive-behavioral


models


depression


are


those


of Martin


Seligman


and


Aaron


Beck.


Seligman


that


(1975)


action


attributed


no bearing


depression


on the


to a learned


outcome


belief


of a situation.


Originally,


this


theory


evolved


from


animal


research


which


rats


exposed


to inescapable


shock


later


gave


effort


more


easily


than


rats


exposed


to escapable


shock


or no shock


(Seligman,


1975)


Seligman


sugge


sted


that


three


conditions


lead


to learned


helpl


essness:


having


been


overprotected


never


having


opportunity


to learn


mastery


environment;


having


never


previously


encountered


failure,


thereby


never


having


learned


mastery;


having


experienced


past


trauma


without


having


been


able


control


negative


events


of life.


The


theory


chosen


to support


basis


this


study


Beck's

negative


Cognitive t

e cognitive


heory

set


of Depression.


established


Beck asserted

childhood is th


that a

basis


- _


L


1


*


-m


L


ml


^^^- ^


* L L









According


to Beck,


individual


develops


a wide


variety


of concepts


about


self and


world


an early


age.


These


concepts


form


basis


of a "reality"


perceiving


the


world


When


reality


conceptually


sound,


forms


basis


a healthy


approach


to the


world


A reality


that


deviates


from


a conceptually


sound


position


leads


to vulnerability


psychological


disorders.


individual


concepts


attitudes


are


drawn


from


early


experiences


from


attitudes


and


opinions


individual


that


others


communicate.


A child


who


learns


feel


that


an unintelligent


or clumsy


person


will


begin


to interpret


future


experiences


from


that


self-identification


framework.


Since


most


crucial


concepts


future


psychological


problems


are


those


that


relate


to the


individual'


attitudes


towards


self,


environment,


and


*the


future,


since


attitudes


towards


environment


future


are


part


based


upon


attitudes


towards


self,


these


early


learning


of self-identification


self-concept


According


clusters


which


are


to Beck'


of self-concepts


individual


pivotal


future


theory,

. Some


experiences


pathology.


individual


clusters


relate


a positive


sense


learns


ways


of self


competency


while


other


dust


ers


relate


to bad


feelings


about


self.


Those


areas


of bad


feeling


-L A 0a-


i a


Q


i *





ft









original


attitude.


Each


experience


further


reinforces


the


negative


self-attitude.


no reverse


learning


occurs,


negative


attitude


becomes


part


individual'


cognitive


structure


thereby


a permanent


part


of the


individual's


view


of self


world.


The


negative


attitudes


towards


self


become


a potent


precursor


depre


ssion


only


when


accompanied


a learned


value


judgment


that


acceptable


to be whatever


negative


trait


might


Furthermore,


individuals


must


believe


their


fault


that


this


trait


present


order


to have


powerful


potential


being


depressive


cognition


A negative


essential


attitude


component


toward


depressive


future

e prone


also


individual.


negative


attitude


towards


future


an underlying


belief


that


things


will


always


work


same


that


there


nothing


people


can


do to change


either


their


perceptions


world


or how


they


are


treated


world.


Beck


asserted


that


depression


prone


person


vulnerable


on the


basis


these


enduring


negative


attitudes


about


self,


environment,


future.


periods


time,


these


thoughts


may


be non-active,


or dormant.


However,


they


are


always


present,


ready


to be activated


fully


to precipitate


depressive


symptomatology


A m


1


.. 1









approximate


original


negative


experiences


which


formed


attitude.


development,


During


individual


learning


becomes


phase


of attitude


sensitized


to certain


types


stressors.


When


these


conditions


are


expressed


either


directly


or indirectly


through


a series


of minor


stressors,


depression


prone


individual


likely


to slip


into


a depressive


state.


Non-depression


prone


individuals


may


interpret


events


or stressors


as disturbing


disappointing;


however,


they


can


re-direct


their


energy


towards


coping


with


new


situation.


The


depress ion


prone


person


will


experience


a "constriction


of his


cognitive


field"


(Beck,


1967,


279)


will


become


overwhelmed


with


negative


thoughts


about


self and


future


, thus


beginning


depressive


cycle.


According


to Beck,


negative


cognitive


primary


and


depres


sive


affect


secondary


depression


(Beck,


1970).


Treatment-SeekinL


Behavior


In order


to attain


treatment,


individuals


need


to seek


help


As stated


previously,


symptomatic


volunteers


may


seeking


treatment


volunteering


research.


Characteristics


help-seekers


general,


then,


are


important to


consider.









of 2264


adults


(1304


women


and


men,


years


older)


who


resided


US households


1976.


findings


indicated


Although


that


may


help-seeking


include


is a complex


"impetus


phenomenon.


of demoralization"


(Veroff,


1981,


p.190),


may


also


include


other


internal


motivations


related


to seek


to positive


psychotherapy.


expectations


Help-seeking


about


seems


efficacy


to be


of help


(Cash,


Kerr,


& Salzbach,


1978;


Veroff,


1981)


orientation


that


inclines


help


-seekers


to perceive


problems


as failures


or inadequacies


self


to be changed


(Robbins,


1981;


Veroff,


1981).


In addition,


help-seekers


tend


to be


those


are


threatened


relying


on others


to help


them.


certain


people,


particularly


college


educated,


help-seeking


also


may


have


more


to do with


self-enhancement


than


demoralization.


Veroff


(1981)


suggested


that


clearly


higher


rate


of help-seeking


among


women


than


men


might


be attributable


to the


time


available


seeking


inadequacies


help,


willingness


family


social


to admit


roles,


feelings


lack


fear


of dependency.


Brown


(1978)


analyzed


data


from


a longitudinal


study


1,106


Chicago


area


adults


aged


Nearly


= 606)


of the


significantly


follow-up


bothered


sample


one


reported


or more


being


of the


identified









= 405)


reported


seeking


assistance


at least


once.


Only


small


proportion


appealed


exclusively


to professionals.


Forty-


eight


percent


= 195)


were


classified


informal


seekers


, contacting


family


and


friends


only),


= 48)


were


formal


seekers


, relying


ely


professional


remaining


= 162


were


considered


both


formal


informal


seekers.


Non-seekers


were


divided


into


groups.


"Self-reliant"


non-seekers


were


those


who


felt


they


could


handle


their


problems


without


assistance


= 69


or 33%


of non-seekers)


The


remaining


of non-seekers


were


reluctant


to seek


help


because


they


felt


that


no one


was


willing,


able,


or available


help,


or they


felt


that


help-seeking


would


too


revealing


effortful.


The


results


analyses


showed


that


only


demographic


factors


non-help-seekers


discriminating


were


race


help-seekers


elderly


from


showed


sharp


drop


help-seeking,


particularly


informal


contacts.


In addition,


blacks


with


ess


than


a completed


high

eithe

other


school

r white

measure


education

s or other

es, there


sought

races

were g


help

with


great


ess


more


frequently

education.


variations


within


than

On all

the


groups


of seekers


non-seekers.


Help-seekers


reported


more


troublesome


measures


events


of personal


than


non-seekers.


social


resources,


However,

as well


on all

as the


* I .


~ I I


*


I


1


1 I









events,


a higher


level


of strain,


inadequate


informal


supports,


and


reluctance


to share


problems


with


others.


Self-reliant

strongest pe


help-seekers


rsonal


had


resources


least


any


group,


strains


while


and

reluctant


non-help


seekers


reported


least


effective


coping


mechanisms,


comparatively


unsupportive


unreliable


informal


networks,


strong


reservations


about


discussing


their


problems


with


others.


Brown's


findings


about


informal


networks


were


confirmed


Horwitz


(1978)


who


interviewed


patients


weeks


after


application


services


at a public


community


mental


health


center


New


Haven,


Connecticut.


Horwitz


found


that


nature


of the


husband-wife


relationship


significantly


impacted


on help-seeking


behavior.


In those


married


couples


where


least


mutual


support


was


evident,


there


was


increased


help-seeking.


Furthermore,


friends


close


were


most


common


sources


of informal


assistance


adults.


When


informal


networks


were


weak


or absent,


formal


help-seeking


was


increased.


Based


County


examined


upon


= 1000),


how


a 1979


community


Yokopenic,


depressive


sample


Clark,


symptoms


correlat


Angeles


Aneshensel

ed with a


(1983)


variety


of factors


to influence


consultation


emotional


problems.


The


researchers


found


that


about


one-third


of the


a .


Sr


_ 02-% _


J *


1


*


*


. .. _w --


h









strong


correlation


between


depressive


symptom


level


problem


recognition.


In addition


to symptom


presence,


previous


servi


exposure


ces


(even


education


curiously)


facilitated


to mental


recognition


health


labeling


of depression.


The


tendency


to give


Soc


ially


desirable


responses


on the


social


desirability


scale


subset


of the


Marlowe-Crowne


Scale)


appeared


to inhibit


problem


recognition.


They


find


sex


difference


general


perception


of problems;


however


, men


women


differed


propensity


to label


themselves


depressed.


Women


were


more


likely


than


men


to call


themselves


depressed.


Neverthel


ess,


at high


level


severe


depressive


symptoms,


men


were


more


likely


than


women


to recognize


depre


ssion


or other


problems.


Of all


people


who


realized


they


needed


help


a problem,


about


one-third


consulted


a mental


health


service.


was


a differentiating


factor


Economic


and


other


practical


issues


also


were


only


minor


in deci


sions


to seek


treatment.


factors


which


promoted


treatment


-seeking


behavior


were


depressive


symptoms,


previous


exposure,


conversations


with


laypersons


who


advised


them


to get


counseling.


Psychological


problem,


factors,


were


such


main


as self


-reliance


reasons


or denial


seeking


help


findings


of Veroff'


study


have


been


confirmed


several


other


studies.


reasons


refusing


referral


- a *an


I_ _









to 8


weeks


anxiety


post-partum


on the


Leeds


demonstrated


Scale.


signs


At 6 months


of depression


postpartum,


women


still


had


raised


depre


ssion


or anxiety


levels.


These


women


were


offered


psychiatric


consultation,


but


half


refused.


reasons


given


refusal


were


stigma


client,


of psychiatric


stigma


treatment


of psychiatric


as perceived by the

treatment as perceived


spouse,


cl ient'


perception


their


own


well-being


differing


from


that


treatment


agency,


and


inconvenience


of attending


a psychiatric


consultation.


Jellinek


(1978)


conducted


a 1-month


follow-up


on 89


referrals


made


from


a psychiatric


emergency


room


Massachusetts


General


an appointment


Hospital.


or visited


Fifty-eight


an outpatient


percent

facility


called

They


were


call


considered


or visit


"completers.


facility


Forty-two


Completers


percent


were


did


significantly


more


likely


to be


older


mean


years


vs.


29.6


mean


years


age).


None


referrals


under


years


completed


Although


there


was


no difference


the


male


to female


ratio


completers,


educational


levels


completers


were


significantly


higher


vs.


11.7


mean


years


of education).


Furthermore,


of all


psychiatric


complaints,


those


people


with


depres


sion


as chief


complaint


diagnosis


were


more


likely


to follow


through









changed


mind


since


their


visit


to the


(31%),


treatment


costly


(10%),


still


considering


recommendation


(10%),


unable


to give


reason


(34%)


DemograDhi


Factors


Asser


(1978)


studied


relationship


between


social


class,


indicated


education


level


occupation,


help-seeking


behavior


data


were


derived


from


hour


interviews


and


surveys.


Asser


found


that


among


lower


social


classes,


both


sexes


preferred


use


help-seeking


where


specific


direction


advice


were


given.


The


higher


social


class,


more


likely


both


sexes


valued


autonomy.


Women


at that


level


favored


a negotiating


help


-seeking


style


which


seeker


uses


help


as a


"sounding


board"


Men,


regard


ess


of cl


ass


, preferred


style


of help


that


was


more


directive


differences


help


-seeking


behavior


were


analyzed


Kess


ler,


Brown,


Broman


(1981)


Based


upon


data


from


four


large-scale


surveys,


they


presented


evidence


that


increased


incidence


of help


-se


eking


behavior


among


women


higher


rate


of labeled


emotional


problems


may


be due


to the


greater


ability


women


to verbalize


vague


emotional


distress


terms


consc


ious


problems


requiring


assistance.


authors


concluded


that


10-28%


of the


excess


-~~~~~ a -


- a


_ _


-I 1


* k J


-


I- -1









Treatment-seeking


behavior


a college


sample


been


found


to have


a positive


correlation


with


education,


as well


as differences


on the


basis


of gender.


O'Neil,


Lancee,


behaviors


Freeman


(1984)


of depressed


examined


students


help-seeking


a university


psychiatric


clinic


sample


population


= 183)


= 238).


with


They


a non-clinic


compared


sample


the


clinic


= 55)


using


Beck


Depression


Inventory


and


an author


designed


questionnaire.


The


findings


showed


that


severity


depression,


particularly


presence


of suicidal


ideation,


most


salient


factor


contributing


to seeking


professional


help.


given


level


of depression,


however,


being


female,


a graduate


student,


being


away


from


home


were


principal


factors


contributing


help-seeking.


Sociocultural


Factors


The


sociocultural


determinants


of help-seeking


behavior


of patients


with


mental


illness


were


studied


48 subjects


after


intake


before


initiation


of treatment


outpatient,


inner


city


Seattle


community


mental


health


centers


(Lin,


correlation


Inui,


was


found


Klerman,

d between


Womack,


modernity,


1982).


alienation,


parochialism


method


of entry


into


tem.


Ethnicity


V j --3-a -flI- s -I -.* .1 -*


*


L


_ A L -


mIA --


L


_ ^ -


_ -"









*to 3


years.


authors


suggested


that


this


delay


indicates


a resistance


to treatment


despite


progress


mental


health


movement.


The


impact


of ethnicity


on treatment


seeking


was


further


groups


examined


of 25 depressed


(1982)


Chinese


In demographically


Caucasian


matched


Americans


Taiwan,


found


a distinct


difference


on the


basis


ethnic


background


means


of coming


to treatment.


Chinese


were


very


somatic


their


presentation;


initially


experiencing


admit


dysphoria,


a dysphoric


affect.


never


Conversely,


admitted


American


sample


presented


with


dysphoria


as a major


complaint,


with


only


presenting


with


primarily


somatic


concerns.


Help-seeking


behavior


been


found


to be positively


related


educational


level.


Differences


help-seeking


behavior


have


been


found


on the basis


gender.


For


depressed


persons,


lack


informal


support


systems,


recognition


of depress


suicidal


ideation


apparently


are


strong


contributors


to help-seeking


Within


certain


parameters,


ethnic


city


may


also


play


a part


both


presentation


of a disorder


follow


through


with


treatment.


Stigma


treatment


seems


to be a major


factor


lack


of follow


through


with


treatment


or referral


treatment.


-. a


I I


L


I









treatment-seeking


through


research.


Given


that


symptomatic


volunteers


first


contact


treatment


system


purpose


of participation


in a study,


important


discuss


volunteer


psychological


research


before


can


be compared


to a clinic


population.


Research


Volunteers


use


of volunteers


behavioral


medical


research


produced


concerns


about


the


1 limited


application


of this


research


to bias


inherent


use


volunteer


population.


Volunteer


bias


defined


as any


aspect


of the


personality


or motivational


system


that


might


make


volunteer


community


or other


different


natural


from


setting


an individual


(Kruglanski,


found


1973).


Rosenthal


Rosnow


(1975)


evaluated


research


conducted


between


1950


1973


that


addressed


the


characteristics


or environmental


determinants


of volunteer


participants


research.


Based


upon


their


premise


that


"70-90%


of studies


on normal


adults


have


drawn


subj ects


from


collegiate


setting"


193) ,


they


statistically


evaluated


groups


of studies


to demonstrate


that


"there


are


good


many


characteristics


that


have


been


found


to relate


predictably


to the


of volunteering"


Applying


statistical


methods


group


results


numerous


studies,


a* -


-L .












relevant


to the


relationship


being


studied


and


proportion


of studies


which


supported


directional


hypothesis,


they


subdivided


each


list


into


four


levels


confidence


determinant.


strength


Characteristics


of that


characteristic


of normal


volunteers


determined


to have


maximum


level


of confidence


predictability


were


that


volunteers


tended


to be better


educated,


more


intelligent,


of a higher


social


class,


more


sociable


than


non-volunteers.


The


situational


determinants


influencing


volunteers


are


listed


below,


descending


order,


they


ranked


level


of confidence:


Conclusions


warranting


maximum


confidence:


Persons


are


more


likely


to volunteer


are


more


interested


topic


and


have


expectations


of being


more


favorably


evaluated


investigator.


Conclusions


warranting


considerable


confidence:


Persons


are


more


likely


to volunteer


research


who


perceive


investigation


as important,


feel


"guilty"


volunteering


or are


made


feel


good


or competent


volunteering,


and


receive


some


especially


type


of greater


incentives


are


material

offered


incentives,


as gifts


advance


without


being


contingent


on subjects


1









The c

confidence


the


conclusions

primarily


recruiter,


warranting

concerned


personal


either


the


some


personal


acquaintance


or minimal

characteristics


of the


recruiter,


aversiveness


the


task,


and


societal


norms


regarding


volunteering


a particular


type


of research.


Although


listed


fifth


place


Rosenthal


and


Rosnow'


work,


incentive


volunteering


and


potential


bias


resulting


from


the


artificial


nature


of a payment


environment


continues


concern


behavioral


researchers.


Rush


Phillips


(1978)


studied


the


bias


of payment


female


research


participants


at a large


midwestern


university


They


evaluated


the


differences


personality


and


performance


on an auditory


selective


attention


task.


Stepwise


discriminant


analyses


indicated


that


the


subj ects


who


volunteered


pay


committed


more


omission


errors


and


were


ess


interpersonally


involved


the


research


procedures


than


unpaid


volunteers.


Conversely,


Dixon


(1978),


his


study


the


effect


of methods


of recruitment


= 134


students),


found


that


paid


volunteers


and


required


"volunteers"


were


significantly


ess


hostile


to experimental


procedures


than


unpaid


volunteers.


Payment,


or course


credit,


also


increased


volunteer


rates


phobia


treatment


among


undergraduates


introductory


psychology


ass


(Levine,


Gorman, &


Sherry,









phobia


question


took


was


30 minutes


designed


per


to determine


week


weeks.


if they


would


A final


volunteer


same


treatment


course


credit


or payment.


offer


alone


course


credit


increased


rate


or payment


addition


of volunteers


to treatment


treatment


37%.


Although


situational


determinants


of volunteering


psychological


research


have


been


investigated,


motivations


volunteering


as a research


subject


medical


studies


been


explored


ess.


motivations


normal

been s


volunteers


tudied


Phase


Novak,


Seckman,


clinical


and


trials


Stewart


, however,


(1977).


have


The


investigators


gave


ques


tionnaires


a hypothetical


protocol


Phase


to 480


research


normal


studies.


individuals


They


who


compared


would


qualify


college


students,


indu


trial


employees,


older


prison


inmates


who


had


previously


participated


clinical


research,


and


newer


inmates


who


previously


participated


clinical


research.


respondents


Three


said


hundred


they


seventy


would


(370)


volunteer


of the


hypothetical


study.


The


most


frequently


given


reasons


, across


groups,


were


to develop


new


medi


cines,


financial


remuneration,


help


sick,


to help


society


the


desire


partic


ipate


something


"important"


The


results


showed


that


older


inmates


who


had


previously


part


cipated


_


1


1









Within


inmate


population


industrial


workers,


race


further


impacted


upon


willingness


to participate


with


blacks


less


willing


than


whites


to volunteer.


Volunteers


research


have


also


been


shown


possess


certain


predictable


characteristics


motivations


that


may


or may


medical


appears


impact


research.


on the


generalizability


Willingness


to be correlated


with


to participate


presence


of behavioral


research


of reward


payment


some


form


of psychological


enhancement.


Nevertheless,


volunteering


does


seem


occur


uniformly


across


groups


of people.


Those


with


experience


volunteering


those


who


perceive


reward


as desirable


are


more


likely


to volunteer


to participate


research.


The

enhanceme


literature


indicates


financial


influence


incentive


of psychological

volunteering


motivations


of normal


subj ects


research.


Until


present


study,


however,


motivations


of symptomatic


volunteers


apparently


been


left


to the


subjective


inferences


of researchers.


Symptomatic


Volunteers


(SVs)


use


of symptomatic


volunteers


(SVs)


clinical


depression

response t


research


o the


a common


difficulty


practi


ce.


of recruiting


developed


suitable


subjects


j~~ *** a -


a a


'-


- -t -


V.I4 i-I-. 1


f'l -- I.. -


1~









treatment


people


people


from


obtain


do not


family p

treatment


meet


physicians


from


strict


internists,


private


criteria


some


practitioners,


study


some


acceptance,


some


people


do not


see


k treatment


and


remain


depressed.


Nevertheless,


recruitment


efforts


often


generate


large


responses


Goldstein,


1973;


from


community


Hersen,


Bellack,


(Barrett,


1981;


Himmelhoch,


Brauzer


1981;


Thase


al.,


1984)


Research


Barrett


(1981)


supported


notion


that


symptomatic


depression.


newspaper


volunteers


He found


advertisements


do, indeed,


that


diagnostic


,411)


depressed


criteria


of respondents


volunteers


were


least


standard


deviations


above


normative


means


Research


Diagnostic


Criteria


either


anxiety


depression.


that


sample


were


considered


acceptable


for research


continued


express


interest


treatment.


Of those,


although


42.3%


they


indicated


were


they had


currently


previous


treatment;


treatment


other


approximately


reported


no history


previous


treatment.


Although


symptomatic


volunteers


differ


from


other


clinic


help


populations


outside


that


research


they


are


structure,


currently


they


appear


seeking


to be


similar


to clinic


populations


diagnostic


demographic


characteristics


that


reinforce


importance


of them


as a


- A -


k ft 1









psychiatric


symptomatology


using


Brief


Psychiatric


Rating


Scale


(BPRS).


Most


symptomatic


volunteers


had


ratings


indicative


of simple


anxious


depressions.


Three


hundred


thirty-one


symptomatic


volunteers


treated


a study


improvements


Brauzer


comparable


Goldstein


those


(1973)


expected


showed


a clinic


setting


on the


BPRS,


Hamilton


Anxiety


Scale,


and


the


35-item


Self-Rating


Scale.


Demographic


variables


sex,


age,


education


were


associated


with


high


risk


depression.


From


this,


authors


concluded


that


characteristics


of symptomatic


volunteers


were


very


similar


to those


of depressives


found


a community


sample.


Through


a unique


of circumstances,


Hersen,


Bellack,


Himmelhoch


(1981)


were


able


compare


solicited


and


unsolicited


depressed


females


as part


of a large


scale


outcome


training,


investigation


comparing


amitriptyline.


psychotherapy,


Forty


-five


social


depressed


skills


females


accepted


from


outpatient


clinic


of Western


Pennsylvania


Psychiatric


females


Institute


accepted


were


following


compared with

newspaper and


37 depressed

radio


advertisements.


Both


groups


were


accepted


into


protocol


based


on the


Feighner


Criteria


.e.


, a checklist


developed


1972


Feighner


which


lists


basic


components


required


to diagnose


a major


depression).


Data


analyses


a -r -


a a -


a S -


*I


1 -


__









assertiveness,


or social


adjustment.


Moreover


there


were


no demographic


differences


between


groups.


Although


clinic


populations


symptomatic


volunteers


are


similar,


some


minor


differences


have


been


noted.


example,


Parker


Blignault


(1983)


compared


66 symptomatic


volunteers


43 psychiatric


outpatients


on demographic,


depressive,


personality


measures.


They


found


that


symptomatic


volunteers


did


differ


significantly


from


clinic


referrals


with


respect


to prior


treatment


history.


However,


analysis


of Zung


Self-Rating


Depression


Scale


scores


showed


some


tendency


symptomatic


volunteers


to be


less


severely


depressed.


Demographically,


symptomatic


volunteers


were


slightly


older


more


likely


to be


married


than


clinic


population.


Their


depress ion


also


tended


be of a longer


duration


with


less


marked


sleep,


appetite,


motor


disturbance.


only


difference


in personality


found


was


that


symptomatic


volunteers


were


slightly


less


extroverted on the

Thase et al.


with


46 clinically


senck


(1984) co

referred


Personality


mpared


Inventory.


79 symptomatic


outpatient


primary


volunteers


depressives


on a number


measures.


They


found


that


symptomatic


volunteers


differ


significantly


from


clinic


referral


samples


on most


symptomatic


demographic


volunteers


were


symptomatic


slightly


differ


variables

nt from c


linic


S--


1









had


longer


episodes


of depression


prior


to seeking


treatment.


Both


groups


were


similar


prevalence


depression


Diagnostic


either


Research


Statistical


Diagnostic


Manual


-III


Criteria


criteria.


(RDC)


The


subjects


treated


with


amitriptyl ine


were


also


compared


with


respect


to overall


dropout


rate,


side


effects,


attrition,


dosage


of medicine


received,


response


treatment.


significant


differences


were


found


between


groups.


lack


of major


differences


symptomatic


volunteers


clinic


referrals


volunteers


need


are


supports


representative


of treatment.


research


position


of the


also


that


depressed


indicates


symptomatic


population


that


differences


between


symptomatic


volunteers


clinic


populations


are


most


negligible


obvious


either


difference


between


treatment


clinic


or outcome.


patients


symptomatic


volunteers


method


which


individual


enters


touches


clinic


treatment


on differences


populations


system.


between


on measures


Although


symptomatic


of introversion,


literature


volunteers


depression,


ass


ertiveness,


or social


adjustment,


there


no indication


that


groups


have


been


compared


on measures


personality


factors


related


to individual


styles


interacting


coping


with


help-givers


style


treatment


a treatment


setting


setting.


may


The


be found


- - A -


S e S e -


- 1 .


q *









measurement


of coping


style


are


pertinent


to this


discussion.


Personality


Early


Theories


Theories


Theories


of personality


have


proliferated


since


ancient

four ba


Greeks.


sic


Hippocrates


temperaments


attributed


(choleric,


what


melancholic,


s considered

sanguine,


phelgmatic)


excesses


four


essential


body


fluids


(yellow


bile,


black


bile,


blood


phelgm).


Aristotle,


contrast,


related


personality


characteristics


to facial


configurations


expression.


In a similar


vein,


during


eighteenth


century,


Franz


Josef


Gall


attempted


to construct


a science


of "brain


physiology"


known


as phrenology.


His


basic


premise


was


that


personality


characteristics


could


be correlated


with


structure


of the


brain.


This


could


be measured


examining


contour


logic,


Gall'


of the


theor


head.

y was


Irrespective


an early


of the


attempt


simplistic


to link


personality


with


body


structure,


primarily


brain


(Millon,


1981).


Twentieth


Century


Theories


Personality


theories


have


become


more


complex,


but


-___ _s__


-- L -.. .-.I--


AKI-i- -


-A--I


-- -- -- A&- --* .. .


1


- LL-L I----









determined,


interpersonal,


factorial


personality


component


(Millon,


1981,


29).


Factorial


approach.


Twentieth


century


theorists


began


to formulate


theories


that


linked


personality


core


traits


combination.


Heymans


three


In the


Wiersma


primary


early


identified


criteria


1900s,


what


evaluating


Dutch


they


psychology


considered


character.


They


determined


that


activity


level,


emotionality,


susceptibility


to external


vs.


internal


stimulation


were


components


types.


that


Although


permutate


their


into


theory


eight


did


basic


achieve


personality


widespread


acceptability


original


form,


these


components


have


re-emerged


more


recent


theories


as activity-passivity,


pleasure-pain


emotionality


a form


of introversive


vs.


extroversive


responsivity


(Millon,


1981).


William


McDougall


1908


developed


a similar


theory


Introduction


to Social


Psycholoav.


McDougall


derived


eight


"tempers"


based


upon


three


fundamental


factors:


intensity


(strength


urgency),


persistency


(inward


vs.


outward


expression),


affectivity


(emotional


susceptibility)


of behavioral


impulses.


Although


evolving


different


labels


throughout


years,


dimension


of persistency


been


compared


to internal


vs.


a A a a a


A ID A --,


* *









Morphological


approach.


1940s,


William


Sheldon


presented


relationships


among


hypothesis


body


type,


concerning


temperament,


the

and


psychopathology.


He specified


three


clusters.


viscerotonic


temperament


pairs


with


endomorphic


or soft,


round


body


type


which


characterized


easy


emotional


expression,


dependence


on social


approval,


an enjoyment


of physical


comfort.


somatatonic


temperament


goes


with


mesomorphic


assertiveness,


or muscular


calmness,


body


type,


energy,


characterized


a desire


to be active


take


steps


to control


situation


when


confronted


difficulties.


cerebrotonic


temperament,


which


related


to the


ectomorphic


or thin,


linear


structure


body


type.


toward


This


temperament


restraint,


painful


characterized


self-awareness,


a tendency


a preference


dealing


with


problems


themselves


(Millon,


1981).


Interpersonal


approach.


In the


1950s,


Cattell


Eynsenck


developed


a modern


factoral


approach


personality.


They


evolved


theories


that


redirected


factors


from


describing


inner


approach


of the


individual


to describing


quality


style


of interpersonal


interactions.


personality


According


can


these


theories,


be accounted


differences


relative


strength


each


component


(Millon,


1981)


t---- -A A. .3


- - -~- S-A-.


--. -a


a


,qlLm q q t


L


*1 .









Million


that


viewed


are


personality


a learned


form


as composed


of instrumental


coping


behavior.


patterns

According


to Million,


child


born


with


certain


basic


capacities


temperament.


In early


stages


of development


child


tries


a variety


of behaviors.


Perceived


reinforcement


shapes


behavior


Million


child'


future


integrated


proposed


behavior


into


that


until


child'


behavior


pattern


"feeling


designed


of self"


to achieve


positive


reinforcements


avoid


negative


reinforcements.


These


coping


styles


are


based


upon


what


individual


"learned


to seek


or avoid


(pleasure-pain),


where


the


individual


looks


to obtain


pleasure


self-others),


and


how


individuals


have


learned


to behave


order


to elicit


escape


reinforcements


(active-passive)"


(Millon,


1981,p.


59).


Million


(1969)


stated


that


there


are


three


principal


determinan

utilize:


current


environment


of the


biophysical


alternatives.


terms


coping


strategies


constitution


child'


energy,


individuals


, past


learn


experiences,


responsivity


drive,


to the


temperament,


intelligence,


sensory


sensitivity,


physical


strength


are


thought


to be biophysically


determined.


experience


environmental


influences


are


colored


child'


innate


propensities.


reactions


of the child


the


experiences


environment


shape


child


process


I ~ ~ ~ ~ ~ ~ -- -- S


e4 -


1


*I _-


i ,


Ir


._









An understimulating


environment


diminishes


or mutates


natural


coping


abilities.


result


might


be that


"normal"


stressors


could


perceived


as overwhelming.


Finally,


whatever


range


coping


mechanisms


child


perceives


available


are


narrowed


objective


reality


any


given


situation


(Millon,


1969).


Basic


patterns.


to Million'


Given


theory


limitations


concept


of biological


of personality


functioning


relative


repetitiveness


of learning


experiences,


child


pervade


develops


every


a distinctive


facet


pattern


of functioning.


of characteristics


They


that


become


personality,


which


an automatic


way


of interpreting,


thinking,


patterns


emerge


responding


are


from


, and


"pervasive


entire


acting.


modes


matrix


Therefore,


of functioning


the


personality


which


individual'


developmental


history,


which


now


characterize


his/her


perceptions


ways


of dealing


with


environment"


(Millon,


1975,


343).


term


"pattern"


reflects


essential


constructs


of this


theory.


First,


behaviors


attitudes


evolve


from


the


interaction


of biological


dispositions


experience.


Second,


these


characteristics


are


tight,


organi


interaction


of needs


, attitudes,


behaviors


a random


compilation


of unrelated


behaviors.


Also


central


to thi


theory


concept


that









interactions,


When


personality


individual'


pattern


perceptions


considered


behaviors


healthy.


foster


personal


discomfort


relationships


are


when


responded


ordinary


responsibilities


to defectively


or inflexibly,


individual


considered


to have


a pathological


personality


pattern.


Million'


theory


espoused


eight


coping


strategies


based


upon


a 4x2


matrix


combining


basic


variables:


individual'


personal


style


nature


of the


reinforcements


reinforcements.


sought


Major


actions


components


used


of the


to achieve


matrix


those


are


kinds


of reinforcements


(positive


or negative)


the


person


seeks,

others)


to whom


person


what


looks


person


does


reinforcements


to get


(self


those


reinforcements.


According


to Million,


a major


distinction


among


people


whether


themselves


their p

or from


primary

others


source

. This


of reinforcement

corresponds to


within


dependent


independent


patterns


of behavior.


According


theory,


dependent


personalities


have


learned


that


feeling


good


(i.e.,


those


feelings


associated


with


pleasure


avoidance


of pain)


best


provided


others.


These


individuals


need


external


support


affection.


Independent


personalities


obtain


maximum


pleasure


4
- a -. -


4
a a -


* -


-


L..









regarding


dependence


on themselves


or others.


These


individual


either


vacillate


or display


overt


dependence


while


supressing


angry


feelings


of being


denied


independence.


Finally,


Million


identified


a pattern


called


"detached"


These


individual


are


unable


experience


rewards


from


themselves


or from


others.


They


tend


to be socially


isolated


or engage


self


-alienating


behaviors.


A second


distinction


style


which


individual


cits


reinforcements


sought.


The


styles


of behaving


are


active


and


passive.


The


active


personality


tends


engage


direct


alert


behavior


order


to avoid


punishment


pleasure


or reward.


contrast,


passive


personality


characterized


apparent


inertness,


lack


of ambition


acquiescence,


behavior


that


demonstrates


little


willingness


to do


much


shape


events


(Millon,


1981)


following


is a brief


explanation


of the


eight


personality


remember


types


that


defined


Million.


psychologically


important


healthy


individual


these


characteristic


are


descriptive


of a personality


style


The


patterns


are


only


cons


idered


pathological


when


they


become


socially


dysfunctional


The


diagnostic


term


dysfunctional


form


of each


pers


onality


pattern


A a


* I









1. The passive-dependent
personality; DSM-III Depen


characterize
one can lean
leadership.
and autonomy
overprotecti
experiences,
comforts of
relations, a
may find, an


others


or'


d by
upon
This
is o
on.
thes
assume
ccept
d wil
der t


a


search
others


pattern


de


fo
for
-


personality's lack
'ften a consequence o
As a function of the
e individuals have s
ing a passive role i
ing whatever kindnes
lingly submitting to


t d
re
aff


(Millon


sorder


ati
cti


ons


o maintain


their


Submissive


) is
hips in whi
security,
both initi
parental
early
ply learned


ch
and
ative


the


interpersonal
and support they
the wishes of


affection.


2. T
perso
insat
and a
capri
consi
guise
signs
be re
every


active-dependent


nality;


able
'fect
ious
erab
lies
of s
leni


DSM-III


and indis
ion. This
behaviors
le indepen
a fear of


social
shed


source


Hist
crimi
pers
give
dence
auto


approval
constantly


pattern


rion
nant
onal
the
of
nomy
and
and


interpersonal


i

i


c D
sea
ty'
app
the
and


(Millon
disorder
rch for
s socia
earance
rs, by
an int


Gregarious
) shows an
stimulation
ble and
of
beneath this
ense need fo


attention. Affection
must be obtained from
contact.


.The


Narcissi
disorder
As a fun
learned
in their
premises
recognize
arrogant
even con:


passive-independent


.ic
is
ion
ov
upe
Ne
the
elf
iou


personal
noted by
of earl
ervalue
priority
verthele
ir speci
-assuran'


s


advantage.


ity
an
y e
the
may
Cs


al
ce


intent,


pattern


; DSM-III Na
egotistic s
experience th
ir self-wort
, however, b
they assume


ness, ma
, and wi
benignly


(Millon


r
e
e
h
e


intain
thout


cissistic
if-involvement.
se persons have
; their confidence
based on false
that others will


an
muc


exploit


air of
h thought
others to


their


4. The
personal
learned
and retr
There is
disposit
are seen


duplic


active-independent


ity;
mist
ibut
an
ion
as


itous


only


DSM-
rust
ion f
indis
to be
just
Aut


means


pattern


III Antisocia
of others and
or what are f
criminate str
reflecting o
fied because ]
onomy and hos


head


a des
It as
ving
othe
people
ility


deceit


(Millon
order)


ire
pas
for
rs;
are
are


and


Aggressive
reflects a


for autonomy
t injustices.
power and a
these actions
unreliable and
claimed to be


betrayal.


5. The
persona
n^nn1l n


*passive ambivalent
lity; DSM-III Compul


pattern
sive di


(Millon
sorder)


Conforming


is
-_-3


based


must


II


r


,









feelings
controls.


that,


on occasion,


break


through


their


personality:


represents
those of th
ambivalence
consciousne
individuals
disappointm
conformity,
next. Thei


DSM-III


an inab
e pass
remain
ss and
get th
ents as
at one
r behav


e anger
of guilt


pattern


Passive-aggre


ility to resolve
ve-ambivalent; h
s close remains 4
intrudes into eve
emselves into enB
they vacillate
time, and aggre!


displays


or stubborness


shame.


an


ssive disorder)
conflicts similar
however, this
close to
eryday life. These
less wrangles and
between deference a
ssive negativism, t
erratic pattern of


intermingled


with


7. The passive-detached pattern
personality; DSM-III Schizoid di
characterized by social impassiv
needs and emotional feelings are
individual functions as a passive
from the rewards and affections,
demands of human relationships.


(Millon
sorder)
ity. Af
minimal
e observ
as well


Asocial
is
fectionate
, and the
er detached
as from the


8. The
personal
fear and
maintain
longing
pain and
previous
themselv


active-detached


ity; DSM-III
mistrust of
a constant v
for affection
anguish they
ly. Only by
es. Despite


learned that it
an interpersonal


pattern


Avoida
others
igil 1
resul
have
active
desire


(Millon


Avoidant


nt disorder) represents a
These individuals
est their impulses and
t in a repetition of the
experienced with others
withdrawal can they protect
s to relate, they have
deny these feelings and keep
(Millon, 1981, pp. 60-61)


Instruments


Demography/Reasons for
Selection Questionnaire


Treatment


Mode


This

provide i


questionnaire


information


was

the


designed


demographic


variables


pertinent


this


study


on the


primary


reasons


subjects


express


The


active-ambivalent


Negativistic


explosive
moments


to




nd
he


is best to
distance.


researcher


(Millon









they


provide


a basis


comparison


volunteer


group


with


high-risk


group


as defined


literature.


"Standard"


demographic


variables


include


age,


sex,


marital


status,


socioeconomic


epidemiological


demographic


studies

variables


status,


and s


often


and


studies


focus


level


of education


focusing

on these


on the

five


because


impact

factors


(Craig


Van


Natta,


1979;


Cooke,


1982;


Myersi


Weissman,


Tischer


et al.,


1984;


Robins,


Helzer,


Weissman


et al.,


1984).


Expressed


Reason


Treatment


Mode


Selection


question


was


a question


designed


to generate


primary


conscious


reasons


approach


to treatment


(i.e.,


through


an appointment


with


a therapist


or through


study).


subjects


were


asked


to indicate


which


of eight


factors


were


considered


either


their


research


decision


or through


to seek


treatment


outpatient


through


services.


They


were


also


asked


to rank


responses


in the


order


of their


relative


importance


responses


deci


were


sion-making


categorized


into


process


one


(Appendix


the


following


groups:


"Finances"


"Direct


referral"


"Pre


"Ease


sure


from


of access"


others"


, (f)


"New


, (d)

drug


"Desire


to help


or treatment


others"


hopes"


"Reputation


of servi


ces


"Other"


"Financial"


responses


include


mention


of the


sliding


scale


fee,


, (g)


I












such


case


worker/physician


sent


me here"


while


"Pressure


from


others"


includes


responses


such


as "My


husband/friends


told


me to call"


"Des


to help


others"


responses


are


those


that


indicate


individual'


desire


further


science


or help


others


the


process


of getting


treatment


themselves.


"Ease


of access"


responses


indicate


that


recruitment


advertisement


or the


various


brochures


distributed


services


clinic


prompted


initiation


of seeking


services.


"New


drug


or treatment


hopes"


includes


responses


about


multiple


previous


drug


counseling


trial


which


failed


to accomplish


treatment


expectations.


The


element


of thi


category


previous


treatment


failure


hope


that


current


effort


will


"the


answer"


The


category


"Reputation


of services"


will


includes


statements


such


as "My


friend


was


treated


your


study


was


helped"


or references


to local


reputation


of specific


therapists


or servi


ces.


category


"Other"


only


used


those


responses


that


deviate


from


-determined


category


es.


Assessment


of Depression


- The


Beck


Depression


Inventory


A depression


rating


scale


was


a necessary


element


study


responses


as a control


In addition


influence


, a measure


of the


depression


of depression


was


erative


since


presence


of depression


was


a requirement


a a a ... -A.


p'


C









presence


increased


numbers


of dysfunctional


attitudes.


These


negative


attitudes


subside


with


improvement


of the


depressive


symptoms.


severe


depression,


these


attitudes


appear


to be


a consequence


depression


(Eaves


Rush,


Blignault,


rather

1984;


1983;


than an antecedent

Hamilton & Abramson


Silverman,


Silverman,


depression


1983;


Eardley,


Parker


1984)


symptoms


depression


may


include


difficulty


thinking


or concentration.


Obviously


, the


more


severe


depress


more


likely


symptoms


of impaired


cognitive


ability


are


present.


means


that


respondent'


level


of depression


may


have


an impact


on the


rel ability


responses,


including


inability


to estimate


their


level


of depression


literature


shown


that


concordance


between


clinical


assessment


and


self-report


depression


only


.56 during


acute


phase


depressive


episode.


At follow-up


10 months


later,


when


depressive


episode


remitted,


correlation


between


self-report


clinical


assessment


increased


(Carroll


, Fielding,


Blashki,


1973;


Prusoff,


Klerman,


Paykel


, 1972).


voluntary


nature


of this


study


method


employed


render


most


appropriate


measure


this


study


to be a self-rating


depression


sca


Hughes,


O'Hara,


flnut


/9 I nf


( '


- -_ -_ -5 A


E -'


L 1


A


I









cognitive


impairment


associated


with


depression


can


lead


subjective


overestimation


of the


intensity


of depressive


symptoms.


Nevertheless,


self-rating


scales


have


adequate


reliability


validity


most


studies


they


are


used


clinically


research


to detect


and


quantify


depressive


states.


The


three


most


commonly


used


self-rating


depression


scales


were


compared


an effort


to pick


the


one


most


appropriate


one


this


study.


The


Center


Epidemiological


Studies


-- Depression


scale


(CES-D)


contains


20 selected


items


from


Beck,


Zung


, and


MMPI-D


scales.


This


scale


been


found


useful


detecting


depressive


symptoms


a community


sample


with


a 94%


specificity


rate,


but


only


a 33%


predictive


value


(Boyd,


Weissman,


Thompson,


Myers,


1982)


Because


focus


of this


study


was


presence


or absence


of depressive


symptoms


a community


sample,


but


rather


severity


of depression


found


treatment-seeking


sample,


CES-D


was


chosen.


The


upon


Zung


Self-Rating


clinical


diagnostic


Depression


criteria


Scale


most


(SDS)


commonly


based


used


characterize


depressive


disorders.


The


reliability


of this


scale


been


established


literature.


However,


been


shown


to discriminate


depressed


persons


from


those


with


other


disorders


(Zung


, 1965)


significantly


-~~ A- a. -


* k


. . 1


*





_









Although


generally


considered


a fairly


useful


scale,


Zung


relies


heavily


on the


neurovegetative


symptoms


depression


asses


sment


of severity


(Boyd,


Weissman,


Thompson,


et al.,


1982


The


neurovegetative


aspects


depression


are


primary


means


which


people


normally


identify


themselves


as depressed,


nor


were


they


focus


of inclusion


criteria


this


study


Therefore


Zung


was


selected


this


use.


Beck


instrument


Depress


designed


Inventory


measure


(BDI)


inten


a 21-


sity


item


of depress


focusing


on the


cognitive


correlates


of depression


thoughts


about


self


life


that


are


part


of the


depressive


episode)


(Hughes


, O'Hara,


& Rehm,


1982


Although


originally


designed


to be administered


a trained


interviewer,


instrument


usually


used


as a


self


-administered


inventory


Items


are


read


the


individual


who


then


notes


intensity


of each


symptom


over


a 1-week


period


on a scale


of 0-3


Parameters


determining


level


intensity


described


next


to each


rating

score.


level


Beck


Item


scores


are


Beamsderfer


totaled


(1974)


to yield


proposed


tha


a single

t cutoff


scores


on the


level


of depress


should


be based


upon


purpo


ses


determining


such


scores.


Neverthel


ess


, they


established


cutoff


guidelines


of mild


i *


.e.


_ L


__


1 r _









purposes


of the


present


study


cutoff


presence


of moderate


depression


was


a total


score


of 10.


Beck


First,


developed


he reviewed


depression


(prior


Inventory


existing


to 1961),


in a systematic


literature


then


manner.


related


he conducted


intensive


study


50 depressed


30 non-depressed


patients


psychotherapy.


After


tallied


of the


symptoms


that


appeared


more


often


depressed


individuals


than


non-depressed


individuals,


ran


a pilot


test


approximately


patients.


He revised


the


instrument


administered


to 966


psychiatric


patients.


The


final


of symptoms


derived


scale


were


mood,


discouragement,


sense


of failure,


lack


enj oyment,


feelings


of guilt,


feelings


punishment,


suicidal


slike


ideation,


of self


, (h)


crying,


self-blame,


irritability,


desire


social


disturbed


withdrawal,


body


inability


image,


to make


difficulty


deci


working,


sions,


sleep


disturbance,


fatigability,


appetite


sturbance,


weight


oss,


preoccupation


with


physical


health,


loss


of sexual


energy.


Validity.


Beck,


Ward,


Mendelson


, Mock,


Erbaugh


(1961)


established


that


was


significantly


related


psychiatrist


ratings


of depression


.65) .


Other


Y- -- -- --


a -


-


a


F*


L









Dein,


Poynton,


Jacobsen,


1975;


Vitger,


Steer,


Bolwig,


Beck,


1975;


Garrison,


Davies,


1986) .


Burrows,


The


also


been


compared


numerous


psychiatric


rating


scales


psychological


tests.


Correlations


have


ranged


from


0.80


(Mayer,


1977;


Steer,


Beck,


Garrison,


1986).


Tanaka


Huba


(1984)


used


a hierarchical


confirmatory


factor


analyses


technique


to analyze


the


and


compare


with


Psychiatric


Epidemiology


Research


Interview.


The


results


indicated


that


both


instruments


showed


primary-order


correlation


three


factors


with


presence


of depression:

difficulties,


negative


and


attitudes/suicide,


performance


physiological


difficulties.


Oliver


Simmons


(1984)


further


examined


the


relationship


DSM-III


Schedule


between


criteria


of the


diagnosis


as measured


Center


of depression


Diagnostic


Epidemiological


according


Interview


Studies


BDI.


Using


a sample


of 298


paid


volunteers,


they


found


that


was


a sensitive


screening


tool


depression


community


sample


the


cutoff


point


of 18/19


were


used


match


with


DSM-III


diagnosis


of Major


Depressive


Episode.


However,

disorder


those

were


individuals


unable


with


intermittent


be differentiated


from


dysthymic


normals


basis


of BDI


scores.


authors


attributed


this


to the


cyclic


nature


disorder


design


Beck


..'L.~~1 J a ..alan a-Sf I a a n -a~


.x:,r,


,,?,L


A3


~Y1.


~ IIIAY


I*~LIII~YII











Reliability.


test-retest


reliability


of the


when


past


the


week


individual


appears


asked


to be in


to describe


70s.


themselves


However,


over


test-retest


reliability


determinable


individual


asked


to rate


themselves


only


time


of testing


since


thoughts


feelings


rated


given


point


time


can


vary


some


extent


during


week


or day,


especially


mildly


or moderatly


depressed


person


(Steer,


Beck,


Garrison,


1986).


Uses


of the


Over


past


years,


the


been


successfully


appropriately


used


numerous


populations


such


as geriatric,


substance


abuse,


post


therapeutic-intervention


groups


(Steer,


et al.,


1986).


of its


many


applications


with


non-psychiatric


populations


been


with


university


students.


The


results


of research


this


population


both


confirm


and


expand


positive


applications


of the


elucidate


areas


of caution


use.


Bumberry,


Oliver


, and


McClure


(1978)


indicated


that


scores


of 56 university


students


correlated


= 0.77


with


psychiatric


depression


ratings.


This


indicates


that


correlations


of BDI


scores


with


psychiatrist


ratings


are


determined


setting


of evaluation.


'-S - -s .2 ---- --


-
- -- -


..-Y-


m --


n-









difference


degree


of depression


experienced


students.


Differences


did


exist,


however,


between


men


women


expression


of the


depression.


The


primary


symptoms


men


reported


were


being


unable


cry,


feeling


oss


of social


interest,


feeling


a failure


at life,


increased


somatic


complaints.


Women,


on the


other


hand,


reported


negative


feelings


towards


self


an inability


make


deci


sions.


Sacco

scores. H


(1981)


addressed


e cautioned


against


time


use


applicability


of the


as a criterion


participation


psychological


experiments


except


day


of the


on which


literature


instrument


is consistent


administered.


with


review


findings


Bumberry


et al.


(1978)


that


correlation


between


psychiatric


ratings


scores


fell


from


when


there


were


to 14 days


between


administration


inventory


psychiatric


interview.


summary,


been


established


as a reliable


valid


tool


assessment


of intensity


of depre


ssion


both


psychiatric


non-psychiatric


populations.


Given


that


instruments


this


study


will


administered


concurrently


that


scores


will


be used


retrospectively


to eliminate


inappropriate


subjects,


issue


time


applicability


of BDI


scores


moot.


.ca a J.b -t-- t. -S


C, ,L,,,


* -


R *


*







Assessment


The


Million


Behavioral


Health


Inventory


Based


upon


his


theory


personality,


Million


developed


an instrument


a medical


assess


the


population


presence


The


goal


personality


the


factors


instrument


provide


the


clinician


with


information


regarding


the


individual'


likely


style


of relating


to health


care


personnel,


as well


as psychosocial


attitudes


and


stressors


that


might


be problematic.


The


150-item


scale


was


developed


for


individuals


years


age


or older


who


possess


minimum


eighth


grade


reading


skills.


Normed


on a medical


population,


generates


scores


on 20 scales


and


takes


approximately


minutes


complete.


The


20 scales


include


8 basic


coping


styles


scales


introversivee,


forceful,


inhibited,


respectful,


cooperative,


sensitive);


sociable,


6 psychogenic


confident,

attitude


scales


(chronic


tension,


recent


stress,


premorbid


pessimism,


future


despair,


social


alienation,


somatic


anxiety);


psychosomatic


correlate


scales


(allergic


inclination,


gastro-intestinal


susceptibility,


cardiovascular


tendency);


and


3 prognostic


index


scales


(pain


treatment


responsivity,


life


threat


reactivity,


and


emotional


vulnerability).


this


study


only


the


scales


measuring


coping


styles


and


nsvchoaenic


attitudes


were


used.


therefore.


discussion


Personality









Coping


Style


sca


items


were


originally


developed


from


1000


items


sen


to accord


with


theoretical


substantive


validation


data.


These


were


reduced


"best"


items


on preliminary


internal-consi


stency


structural


validation


grounds


This


289-


item


personality


form


was


administered


over


2500


persons


a variety


settings


The


university


majority


None


were


persons


medi


were


patients


students


After


an urban


form


been


administered


to all


subj ects,


several


procedures


were


items


followed


with


to eliminate


a correlation


overlap


were


ensure


included


that


on the


only


final


scal


The


biserial


correlation


between


each


item


ass


signed


sca


was


sca


es.


The


final


revision


left


64 coping


style


items


on the 150-


item


instrument


(Millon,


Green,


& Meagher


, 1982).


similar


method


was


used


to develop


items


Psychogenic


Attitudes


scal


Approximate


to 60


items


were


developed


each


SIX


sca


on the


basi


other


researchers


' work


on stre


ssful


life


events


These


lists


were


rated


experienced


clini


cians


area


psychological


influences


upon


physical


illness.


Items


"correctly"


ones


placed


included


> 75%


Psychogenic


clini


Attitude


cians


sca


were


adds


only


items


to the


total


(Millon


et al.,


1982).












changes


in circumstances.


Despite


that


disclaimer


most


the test


-retest


reliabiliti


on an undefined


"general


population


to whom


the MBHI


was


admini


stered"


were


mean


reliability


was


psychogenic


attitude


scal


maintained


an average


test


-retest


reliability


of approximately


Mean


elapsed


time


between


testing


was


.5 months


(Millon,


et al


1982


, p.25)


Validity


Item


overlap


resulting


joint


-scale


keying


was


examined


ermined


to be des


irable


theoretically


structurally


(Millon,


1982)


Neverthel


ess


, empirically


obtained


intercorrelations


among


scal


are


greater


than


what


can


be expected


item


overlap.


According


author,


high


correlations


exist


among


scal


expected


demonstrate


such


relationships


.81 between


Inhibited


Style


Sensitive


Style),


however,


importance


these


factors

collapse


in a configural


or otherwi


supersedes


modify


sca


propositions


es.


The


Coping


Styles


Psychogenic


Attitudes


sca


MBHI


have


been


compared


with


specific


scales


on 11


standard


inventor


Personality


inventories


used


assess


include


Inventory


convergent


Minnesota


(MMPI),


validity


Multiphasic


Symptom


Checklist


(SCL-


90),


Rotter'


Locus


of Control,


Beck'


Depre


ssion


Inventory,


Personal


Orientation


Inventory,


Life









Activity


Survey


(JAS),


California


Personality


Inventory


(CPI).


Each


eight


coping


style


scales


psychogenic


attitude


scales


correlate


>.32


on at


least


related


scales


from


correlated


instruments


(Millon,


et al


1982).


Million


MBHI

the


a relatively


Journal 1


new


of Counselin


scale.

a and


Reviews


Development


the

(Rustad,


1985)


Allen


Lanyon


(the


Mental


Measurements


Yearbook,


1985)


indicate


that


premise


instrument


good.


Neverthel


ess


, the


limited


use


MBHI


to date,


along


with


insufficient


reliability


validity


data,


make


difficult


to determine


true


efficacy


of this


instrument


Despite


providing


information


limitations


purports.


measurement


concerns,


MBHI


appeared


to be a valid


instrument


investigate


relationship


coping


style


psychogenic


stress


treatment


seekers


enter


a psychiatric


treatment


service


in a medical


setting.


Summary


primary


factors


which


determine


whether


individual


seeks


treatment


are


their


beliefs


about


efficacy


of treatment,


nature


of their


social










Within


subgroup


treatment


seekers


there


are


sub-groups


of individuals


seek


treatment


through


different


means.


Traditional


help


-seekers


search


normal


channels,


such


as therapists


clini


CS.


Symptomatic


volunteers


seek


help


through


volunteering


treatment


research


studies.


depressed


symptomatic


volunteer


depressed


clinic


patient


are


more


alike


than


different


many


ways.


Both


are


willing


to seek


treatment


, both


are


depressed,


both


are


similar


in personality


variables


such


as age,


gender,


education.


Depression


a serious


prevalent


problem


. Not


only


are


implications


regarding


potential


suicide


quality


of life


of great


concern,


frequency


occurance


is significant.


Neverthel


ess


, many


persons


do not


seek


appropriate


treatment.


Because


of this,


symptomatic


volunteer


who


does


seek


treatment


through


available


means,


rather


who


responds


to recruitment


efforts


treatment


research


of great


interest.


There

volunteer.


little


Further


literature


examined


this


about


study


the


were


symptomatic

the


differences


patient


between


area


symptomatic


of demography,


volunteer


expressed


clinic


reasons


selection


treatment


mode,


personality


variables


related









questionnaire,


Beck


Depression


Inventory,


Million


Behavioral


Health


Inventory.














CHAPTER


METHODOLOGY


This


study


was


designed


to explore


the


individual


characteristics


depression


persons


those


who


seek


directly


help


seek


being


counseling


a research


volunteer.


Depressed


symptomatic


volunteers


clinic


patients

between


were

the g


examined


roups


to determine


regard


differences


to demographic


exist


variables,


reasons


selection


of treatment


mode,


styles


of coping


attitudes


towards


psychosocial


stressors.


Samples


descriptive


study


were


compared


using


data


from


Beck


Depression


Scale,


Million


Behavioral


Health


Inventory


, and


a Demographics/Reason


Treatment


Mode


Selection


questionnaire.


Population


Samolin.


population


investigated


were


adults


seeking


treatment


depression


either


as volunteers


research


or through


a clinic.


Volunteers


and


clinic


patients


were


from


Chittenden


County,


Vermont,


also


known


as the


greater


Burlington


area.








Colchester,


Essex,


Shelburne,


Winooski,


and


Williston.


Burlington,


population


largest


city


of approximately


Vermont,


38,000


a 1987


Swainbank,


Lake


Champlain


Chamber


1987).


was


activity


of Commerce


hub


state,


, personal


of cultural


although


communication,


and


not


July


educational


capital.


In 1987,


University


of Vermont


had


an enrollment


approximately


10,000


students,


about


half


of which


were


residents


of Vermont


remainder


were


primarily


from


New


England


states


Wrest,


University


of Vermont


Public


Relations


Because


skiing


expensive


States,


Office,


of its


personal


location


locale,


communication,


Green


reputation


and exclusive

drew wealthy


state un

students


July


Mountains,


as one


the


iversities


who


1987).


alpine


most


the


significantly


United

boosted


the local e

(IBM) plant


economy.


Essex


International


Junction


employee


Business

d about


Machines

6,000


individuals,


making


largest


employer


area


Carpenter,


IBM


Plant


Communications


Manager,


personal


communication,


July


10, 1987).


was


noted


comparatively


high


salaries


good


benefits,


which


also


boosted


local


economy.


Conversely,


because


agricultural


economy


state,


as well


as the


attraction


of the


state


persons


who


desired


more


rural


environments,


underemnm 1 ovmin


anti


Csa*O Ti tC n* r


ntrr^tiry+r


* E(. *n


~ra~fia~








Vermont


a uniquely


percentage


of blacks.


Chittenden


had

The


County,


approximately


maj ority


the

466


most

black


of blacks


populated

residents


the


state


county

(1980


were


census


faculty


state,

data).


or students


at the


university


Swainbank,


personal


communication,


July


1987) .


This


means


that


poverty


underemployment


the


state


were


racially


weighted


other


areas


of the


country.


Despite


local


economic


constraints


and


a small


population

resources


base,

were r


physical


prolific


mental


readily


health treatment

available. Chittenden


County


had


physicians,


of which


were


psychiatrists


Kappel,


State


of Vermont


Department


of Health,


Department


of Statistics,


personal


communication,


July


1987).


There


were


also


psychotherapists


social


workers


Chapter


area


of National


communication,


July


Pugh.,


Association


1987).


President,


Vermont


of Social Workers,

In addition, Howard


personal

Mental


Health,


a county


state


supported


community


mental


health


center,


was


available


those


who


have


financial


constraints


or who


require


aftercare


services.


University


Associates


Psychiatry


(UAP)


was


the


treatment


Medicine,


division


Department


University


Psychiatry.


of Vermont


As part


, College


of the


University


Health


Center


UL. I


outpatient


coarorate


umbrel 1 a


*







families;


clinic;


short-term


behavioral


dynamic


medicine


psychotherapy;


service;


assessment


and


psychopharmacology


clinic.


person


was


refused


treatment


because


of inability


pay


All


fees


were


negotiable,


and


a health


center-wide


reduction


program


existed


for


individuals


who


demonstrated


financial


hardship.


summary,


the


greater


Burlington


area,


which


was


the


most


populated


area


of the


state


of Vermont,


had


financial


resources


which


were


enhanced


the


IBM


plant


and


the


University


Vermont


but


which


were


limited


general.


Racially,

services


the area

for mental


was


nearly


health


totally


problems


caucasian.


were


readily


Treatment

available


both


the


public


and


private


sectors,


and


a wide


range


costs.


The


sample


was


drawn


from


two


sets


individuals


who


contacted


the


University


Associates


Psychiatry


outpatient


services


for


treatment.


One


were


symptomatic


volunteers


being


recruited


for


a depression


research


study.


The


other


set


were


patients


who


came


the


University


Associates


their


initial


assessment


or therapy


and


who


had


depression


as part


their


presenting


problem.


Samplina


Procedures


A total


60 participants


were


obtained,








Free


Press)


an alternative


paper


(Vanguard


Press).


Advertisements


were


worded


as follows:


DEPRESSED?


Everyone feels down at t
away, or has lasted 2 to
you've noticed a change
difficulty in concentrate
seem less enjoyable, the:
could be helped by medic;


times. If your depression won
6 weeks or even longer, and
in your sleep or eating habit
ion, and if your normal activ
n you might have a depression


't go
if
s,
ities
that


The University
seeking people
promising newe
medications.
antidepressant
laboratory and
program can be
private medical


of Vermont
to particip


De
at


r antidepressa
Patients will
medications,
physical eval
coordinated w
1 treatment.
you are inter


Univers


pres
e in
nts
rece
requ
uati


ith


sio
pr
wit
ive
ire
ons
ong


ested,


Treatment


ograms
h stand
at no
d physi
Part
going ps

please


Geraldine Amori, M.S.
Clinical Coordinator
656-4560
itv Associates in Psv


.4


Program


comparing
ard antidepr
cost:
cian visits,
icipation in
ychotherapy


essant


and
the
or


call:


!chiatry


incoming


phone


calls


were


answered


University


Associates


Psychiatry


receptionist.


In order


ensure


that


each


caller


received


an uninterrupted


telephone


interview,


the


receptionist


scheduled


a 1/2


hour


telephone


appointment.


clinical


coordinator


of the


Psychopharmacology


Service


(the


researcher


this


study)


returned


phone


call


screen


the


individual


using


criteria


established


eligibility


drug


clinical


study.


These


criteria


included


presence


of symptoms


indicative


of a major


depressive


disorder


excluded


>n









determined


that


volunteer


was


either


eligible


ineligible


drug


study,


coordinator


requested


their


participation


as follows.


At this


doing
part
study
resea
feel
volun
that


another
cipate,
This
rch. Si:
that it


teer
will


help


time


study
regard
study i
nce we
is impo
through


us fi


Psychiatry


on volunteers i
ess of their el
s about individ
are constantly
rtant to under
this knowledge
nd ways to help


Outpatient


which a
ibility
Is who
ing dru
nd peop
hope t


people


Research
11 caller
for the
volunteer
g studies
le who
o learn m


find


Unit
s can
drug
for
, we


ore


treatment.


Your


participation


you complete three
pages in length.
demographical info
primary reason was
second questionnai
is a standard inve
depression you are
questionnaire is t
is a personality s


interact
should ta
Furthermo
volunteer
response
will send
stamped,
participa


study


would


brief questionnaires tha
One questionnaire request
rmation and asks you to s


for
re is
ntory
curr
he Mi
cale


hea
re
re
re


to any indi
you a pack
self-addres


ith
tha
spo
wil
vid
et
sed


volunteering for
the Beck Depres
used to measure
ently experience
lion Behavioral
that assesses di
care givers. T
n 1/2 hour of yo
nses will be gro
1 be no way to t
ual. If you agre
with the auestio


envelope.


completing


Ta--------------------------


Are


the
sion
the
ng.


only require t
t total five
s some
tate what your
drug study.
Inventory. I
severity of t]
The final


Health
fferent
he ques
ur time
uped wi
race an
e to pa
nnaires


you


Inventory.
styles of
tionnaires

th other
y given
rticipate,


hat


A
t
he

It


willing


questionnaires?


Those


symptomatic


volunteers


who


were


not


treatment


elsewhere


agreed


to participate


were


asked


address


were


sent


packet


as described


above,


regardless


of their


screening


status


the


clinical


study.


This


process


continued


until


30 participants


with


a Beck


flonoca nn rn~a4- f~t7 r' raI f raenntilaA


w


L

!


L
4


nPnrP a a ; nn


TmtanCnrrl


lr yr hrd









Psychiatry


their


initial


visit


with


a therapist.


Originally,


new


patients


were


asked


come


40 minutes


prior


to their


appointment


time


to complete


some


forms.


When


they


arrived


they


received


an informed


consent


form


from


secretary.


patients


who


agreed


to participate


received


a packet.


informed


consent


form


read


follows:


are


services
patients
design o
are best
1) How
demograp
motivate
What are
interact
character


doing


. These studi
. We hope tha
ur services so
served. The
depressed are
hic character


s

i
r


The benef
Your their
about you
by helping
Any
and will
will be g


re
at

fo
pa


th
mai


people to
the charac
on with he
istic styl
its of par
apist has


, at
g us
forms
be tr
roupe


sponses to
the Univer
If you a
rm and hand
cket with e
If you a
erapist to
y indicate
Complete


receptionist
therapist.
I have
participate


no co
learn
you
eated
d to
hese
ity A
e wil


re
th
t
in


INFORMED CONSENT
several studies in our


es


look


outpatient


characteristics


our


t by doing so we might be able to help
that the greatest number of people
questions that we are examining are:
our patients? 2) What are the


sti


seek
terist
alth c
es of
ticipa
increa


st
h
fi
a
ma


CS 0
trea
ic s
are
our
tion
sed


f our pat
tment thr
tyles of
givers?
patients
in this
treatment


ient
ough
our
5)


s? 3) What
our services? 4)
patients regarding
What are the


in respon
study are
-related


to you. You also he
ow to best serve our
11 out will be complex
s clinical records.
intain patient confid


inventor


S
1


t to
rythi
will
ceive
is on
he fo


t


SOC1
ing
the
ng y
ing
the
the
rms


ate
to
rec
ou
to


now


pa


find


bott
now.


envelope


rtici
tioni
ed to
rtici
ings
om of
You


prio


read the information
in the study.


not
in t
te,
. S


comply
pate,
of the
this


can


r to

above


se to stress?
twofold.
information


future patient
jients.
y confidential
reported data
iality. Your
your treatment


b


he future.
please sign thi
he will give yo
ete the forms.
but do not want
questionnaires
sheet.


return
your m

and a


S


S
U
u


your
, you


them


meeting


with


your


m willing


*









This


procedure,


however,


relied


heavily


on support


staff


cooperation.


Data


collection


was


insufficient


within


a reasonable


period


of time,


and


appropriate


subj ects


were


being


approached


participation.


Consequently,


procedure


was


changed.


The


revised


procedure


involved


fewer


staff


and


thereby


was


more


efficient


patients


effective.


received


In the


a packet


modified


mail


procedure,


identical


new


to those


received


symptomatic


volunteers


with


exception


cover


letter.


(For


more


details


on the


revised


procedure


see


"Limitations


to General


ability"


section


Chapter


Combining


data


collected


from


both


procedures,


first


30 respondents


who


demonstrated


depres


sive


symptomatology


defined


a score


of 10


or more


on the


Beck


Depression


Inventory)


completed


forms


were


included


study.


Variables/Instruments


variables


categories


measured


of demographics,


analyzed


expressed


fell


reasons


into


treatment


mode


selection,


level


of depression,


basic


personality


coping


styles,


instruments


and a

used


attitudes


this


towards

study i


psychogenic


stressors.


included


Demographics/Reason


Treatment


Mode


Selection


niae4_ 4* 4f


nanua ~ ~ ; hn


I rJ aa i rr~ra~


4-^i


a4-,,.I


4-^ia


QartI


rnr


I









The

included


demographic


those


variables


identified


selected


literature


measurement

to be associated


with


help-seeking


behavior.


These


variables


included


age,


gender,

The


marital

reason


status,


income,


selection


educational


of treatment


mode


level.


was


categorical


variable.


The


query


of "What


contributed


your


deci


sion


to seek


help


here/


through


a study?"


generated


respond


ses


pre-determined


categories


that


were


evaluated


both


frequency


rank


order


of importance.


was


a unique


variable


both


way


that


the


data


were


generated


handled


analysis.


Demoaraphics/Reasons


Treatment


Mode


Selection


questionnaire


(located


Appendix


was


a 1-sheet


questionnaire


developed


researcher


asking


specific


questions


about


individual'


age,


gender,


educational


background,


and


income.


The


reason


selecting


treatment


mode


question


was


designed


to eli


respondent'


conscious


rationale


choosing


to seek


help


through


traditional


research


clinic


study.


setting


or through


categories


provided


participation


were


Finances/Cost


of Services;


Referred


Physician,


Therapist,


or Agency


Pressure


from


Family


or Friends;


Desire


to Help


Others


or Further


Science


Easy


Access


to Talk


with


Someone;


Hope


that


a New


flri~ inr I 471wa ra .1* ***TA -j


a,,~"4.C A 4


tr i | |


T*7-*t-j *


Ul 1


A*


' I









to specify


nature


statements


that


they


considered


"other"


The


which


level


of depression


individual


is a measure


is currently


experiencing


extent


depressive


symptomatology.


This


variable


was


defined


as the


score


Beck


Depression


Inventory.


A minimum


score


of 10


was


required


to denote


presence


of depress


ion.


Beck


Depression


Inventory


(BDI)


(Beck


et al.,


1961)


a 21-item,


self-rating


depression


scale


that


yields


single


score.


The


individual


reads


a stem


statement,


then


rates


intensity


of the


indicated


symptom


over


the


past


week


on a scale


of 0


Descriptor


phrases


printed


next


rating


scale


helps


individual


determine


appropriate


intensity


level


responses


are


totaled


scale


score.


In a normal


or medical


population,


non-depressed


individuals


should


score


less


than


a 10


on the


scale

(i.e.,


(Beck


& Beamsderfer,


a person


experiencing


1974)

g 4-6


A mildly

significant


symptomatic

ly impairing


to 10 mildly


impairing


symptoms)


or a temporarily


depressed


person


scores


from


to 20


on the


scal


score


or greater


indicates


presence


a serious


depression.


purposes


of this


study,


a score


or more


was


required


inclusion


under


the


criterion


that


individual


must


experiencing


symptoms


of depres


sion.


m t o1 al -.41 44-., ni -*


A* r~


F m --v CI


q





,IL, L 'I


U1~T krrn L*









Nevertheless,


test-retest


reliability


limited.


Ratings


measured


any


single


point


time,


particularly


mildly


depressed


retest


individual


reliability


(Bumberry,


subject

Oliver,


to wider v

& McClure,


variations

1978).


Validity


of the


has


been


established


on a number


criteria.


The


Beck


been


significantly


correlated


with


psychiatric


ratings


numerous


studies


(Bech


et al.,


1975;


Davies


et al.,


1975;


Steer


et al., 1986).


In addition,


correlations


ranging


from


0.50


to 0.80 have


been


determined


with


numerous


psychiatric


rating


scales


psychological


tests


(Mayer,


1977;


Steer


et al.,


1986)


The


Million


Behavioral


Health


Inventory


(MBHI)


(Millon


et al.,


1982)


a 150-item


scale


designed


measure


variables


considered


pertinent


to a patient'


cooperation


with


health


care


givers.


Although


initially


designed


to be


used


with


individuals


experiencing


some


type


of physical


illness,


was


particularly


applicable


population


help-seekers


this


study


since


help


was


being


sought


medical

150-item


clinic


questionnaire


or older.


psychiatry

designed


items


consist


service


The


individuals


of descriptive


MBHI


years


statements


to which


individual


responds


true


or false.


The


MBHI


measures


personality


characteristics


attitudes


towards


psychosocial


stressors


with


theoretical


position


that


- S SI -- -


a .


*


a L


-( -





m Aa












Million


Behavioral


'Health


Inventory


yields


raw


base


rate


scores


which


are


then


developed


into


a profile.


The


sca


Coping


plus


measures


Styles


scores


variabi


, Psychogenic


patients


categories


resors


exhibiting


, Prognostic


specific


of Basi


Indices,


sease


syndromes.


purposes


of this


study,


the


coping


styles


psychogenic


attitudes


sca


were


included


data


set.


According


to Million


(198


test-retest


reliability


of the


instrument


determined


on a general


population


undefined


over


an elapsed


time


of 4


.5 months


averaged


.85.


Validity


was


determined


correlation


with


eleven


established


psychological


assessment


tool


The


eight


coping


style


scales


psychogenic


attitude


sca


correlate


>.32


on at least


related


sca


from


compared


instruments


(Millon


et al


1982


Basic

introversiv


personality

e style, in


coping


hibited


style

style,


variables


were


cooperative


style,


sociable


style


confident


styl


forceful


style


, respectful


style


sensitive


style


as defined


scal


from


Million


Behavioral


Health


Inventory


These


eight


sca


measure


basi


coping


styles


as they


pertain


to the


individual'


interaction


with


health


care


givers.


The


Introversive
sCAE., 4 nra *.


Style


sca


aiLL..


measures


individual'


pattern


* S*


:LL


~Yf


,,,,: L1


f


iu









encouragement


from


health


care


givers


to gain


cooperation.


An individual'


score


Cooperative


Style


scale


reflects

specific


to what


extent


instructions


individual


tend


to become


tends


require


dependent


on the


profes


sional.


Sociable


Style


scale


measures


the


extent


to which


an individual


likely


engage


treatment


an early


stage


of the


process


but


becomes


ess


dependable


reliable


scale


an individual


but


compliance


Confident


will


be motivated


with


Style


behave

a need


treatment


measures


a calm

ensure


as time


progresses.


extent


confident


their


to which


manner,


well-being.


Forceful


Style


scale


measures


extent


to which


individual


engender


needs


trust


individual's


score


a very


gain


on the


direct,


compliance


Respectful


explicit,


with


strong


treatment


Style


scale


style


plans.


measures


extent


to which


or she


may


have


the


tendency


to deny


symptoms


feelings


while


being


cooperative


conforming.


extent


Scores


to which


on the


an individual


Sensitive


may


Style


be moody


scale


and


measure


erratic


treatment


compliance,


switching


from


cooperating,


complaining,


to non-cooperating


on an erratic


basis.


Each


of these


variables


reflect


a style


of relating


to health


care


profess


ionals


that


may


impact


choice


course


treatment


(Millon


et al.,


1982).


mt -


a~ J 2 - -------------------------------------I-A- -


,I,,


m nA--









as measured


psychogenic


attitudes


scal


on the


Million


Behavioral


Health


Inventory.


These


scal


measure


individual'


perceptions


of stressors


that


may


influence


susceptibility


to physical


illne


SS.


The


Chroni


Tension


scale


measures


extent


to which


an individual


lives


life


a state


of constant


self-imposed


tension.


The


Social


Alienation


scale


measures


extent


to which


an individual


experiences


ability


to rely


on a social


support


system


score


on the


Somatic


Anxiety


scale


measures


extent


to which


an individual


may


be experiencing


concerns


or fears


about


their


physical


health.


These


scal


measure


individual'


experience


of chronic,


recent,


current


stress


(Millon,


et al., 1982)


HvYotheses


The


following


hypotheses


were


tested


at the


.05 level


of significance:


There


will


no difference


-between


symptomatic


volunteers


clinic


patients


on the


demographic


variables


age,


educational


level


, or income.


There


will


no difference


between


symptomatic


volunteers


and


clinic


patients


on the


basi


of gender









volunteers


clinic


patients


on the


basis


of marital


status.


There


will


no difference


between


symptomatic


volunteers


clinic


patients


on the


basi


of expressed


reason


treatment


mode


selection.


Ho5:


There


will


no difference


between


symptomatic


volunteers


clinic


patients


on the


basis


of level


depression,


as measured


Beck


Depression


Inventory.


Ho6:


There


will


no difference


between


symptomatic


volunteers


styles,


clinic


as measured


patients


Million


patterns


Behavioral


of coping


Health


Inventory.


There


will


no difference


between


symptomatic


volunteers


clinic


patients


perceptions


psychosocial


stress,


as measured


the


Million


Behavioral


Health


Inventory.


Analyses


Data


dependent


variable


this


study


was


mode


treatment-seeking


(i.e.,


through


a clinic


or through


ra a a n r n a A a a A a -


S1'


S
a a a


ra a a a vn)r


Irt-,rztr,\


Ill k r









expressed


depression


reason


choice


interval


data


treatment


as are


mode.


scores


Level


coping


styles


attitudes


towards


psychosocial


stressors.


Simple


frequencies


were


computed


on all


data


preliminary


comparison


of the


groups.


Nonparametric


statistical


procedures


(Chi


-square)


were


used


to test


hypotheses


and


which


are


categorical


demographic


data


and


expressed


reasons


treatment


mode


selection.


Hypothesis


, which


included


interval


level


data


age,


educational


level,


and


income,


was


tested


using


at


test


Chi-square


was


additionally


used


to test


differences


between


groups


patterns


response


distribution.


Hypothesis


was


similarly


tested


using


test


overall


level


of depression.


Further


analysis


data


included


a t


test


of the


individual


items


determine

specific


there


depressive


were


differences


symptoms


and


the


a Chi-square


intensity


analysis


total


score


distribution.


Discriminant


function


analyses


were


used


to test


Hypotheses


6 and


statistical


application


allowed


determination


of the


ability


to predict


group


membership


basis


differences


between


scores


on specified


variable


In addition,


at


test


was


used


to test


significant


differences


between


groups


on individual


. '-- -- a--- 'a- -L-


mt -


I-


__ A..


1


_


L-









rate


scores


perceptions


of psychosocial


stress


was


used


to determine


difference


between


groups


with


regard


to perceptions


of past,


chronic,


and


recent


stress.


significance


level


accepted


analyses


this


study


was


.05.


Limitations


Limitations


this


study


are


those


inherent


small


descriptive


study.


Concepts


such


as personality


characteristics


groups


are


difficult


to generalize


on the


basis


of a small


influenced


study. En

inability


during


representative


to control


sampling


subj ect


self-selection,


consequently


the


measurement


bias


intrinsic


to subject


self-selection.


In addition,


psychometric


instruments


were


used


this


study;


therefore,


measures


are


dependent


upon


reliable


patient


self-report.


Despite

important


these i

t first


nherent


step


difficulties,


this


investigation


study


of differences


between


symptomatic


volunteers


depressed


clinic


patients


on variables


related


to their


approach


to help-seeking


their


style


of relating


to health


care


givers.















CHAPTER 1
RESULTS


This


study


was


designed


to investigate


possible


differences


between


groups


individuals


who


seek


help


through


clinical


research


or through


traditional


outpatient


services.


Symptomatic


volunteers


an outpatient


antidepressant


medication


study


new,


symptomatic


patients


an outpatient


treatment


program


were


compared


a number of

demographic


reasons


variables.


characteristic


selection


variables

severity


of treatment


compared


were


of depression,


program,


stated


styles


interacting


with


health


care


givers


(coping


styles),


perceptions


of psychosocial


stre


SS.


The


goal


this


comparison


was


to attempt


identification


of characteristics


that


might


account


difference


help-seeking


approach.


Forty


respondents


to a recruitment


advertisement


antidepressant


medication


study


were


asked


the


researcher


during


a telephone


interview


to participate


study.


return


rate


the


symptomatic


volunteer


group


was


= 35).


From


among


35 respondents,


5 sets


of data


were


used


r Three


sets-a


of drta+


Wsrs*P


1J


1 ~nareisd


hsr'aneii









Depression


Inventory


score


10 and


other


sets


of data


were


included


because


they


arrived


after


the


data


collection


period


was


terminated.


final


usability


rate


symptomatic


volunteers


was


= 30)


of the


initial


respondents


to the


advertisement.


Relatedly,


of the


clinic


patients


asked


to participate


this


study


returned


completed


questionnaires,


13 of


them


could


be used.


Eleven


Beck


Depression


Inventory


scores


less


than


10 and


response


sets


were


returned


after


data


collection


was


completed.


Therefore,


final


usability


rate


of the


clinic


patient


group


was


= 30)


Chi-square


analysis


response


rate


showed


no significant


difference


between


groups


(Chi-square


.54,


.05).


Evaluation


of Hypotheses


hypotheses


were


evaluated


using


the


statistical


procedures


analyses


delineated


Chapter


III.


The


results



Hol


of these



: There


evaluations


will


are


as follows.


no difference


between


symptomatic


demographic


volunteers


variables


clinic


age,


patients


educational


on the


level,


or income.


0'rmr an 4. 4


,.I -IL~ a'*Y- aa-a -a-aa--- .0-a- -S' a 1


YL L I~~


C,,,


L,. u ..--%


ir


1


r


An ~









t-test


analysis


did


indicate


a significant


difference


between


groups


= -.40


, df = 58,


.05)


Frequency


data


within


groups


indicated


a fairly


well


matched


distribution;


see


Table


Table


Symptomatic


Age


Volunteers


Distributions of


Clinic


Patients


Symptomatic
Volunteers


Age


Clinic
Patients


Range


20-29
30-39
40-49
50-59
60-69
70+


Symptomatic


volunteers


reported


from


.e.


high


school


graduate)


to 20


years


of completed


education


= 14.6


, s.d.


while


clinic


patients


ranged


from


to 20


years


completed


education


= 13.4,


s.d.


Although


a trend


was


noted


clinic


patients


to have


ess


total


education


see


Table


no significant


difference


educational


level


between


groups


was


found


following


a t-test


analysis


= 1.52


df = 58,


.05)










Table


. Educational


Symptomatic


Experience


Volunteers


Distributions


Clini


Patients


Symptomatic Clinic
Volunteers Patients
# Years n n


<12 8 13
12<16 15 12
16+ 7 5


Reported


income


symptomatic


volunteers


ranged


from


$5,000

Clinic


to $50,00

patients


annually


reported


incomes


22,000,

ranging


s.d.

from


= $11,630)


4,000


$65,000


per


year


= $22


,300,


. = $18,


230)


The


respective


frequency


distributions


were


examined


because


differences


in within-group


variability


as indicated


standard


deviations


greater


number


of clinic


patients


lower


of the


income


range


see


Table


. No


significant


differences


income


were


found


between


groups


-.07


, df


= 40.5


.05)


Table


Symptomatic


. Income


Volunteers


stributions


Clinic


Patients


Symptomatic Clinic
Volunteers Patients
Income n n


<10
10-19
20-29


- $