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The social context of depression : How NPs can better address women's healthcare needs Keddie, Heather Apr 30, 2016

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THE SOCIAL CONTEXT OF DEPRESSION: HOW NURSE PRACTITIONERS CAN BETTER ADDRESS WOMEN’S HEALTHCARE NEEDS  By Heather D. Keddie, RN, BSN    CULMINATING PROJECT SUBMETTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF   MASTER OF NURSING-NURSE PRACTITIONER In THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES School of Nursing THE UNIVERSITY OF BRITISH COLUMBIA © Heather Dawn Keddie  THE SOCIAL CONTEXT OF DEPRESSION   2 Abstract  Women with social disadvantage often experience the most severe effects of depression and rely heavily on primary care for depression management. NPs, within the primary care sector, must know how to diagnose and treat depression and also recognize the root causes of depression that are influenced by social factors including disparities in the social determinants of health, adverse childhood events, and the experience of trauma and violence. Challenges to current depression management have significant economic and social costs to women, families, communities, and the health care system. Through the implementation of collaborative care practices, using trauma- and violence-informed principles to support and empower women, NPs are well positioned to be leaders in the management of depression care. As advocates at the clinical, community, and policy levels, NPs can address the root causes of depression, mitigating the long-term consequences related frequently to the experience of social inequities, trauma, and violence.  Keywords: Depression, Women, Social Disadvantage, Trauma and Violence, Collaborative Care, Nurse Practitioners   THE SOCIAL CONTEXT OF DEPRESSION   3 The social context of depression: How NPs can better address women’s healthcare needs Depression, according to the World Health Organization (WHO, 2008), is listed in the top three most prevalent, non-communicable diseases for high-income countries and is expected by 2030 to be the foremost leading cause of non-communicable burden of disease worldwide. Varying in its degree of severity, from extremely debilitating to the more mild and moderate types (McPherson & Armstrong, 2012), depression often lasts years with little to no relief. Worldwide prevalence continues to increase and currently the average rate of major depression diagnosis is approximately 3.2% of the population (McPherson & Armstrong, 2012). Although both men and women are affected, it has been found that women, within the general population, carry a 50% higher burden of disease from depression compared to their male counterparts in low-middle and high-income countries (WHO, 2008). In Canada and the United States (U.S.), females aged 12 to over 60 years, have consistently higher rates of depression compared to males (Centers for Disease Control and Prevention [CDC], 2012; Wong et al., 2014), with the highest prevalence being amongst women of child-bearing age (15-44yrs) (O’Connor et al., 2016; Wong et al., 2014). When this gender disparity intersects with social, economic, and environmental inequities (i.e. those who experience poverty, poor housing, lower education, interpersonal violence, racial and ethnic disparity), there is strong evidence to support that women with social disadvantage, even in high-income countries, are disproportionately affected by depression (Allen, Balfour, Bell, & Marmot, 2014; Devries et al., 2013; Douge, Lehman, & McCall-THE SOCIAL CONTEXT OF DEPRESSION   4 Hosenfeld, 2014; Langer et al., 2015; Plichta & Falik, 2001; Schwarz, McVeigh, Hoven, & Kerker, 2012).1 Primary care (PC) is frequently the first point of entry into the health care system for patients seeking help with mental health conditions (King et al., 2015; Wong et al., 2014).  U.S. Statistics show that once diagnosed with depression, over 57.3% of Americans continue to be seen and treated in the PC setting (CDC, 2010). This is consistent with research that shows most patients rely almost solely on primary care practitioners (PCPs) to help them manage their depression (Archer et al., 2012; Baik, Crabtree, & Gonzales, 2013; Curran, 2007; Kaltman, Pauk, & Alter, 2011; Lim, Jacobs, & Dewa, 2008). However, management of depression in the primary care setting is often inadequate (Archer et al., 2012; Baik et al., 2013; Barley, Murray, Walters, & Tylee, 2011; Donohue & Pincus, 2007; Gilbody, Bower, Fletcher, Richards, & Sutton, 2006; Kaltman et al., 2011; Nutting et al., 2008; Sighinolfi et al., 2014; Thota et al, 2012), lacking for example both appropriate recognition of depression and timely access to mental health resources (Biak et al, 2013; McPherson & Armstrong, 2012). As a result, poor depression management has significant social and economic consequences not only for women with social disadvantage, but also for their families, communities, and society as a whole.  Nurse practitioners (NPs), within the PC sector, must know how to diagnose and treat depression and must be prepared to recognize the root causes of depression that can be both biologically based and influenced by social factors. Examples of social factors include the many social determinants of health (SDOH) and women’s experiences that may stem from trauma and violence. Thus, the purpose of this article is threefold. First, it will examine current depression                                            1 [‘Social disadvantage’ is used throughout this article and refers to women who are affected by structural conditions, such as poverty, poor housing, and racial or ethnic disparity that expose them to disproportionate levels of suffering (Browne et al., 2012)]. THE SOCIAL CONTEXT OF DEPRESSION   5 management strategies including the significant costs of depression and challenges related to depression care. Second, it will briefly discuss how specific social forces, such as poverty, gender inequity, adverse childhood experiences, and trauma and violence intersect with the development of depression in women. Finally, it will highlight how NPs are well positioned to be leaders in collaborative care practices, using trauma- and violence-informed principles to effectively manage depression, empower women, and thus work to create social and economic change within healthcare and the wider social systems. Although the focus of this article will be predominately on depression, NPs ought to be aware that anxiety and post-traumatic stress disorder (PTSD) states are often co-morbid with depression and are affected by the same social and economic factors that will be discussed.   Depression management in primary care Costs of Depression Due to the high prevalence of depression, the economic burden in both Canadian and American society is significant. Healthcare utilization and lost workplace productivity are discussed throughout the literature as two of the greatest economic burdens of depression (Canadian Task Force, 2013; Donohue & Pincus, 2007; Gagne, Vasiliadis, & Preville, 2014; Jacob et al., 2012). The U.S. Preventive Services Task Force (USPSTF) estimated that the economic burden of medical costs associated with depression in 2009 were upwards of $22.8 billion, most of which is accounted for by prescriptions (52.8%) and visits to PC (35.8%) with another $23 billion in lost workplace productivity (O’Connor et al., 2016). Interestingly, however, while healthcare utilization has been reported to be up to 1.5 times higher for those with depression compared to those without (Wong et al., 2014), most PC costs for patients are THE SOCIAL CONTEXT OF DEPRESSION   6 not actually related to depression treatment but rather to overall increased healthcare concerns often related to comorbid illness (Donohue & Pincus, 2007) such as diabetes and cardiac disease. Furthermore, the above estimates only account for the economic burdens experienced by ‘systems’ in society and overlooks the many indirect costs that are more difficult to measure in the lives of individual women and families. For example, poor mental health in mothers increases the likelihood of ill-mental health in children by five-fold (Allen et al., 2014). Studies have shown that infants whose mothers are depressed in the pre- and post-natal period often experience lower birth-weights and poor attachment with higher levels of neglect in early childhood (Allen et al., 2014; Langer et al., 2015; WHO, 2012). This subsequently increases a child’s risk for long-term adverse health outcomes and even the development of ill-mental health as they grow (Bell, Donkin, & Marmot, 2013; WHO, 2012).  Women play key roles in both intergenerational and societal health. In an attempt to measure the invaluable work that women do outside of the workplace, the U.S. American Association of Retired Persons published a study that estimated the unpaid economic value of family caregivers (largely women) to be approximately $450 billion in 2009 (Feinberg, Reinhard, Houser, & Choula, 2011). This does not include ‘normal’ parental care of children but rather the extra familial and community caregiving that occurs for the elderly and those with disability. Although this caregiving can be part of the burden that leads to burnout and depression for women (Feinberg et al., 2011), it is important that the value women add to the home and societal health – both economically and ethically – be recognized (Langer et al., 2015) when considering the indirect costs of depression. Therefore, effective depression management must be a focus in our primary care system, not only to decrease healthcare utilization and THE SOCIAL CONTEXT OF DEPRESSION   7 improve workplace productivity but more importantly to support the development of healthier women, which impacts the health of families, communities, and societal well-being. Current approaches to depression management Current depression management takes a biomedical approach in that antidepressant medications dominate treatment (Archer et al., 2012; Barley et al., 2011; McPherson & Armstrong, 2012). Many patients never actually meet DSM-IV/V criteria for major depression or other depressive disorders (Mojtabai, 2013), however, once given a depression diagnosis by a medical practitioner (even without meeting DSM criteria) 74-85% of patients are prescribed antidepressant medications (Mojtabai, 2013; O’Connor et al., 2016; Wong et al., 2014). Although medications are a first line treatment of depression, there is good evidence to support that this treatment combined with psychotherapy is more effective at improving time to remission (Busch & Sandberg, 2012). Despite the rise in treatment of depression with antidepressant medications over the past two decades, research shows that up to 60% of patients still remain undiagnosed (Pottie et al., 2011). The USPSTF states that although most patients eventually get treatment, many wait an average of 4 years from onset of initial symptoms (O’Connor et al., 2016; Wang et al., 2005), missing the optimal window for recovery and increasing the chance of future relapse.  Challenges to depression management  Challenges to diagnosing and managing depression in primary care are multifactorial and involve both provider and patient-related barriers including: lack of recognition (Barley et al, 2011; McPherson & Armstrong, 2012), lack of time with PCPs (McPherson & Armstrong, 2012), lack of specialized mental health resources (Baik et al., 2013; Barley et al., 2011; THE SOCIAL CONTEXT OF DEPRESSION   8 Donohue & Pincus, 2007; McPherson & Armstrong, 2012), lack of funding or reimbursement for specialized services (Baik et al., 2013; Barley et al., 2011; Donohue & Pincus, 2007; McPherson & Armstrong, 2012; Nutting et al., 2008), and a high prevalence of stigma associated with a depression diagnosis (Barley et al., 2011; Canadian Task Force, 2013; McPherson & Armstrong, 2012; Thota et al., 2012). Consequently, treatment for depression in PC is often inadequate (Archer et al., 2012; Baik et al., 2013; Barley et al., 2011; Donohue & Pincus, 2007; Gilbody et al., 2006; Kaltman et al., 2011; Nutting et al., 2008; Sighinolfi et al., 2014; Thota et al, 2012). Nevertheless, even when treatments are available, research has questioned why ‘desired’ outcomes are not always observed (Baik et al., 2013).  In part, the challenges related to depression management are shaped by a vast array of interactions between biological (i.e. serotonin levels and genetics), social, economic, political, and cultural forces (WHO, 2004) inherent to a woman’s life. These conditions influence the likelihood of achieving remission and sustaining recovery after a depressive episode. For example, if serotonin levels are low, medications are likely to be effective. However if serotonin levels are low and stress from financial, food, and housing insecurities are high, medications alone are unlikely to be effective. Medications may assist the woman in taking necessary steps to acquire secure food and shelter, but more attention is needed to the root problem that caused the financial insecurity. Over the past several decades the social forces underlying the development of depression and other chronic diseases tend to be pushed to the background as medicine concentrates its efforts on ‘scientific’ discovery and curative approaches to disease states (Farmer, Nizeye, Stulac, & Keshaviee, 2006). Although the importance of biomedical advances are not to be minimized, Farmer and colleagues highlight the significant role that social, economic, and environmental forces play in not only the development of illness but also the effectiveness of and THE SOCIAL CONTEXT OF DEPRESSION   9 adherence to management plans. Therefore without attention to the inequitable social, economic, and environmental conditions that place woman at risk for developing depression, remission is difficult to achieve and unlikely to be sustained.  How social context influences depression among women Poverty Inequities in the SDOH are often foundational to women’s health concerns and health disparities (Archibald & Fraser, 2013). Mental illness is closely related to poverty and the conditions that accompany it such as low education levels, high unemployment, and unstable housing (WHO, 2012). Poverty also limits accessibility to needed healthcare resources. For example, the cost of evidenced-based psychotherapy is far above what those in poverty can afford (McPherson & Armstrong, 2012) and are not generally covered by basic medical plans or workplace benefits. Similarly, pharmacological options to treat depression or other health concerns are restricted for women with social disadvantage to only those fully covered by Medicaid (U.S.) or provincial medical service plans (Canada). In Canada for example, not all medications are fully covered limiting a woman’s choice in treatment options, while those with affluence can choose the medications most suited to their needs or preferences. While poverty places women at a higher risk for depression, depression itself increases the likelihood that women will experience and remain in poverty (Lund et al., 2011; WHO, 2012). Gender roles & inequality Poverty and gender inequity are also well recognized for their synergistic effects (Langer et al., 2015). Although more women than ever are employed in the workforce, salaries are generally not equitable to men and jobs are often less secure (Langer et al., 2015). Single THE SOCIAL CONTEXT OF DEPRESSION   10 mothers, for example, often have to work two jobs to make ends meet and poverty reduces their means to efficient travel, access to nutritious food, and residence in safe housing. According to the National Center for Health Statistics (2012), the prevalence of depression for those living below poverty levels in 2010 in the U.S. was 5 times higher than those in affluent populations (income >400 % of poverty level). Additionally, women are often expected to maintain traditional domestic responsibilities while working full time hours (Langer et al., 2015; WHO, 2012), which adds to high levels of stress and burnout that contribute to depression and other physical illness. Indeed, women in the lowest income bracket in the U.S. (<$25,000 per year) often work an extra 20hrs per week in caregiving roles and spend more than 20% of their full time salary on caregiving expenses (Feinberg et al., 2011). These socially defined gender roles expose women to significant stressors that, when combined with histories of adverse childhood events and current or previous interpersonal violence, result in greater prevalence of depression and anxiety (Leach, Christensen, Mackinnon, Windsor, & Butterworth, 2008; WHO, 2012). Adverse childhood events Adverse childhood events (ACEs) are another social factor that contribute to the development of depression by women (Leach et al., 2008). Forms of ACEs include exposure to domestic violence [including interpersonal violence (IPV)], verbal and physical abuse, parental substance abuse, and neglect (Chapman et al., 2004; Ponic, Varcoe, & Smutylo, 2015). Several studies have demonstrated that women who have experienced ACEs have a higher occurrence of depressive symptoms across their lifetime compared to those without exposure to ACEs and when multiple ACEs occur, depressive symptoms rise (Chapman et al., 2004; Fogarty, Fredman, Heeren, & Liebschutz, 2008). Further, there is growing evidence that the relationship between childhood abuse and adult depression in women also has strong links to PTSD and the THE SOCIAL CONTEXT OF DEPRESSION   11 development of chronic pain conditions, thus underscoring the significance of timely recognition and management of ACEs to minimize long-term negative health consequences (Wuest et al., 2010). Managing depression in the primary care setting therefore requires NPs to be aware of the significance of inequities in the SDOH, the cumulative effect of ACEs on women’s health, and the long-term effects that trauma and violence have on ones’ ability to participate in what are often agentic (individualistic) versus structural (systemic or social) (Rice, 2011) approaches to depression care. The links between trauma, violence, and depression  In order to appreciate the impact of trauma and violence on women’s health, NPs must first understand how trauma and violence are defined. Trauma is the response an individual has to the experience of a significant negative event (acute trauma) or a repetitive set of circumstances (complex trauma) that is overwhelming to the psyche and has long-lasting detrimental effects on ones social, psychological, and physical well-being (Ponic & et al., 2015; Substance Abuse and Mental Health Services Administration [SAMHSA], 2014; Williams, 2006). The experience of trauma is subjective and what causes trauma to one person may not be traumatic for another (Green et al., 2015; Williams, 2006). Violence, often the cause of traumatic experiences, can be interpersonal (i.e. emotional, sexual, physical abuse) or structural (i.e. poverty, lack of access to healthcare, social exclusion, war) (Browne, Varcoe, Ford-Gilboe, & Wathen, 2015) and is defined as anything that causes harm or injury to an individual or community (Browne et al., 2012; Farmer et al., 2006). Although both interpersonal and structural violence play a role in the development of depression, the inequities in structural conditions experienced by women with social disadvantage, subsequently increase an individuals’ chance of experiencing interpersonal violence (Browne et al, 2012; Browne et al, 2015). For example, THE SOCIAL CONTEXT OF DEPRESSION   12 urbanization has led to increased fragmentation in neighbourhoods and communities that reduces social cohesion and increases the chance and ability for IPV to occur (Langer et al., 2015).  Individuals who are exposed to trauma experience neurobiological changes resulting in alterations in the way the brain and the nervous system process emotions and subsequent life events (Anda et al., 2006). Although these neurobiological changes are temporary, when left unmanaged the brain may become more permanently altered and dysfunctional coping mechanisms, such as substance use, disordered eating, and others often follow (Chapman et al., 2004; Gutierres & Van Puymbroexk, 2006; Ponic et al., 2015). While both adults and children experience alterations in neurobiological processing, the damage from trauma and violence in children can be devastating to their psychosocial development (Ponic et al., 2015; Williams, 2006). Additionally, major depression in adolescent girls heightens the risk for alcohol or substance use, which, if started in adolescence, is more likely to become a patterned behavior, subsequently increasing risk for IPV (Kaltman et al., 2011; Langer et al., 2015). Considering the extensive harm that trauma and violence have on women, engagement with nurse practitioners about healthcare needs is influenced by the ability to develop rapport and trust in the relationship (Green et al, 2015). Therefore, how NPs interact, collaborate with, and support women who have and continue to experience trauma and violence is of utmost importance in avoiding any further harm being inflicted on the individuals through healthcare providers.  Collaborative care using a TVIC approach: What NPs need to know Relationships are the key to effective depression management and women who experience trauma and violence require a team of professionals who can support their many complex needs. As primary care is sometimes the only entry to the healthcare system for women THE SOCIAL CONTEXT OF DEPRESSION   13 affected by structural inequities (i.e. immigrants, low-income populations) (Kaltman et al., 2011), a multi-systems approach needs to be coordinated within the primary care setting. Collaborative care is one approach to depression management that has shown, through multiple systematic reviews, evidence of better adherence to management plans and improved remission and recovery rates, while being cost-effective for primary care settings (Gilbody et al., 2006; Jacob et al., 2012; Sighinolfi et al., 2014; Thota et al., 2012). Key participants in collaborative care models include the PCP who oversees care; a case manager who supports both the patient and the PCP through facilitating communication about patient care needs and who provide patient education, follow-up, and monitor adherence; and a mental health specialist (i.e. psychiatrist or psychotherapist) that the PCP can consult with and refer to on an as needed basis (Kaltman et al., 2011; Thota et al., 2012). Intersectoral collaboration: NP considerations Although there are few studies that evaluate the collaborative care model in populations with social disadvantage, a 2011 study by Kaltman and colleagues used the principles of collaborative care effectively to address the depression management needs of low-income immigrants. Important adaptations were necessary however due to the prevalence of trauma and violence in the immigrant population including: the addition of a family support worker to address social service needs such as food, clothing, shelter, and employment; and inclusion, management, and monitoring of common co-morbid conditions such as anxiety, PTSD, and panic disorder prevalent in trauma survivors (Kaltman et al., 2011). Similarly, working with women who experience social disadvantage often involves complex social and psychological needs that NPs on their own are not equipped to address. Although some access to psychotherapists is part of regular collaborative care models, therapists with extensive training in THE SOCIAL CONTEXT OF DEPRESSION   14 trauma treatment are vital in these settings (Kaltman et al., 2011). Thus, intersectoral collaboration is a crucial element of the management team. Implementation of collaborative care models allow for the development of relationships and continuity of care that are essential for effective depression management.  A TVIC approach: Strengthening the NP-patient relationship Trauma- and violence-informed care (TVIC) is a specific approach to the provider-patient interaction that is relational (Ponic et al., 2015) and that acknowledges the multifactorial effects and connections between interpersonal and structural violence (Browne et al, 2015). Used in a collaborative care model, services and programs offered from a trauma- and violence-informed approach help to limit harm from healthcare interactions and support healing and recovery (Ponic et al., 2015). TVIC assists practitioners to recognize that the context of ones life is central to the development and management of depression. TVIC also encourages NPs to approach all patient-provider interactions with the assumption that every individual has experienced trauma and violence in some way (Ponic et al., 2015). This approach thereby creates an environment that is safe, non-judgmental, and trusting and which also avoids the dynamics of power that are too often present in the health care encounter (Browne et al., 2015). Additionally, TVIC appreciates how the current and persistent effects of trauma and violence for women who experience social disadvantage affects adequate treatment and sustained achievement of recovery (Browne et al., 2012). Further, a TVIC approach minimizes the likelihood of PCPs intentionally, or inadvertently, suggesting that the problem of depression resides solely with the individual (Browne et al., 2015). This is because NPs (and other PCPs) who practice from a TVIC approach recognize the structural conditions that contribute to and sustain the multiple and far-reaching effects of health inequities. THE SOCIAL CONTEXT OF DEPRESSION   15 NP Practice Recommendations  As leaders in primary care NPs must be advocates for change in how depression care is currently managed if the lives and health of women who experience depression, and are affected by social disadvantage, are to improve. The following practice recommendations are offered in order to assist NPs in their efforts to empower women, cultivating capacity and resilience, by addressing the social and structural conditions that impede attainment of optimal health and well-being.  First, NPs must reflect upon their own personal biases and assumptions about what they believe are the causes of depression and disadvantage in women. In line with the findings from Browne and colleagues, in order to work effectively with women who experience social disadvantage NPs must be aware of any misconceptions or preconceived judgments they hold that may affect their ability to be open and accepting of patients and their circumstances (Browne, Doane, Reimer, MacLeod, & McLellan, 2010). For example, if an NP believes that poverty is purely related to an individuals’ choices, they risk inciting further harm on the patient by locating ‘the problem’ within the individual (Browne et al., 2010; Browne et al., 2015), thereby holding them solely responsible for ‘fixing’ conditions that may be well outside of their control. Through the practice of critical reflection on ones own values and often deeply held beliefs, NPs are more able to respond to the needs of the women they encounter without bias and judgment, thus enabling better relationships and support.  Second, NPs need to intentionally seek training in trauma and violence informed care (TVIC) approaches as part of their annual continued education hours and advocate for training of all employees in their practice setting. TVIC training focuses on the root cause of depression THE SOCIAL CONTEXT OF DEPRESSION   16 through the assumption that something has happened to the person rather than assuming something is wrong with them (Harris & Fallot, 2001; Ponic et al., 2015). It also supports the development of effective communication skills, teaching how to avoid ‘triggering’ language and thus re-traumatization that so often occur in healthcare interactions beginning with front-desk staff to PCPs (Green et al., 2015). Further, training programs help practitioners to connect the links between the experience of violence and the negative effects on both mental (i.e. depression) and physical health outcomes (Browne et al., 2015). This connection promotes an integrated bio-psychosocial approach to depression management, improving adequacy of care. Through being knowledgeable in trauma- and violence-informed approaches, NPs can foster an environment of compassion, safety, and healing from the first interaction, making women more likely to seek and access necessary care in a timely manner. Third, through the creation of strong and trusting relationships with patients NPs can empower women by focusing on strengths and capacities rather than specific symptoms of depression or negative coping mechanisms. Although negative coping mechanisms (i.e. substance use) require some attention, these all too often become central to the NP-patient interaction, with little regard for the patients identified needs. Allowing women to identify and prioritize their needs, thus taking the lead in their own healthcare decisions, gives them a ‘voice’ that, as victims of trauma and violence, is too often silenced (Harris & Fallot, 2001).  Fourth, NPs have a strong presence in work with populations who experience social disadvantage and therefore are well positioned to be leaders and advocates for the implementation of collaborative care practice within the primary care setting. Recognizing the many complex needs of those with disadvantage, NPs are adept at coordinating care. Also, the structure of NP practice, being often salaried (particularly in Canada) instead of fee-for-service, THE SOCIAL CONTEXT OF DEPRESSION   17 allows the necessary component of time with patients that many General Practitioners lack due to high patient loads and expected delivery outcomes, a current barrier to effective depression care management (McPherson & Armstrong, 2012). Within a collaborative care team, depression management can be tailored to specific patient needs and creativity can be used to find out what works best for a patient rather than simply following routine policies or procedures (Harris & Fallot, 2001). Finally, NPs must be aware of and advocate against the dominant socio-political climate within Canada and the U.S. that influences healthcare reform, often favouring individualistic responsibility for illness rather than acknowledging the structural conditions that contribute to poor mental health. Through taking an active role in the communities that NPs live and work, by attending social housing forums and community-planning meetings for example, NPs can be the voice that advocates for better housing and safer communities for women who experience poverty. Further, seeking positions on social and political committees that are involved in the development of public policies NPs can inform policy making in ways that call for gender equality and better support for survivors of trauma and violence.  Conclusion Nursing, as a profession, aims to be socially responsive and is recognized for its history in providing contextualized care (Archibald & Fraser, 2013). Although depression management requires strong biomedical and pharmacological expertise, NPs must also be well informed of the social, economic, and environmental inequities that create and sustain disadvantage, leading to increased prevalence of depression in women. Through recognizing that structural conditions are modifiable and that addressing them is imperative for effective and meaningful recovery from THE SOCIAL CONTEXT OF DEPRESSION   18 depression (Farmer et al., 2006), NPs can play a pivotal role in the creation of equitable, safe, and inclusive health care systems and societies. Thus effectively improving depression management in not just women with social disadvantage, but all women and men who suffer from depression and other mental health conditions.   THE SOCIAL CONTEXT OF DEPRESSION   19 References Allen, J., Balfour, R., Bell, R., & Marmot, M. (2014). Social determinants of mental health. International Review of Psychiatry, 26(4), 392-407. doi:10.3109/09540261.2014.928270  Anda, R.F., Felitti, V.J., Bremner, J.D., Walker, J.D., Whitfield, C., Perry, B.D., Dube, S.R., Giles, W.H. (2006). The enduring effects of abuse and related adverse experiences in childhood. 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