Rural perspectives challenging pharmacotherapy

Abstract

Depression pharmacotherapy is the predominant treatment available in the rural U.S., yet little is known about the broader contextual factors that rural consumers and providers identify as shaping pharmacotherapy use. Thematic analysis was employed to identify emergent themes from interviews and focus groups about pharmacotherapy adherence, effectiveness, and treatment decisions conducted with Appalachian Kentucky women with depression (N=37) and diverse healthcare providers who care for this population (N=21). Pharmacotherapy was seen as inadequate to treat depression in the context of extensive socioeconomic burdens and other health comorbidities. Participants felt that providers over-prescribed pharmacotherapy, a pattern attributed to deficiencies in the rural healthcare system overall. Efforts to improve treatment engagement must acknowledge the significant doubts that rural consumers hold about the potential of pharmacotherapy and should consider the utility of extending broader strategies to address the social conditions shaping vulnerability to depression.

Introduction

Though studies analyzing large national data sets find that rural residents experience depression at similar rates as the general U.S. population,^{1, 2} studies estimating the prevalence of depression among rural women in smaller primary care-based samples find significantly higher levels of depression, ranging from 33–44%,^3–6 and higher rates of suicide.⁷ Compared to urban residents, residents of the most rural areas receive less mental health treatment.⁸ The depression treatment rural residents do receive is more likely to be pharmacotherapy than psychotherapy,⁹ disproportionately received from primary care providers due to mental health provider shortages in rural areas.^{10, 11} Even when rural residents access guideline concordant care, it is not shown to have the same effectiveness as for urban populations.¹² Though pharmacotherapy remains the predominant option for rural residents with significant need, little is known about their perceptions of this treatment form.

Broadly, research shows that patients prefer psychotherapy to pharmacotherapy, expressing doubt in pharmacotherapy’s adequacy and distrust of its side effects.^{13, 14} The perceived stigma of using depression medication has been shown to lower adherence to clinician recommendations.^{15, 16} Consistent with such an approach, recommendations and interventions to improve adherence to pharmacotherapy have focused on changing consumers’ attitudes about medication, combatting stigma, and improving practitioner communication.^{17, 18}

In contrast to this focus on individual decisions about pharmacotherapy consumption, recent anthropology and sociology research has explored how consumers’ perceptions of pharmacotherapy interact with broader factors shaping their lived experience of pharmaceuticals, including healthcare availability, social conditions, and health needs. These studies raise questions about how consumption of psychiatric medication impacts patients’ sense of themselves, and further, how local experiences of pharmaceutical consumption interact with broader social, cultural, and economic processes.^{19, 20} Attention to the context of decision-making holds great relevance for better understanding the broad factors shaping pharmacotherapy use, and therefore, for pointing toward novel, culturally appropriate strategies to improve treatment access.

Guided by this framework, this study examines emergent themes about pharmaceutical use that arose during semi-structured interviews and focus groups in rural Appalachian Kentucky among women with depression and diverse health professionals who provide care to them. All participants lived in southeastern Kentucky, a subregion with a high prevalence of depression and mental health provider shortages where most counties are classified as economically distressed.²¹ Thematic analysis focused on broader social factors shaping pharmacotherapy use, the specific barriers and problems consistently reported by pharmacotherapy consumers, and treatment preferences.

Methods

The data presented in this paper were collected during multi-phase research from 2014–2016 to identify the social-cultural factors shaping treatment-seeking among rural Appalachian women with depression, with the goal of informing culturally appropriate, feasible treatment options. All phases have been approved by the University of Kentucky Institutional Review Board and have been conducted in collaboration with the Center of Excellence in Rural Health (CERH) and community health workers (CHWs) at Kentucky Homeplace, both located in Appalachian Kentucky. The thematic analysis presented here concentrates on themes about the cultural meanings of pharmacological treatment that emerged throughout the study’s phases.

From 2014–2016, community-based researchers at CERH recruited consumers and health professionals through purposive sampling, employing community-engaged relationships to identify vulnerable rural women who may not identify as depressed through CHWs and regional clinics. All consumers were screened for depression with the CES-D but were not required to be in treatment or be formally diagnosed as depressed. Healthcare professionals from a variety of backgrounds were purposively sampled in order to capture perspectives of those caring for women with depression who sought treatment and those who did not. The backgrounds of all study participants is described in Table 1. Research coordinators described study procedures and obtained informed consent. Semi-structured interviews (37 with consumers, 21 with providers) and focus groups (2 with consumers, 2 with providers) were conducted with Appalachian women with depression (N=37) and healthcare professionals (N=21). (Of the healthcare professionals, 9 were interviewed in both phases and 3 in only one phase.) The senior author conducted interviews of 30 minutes to 1.5 hours in locations most feasible for participants. Though interview guides varied by study phase, all interviews encompassed discussion of the lived experience of depression among rural women, access and barriers to treatment, and strategies to improve care. Pharmacotherapy was discussed in 73% of the interviews. Demographic information about participants was collected in questionnaires and interviews were recorded and transcribed.

Table 1:

Participant Demographics

I. Consumers (N=37)
	N	SD
Age	41.38	12.42
Years lived in Appalachia	32.90	15.66
Number of people in household	2.87	1.37
Years of education completed	13.70	2.38
	N	%
Currently in treatment for depression	17	46
Female	37	100
Race1  White (not Hispanic)	36	97
Black	1	3
Marital status  Married/partnered	22	59
Divorced	7	19
Widowed	1	3
Never married	7	19
Currently employed	24	65
Household income  <$10,000	7	19
$10,000–20,000	11	30
$20,000–30,000	8	22
$30,000–40,000	4	10
$40,000 and above	7	19
Insurance coverage  Private insurance	8	22
Company insurance	11	30
Medicaid	6	16
Medicare	10	27
Veterans’ insurance	1	3
No insurance	2	5
Providers (N=21)
	N	SD
Age	43.85	9.18
Years lived in Appalachia	34.71	16.56
Years worked with consumer population	12.97	9.33
	N	%
Gender  Female	17	81
Male	4	19
Race  White (not Hispanic)	20	95
Black	1	5
Job title  Community health worker	11
Social worker, counselor (LCSW, LPCC)	5
Healthcare administration (RN)	2
Psychologist	1
Primary Care Provider (MD, NP)	2
Location of practice  Community outreach center	11
Public clinic	5
Community Mental Health Center	2
Administration	2
Hospital	1

Note: “Insurance coverage” allowed more than one count.

¹Participant racial backgrounds reflect the demographics of Appalachian Kentucky, which is a predominantly non-Hispanic White population: 96.8% of central Appalachian residents describe themselves as White, 2.2% Black or African American, and only 0.5% Hispanic.

Analysis was guided by thematic analysis, a systematic approach to understanding themes across a qualitative dataset.²² In preliminary analysis, all content about experiences of and attitudes toward pharmacotherapy was coded. Within these coded segments, open coding was employed to identify primary themes about pharmacotherapy use. Preliminary definitions for the codes were constructed and applied line by line to the transcripts. In independent memo writing during the coding processes and weekly meetings, the code definitions were refined and codes were compared across participants. Finally, a model was built to elaborate the relationships between themes.

Results

Participants endorsed two broad themes. First, participants agreed that pharmacotherapy, the predominant treatment option for women with depression in the region, was inadequate to single-handedly promote recovery in a context with high needs. Second, participants reflected on how over-reliance on pharmacotherapy in Appalachian Kentucky revealed deficiencies in the rural mental health system.

Consumers and providers voiced doubts about the adequacy of pharmacotherapy to treat depression in a region where complex social conditions and high prevalence of multiple morbidities intensify symptoms of depression. In particular, they cited the frequency of competing comorbidities that patients managed, the challenge of supporting one’s family in an economically depressed region, and the stigma of the region’s substance abuse epidemic. Some providers, particularly CHWs, noted in general how pharmacotherapy obscured attention to broader social conditions they felt were at the root of depression in the region: “That pill is not going to fix that depression. It’s not going to make it go away. They need family support and a lot of people don’t have that.”

When faced with comorbidities and extensive social demands, consumers and providers indicated that taking psychiatric medication pushed the limits of how many diagnoses patients were willing to acknowledge and manage. One CHW commented that patients were reticent to mention their depression to providers because, “well if I say something else to the doctor, that’s going to be another pill that I’m going to have to take.” Consumers reported that obtaining pharmacological treatment constituted “a headache” of continued provider experimentation with little effect besides reduced time to meet their intensive job and family demands.

Many consumers contrasted the casual manner in which they felt pharmacotherapy was dispensed with their own perceptions of its severe impacts on their bodies and mental health. Specifically, they emphasized the risk that pharmacotherapy would lead to additional health problems—particularly, substance abuse. In a region with high rates of prescription drug abuse, one participant reported feeling that psychiatric pharmacotherapy would function as a gateway to abuse of illicit substances: “This can lead to this and this can lead to that and before you know it, you’re a full blown addict.” Others commented that pharmacotherapy itself constituted a risk unto itself: “I told [the doctor] I didn’t want to be on anything; that that would just make me another statistic.”

Secondly, participants felt that the predominance of pharmacotherapy demonstrated dysfunctions in the rural healthcare system. Providers and consumers critically portrayed pharmacotherapy as “pills” that were “pushed on” or “thrown at” patients in a context with limited treatment options and overburdened mental health providers. As a consumer described: “Somebody is [quick] to give them, ‘here, now take this Xanax real quick and you’ll be alright,’ because there’s nothing else here.” Some participants endorsed the importance of pharmacotherapy but expressed distaste for its overuse in their community. As one consumer remarked, “If you need medication, that’s fine as long as it’s monitored and you do it right. But there’s a lot of these being put on it that don’t need it.” Even women who had positive experiences with their providers portrayed them as the exception, linking pharmacotherapy to stereotypes of rural opiate over-prescription: “I’m very fortunate with my family doctor. He doesn’t just throw pills at me and I know that that’s a stigma around in eastern Kentucky and that there are all kinds of pain pill doctors.”

Furthermore, participants commented that provider reliance on pharmacotherapy represented negligence because it replaced meaningful discussion of patients’ experiences and needs. One consumer reported that when she told the doctor “I needed something for depression… They didn’t ask me what I was depressed about or anything. They didn’t ask any questions; they just wrote it out and that’s it… And they say, if this doesn’t work, we’ll get you on something else.” One nurse expressed frustration with provider promises—“I’ll give you a medication and this is going to make it better”—that she perceived as disingenuous in the absence of psychotherapy resources: “they never got the group meetings and the ability to voice things.”

Implications for Behavioral Health

In a rural region where pharmacotherapy constitutes the predominant form of treatment⁹ to stem a high prevalence of depression,²¹ this study sought to understand the broader social context shaping pharmaceutical use in order to illuminate the complex rationale of rural treatment decisions. Even as many cited the necessity of pharmacological treatment to alleviate rural depression, consumers and providers alike voiced deep ambivalence and frustration about pharmacotherapy as the sole treatment option to address the high prevalence of depression they felt arises from challenging social and economic conditions. This study’s Appalachian sample and focus on female consumers is not fully generalizable to all U.S. communities, yet the thematic analysis approach highlighted repeated themes that resonated across participants of diverse social locations in one community. A limitation of this study was the restricted number of primary care providers in the sample. Primary care physicians prescribe mental health pharmacotherapy far more often than specialists²³ and soliciting their corroboration of these themes is an important consideration for future research.

Much research on pharmacotherapy reports dichotomously positive or negative attitudes toward pharmacotherapy.^{13, 16} Instead, this study found variation in attitudes toward pharmacotherapy, along with agreement that pharmacotherapy was insufficient. Such commentary engaged the question of why pharmacotherapy is often the only treatment option in rural areas with extensive mental health provider shortages,²⁴ echoing broader sentiments in rural areas questioning whether rural healthcare is adequate²⁵ and whether rural residents are forgotten.²⁶ As efforts to expand the mental health workforce and telemedicine in rural areas have met continued obstacles,¹¹ there is a need to appraise other opportunities with the potential to build community capital to improve mental health, such as shifting more mental health care tasks to community health workers who live in rural communities, as has been shown to be a viable option in rural communities globally.²⁷ Participants hoped pharmacotherapy could fit within comprehensive healthcare and safety net services alongside quality, accessible psychotherapy. Further, participants illuminated the relative absence of psychotherapy resources, demonstrating that providing practices rarely align with guidelines to offer choices and education.²⁸

Study results draw attention to how, for many, pharmacotherapy is “just another” pharmaceutical, thereby associating pharmacotherapy with broader health regimens and other pharmaceutical stigmas. First, many participants questioned the urgency of depression compared to other competing comorbidities, suggesting that future research on depression and pharmacotherapy stigma interrogate the comparative weight of such stigma in the context of broader health issues. Second, with pharmacotherapy abuse^{21, 29} and prescription drug abuse constituting compelling health and social challenges within many rural American communities,³⁰ this study illuminates a deeper context to ideas about the addictive potential of pharmacotherapy shown in studies from other cultural groups.^{13, 31} Whether the valence is casual (as with comorbidities) or dangerous (as with substance abuse), consumers’ evaluations of pharmacotherapy within a broader pharmaceutical regime move closer to the complex calculations—of economics, overall health, and social conditions—that shape treatment engagement and adherence among mental health consumers, regardless of their backgrounds.^{19, 20}

Rural discontent has been described as a political issue,³² related to feelings about declining status and the poor mental health that follows.^{33, 34} This analysis illuminates how feelings of exclusion extend even to the experience of mental health treatment—resounding in the voices of consumers and providers demanding more equitable distribution of healthcare resources to address their distress alongside improving the social conditions that make them vulnerable to depression. In contrast to previous research on pharmacotherapy perceptions that recommend interventions that improve adherence,^{13, 17, 18} these findings support efforts to address the demand for more accessible psychotherapeutic options in rural areas³⁵ as well as interventions to improve the social determinants of mental health, such as through housing or income supplementation.³⁶ By improving the structures that create opportunities, upstream interventions can produce lasting, expansive results on promoting mental health.