The Effects of the COVID-19 Pandemic on the Mental Health of Healthcare Workers

Yıl 2023, Cilt: 8 Sayı: 2, 691 - 697, 21.06.2023

Elmas Merve Malas , Selma Arıkan

Öz

The COVID-19 disease, declared a pandemic due to its global impact, has affected the entire world. COVID-19, a respiratory virus, has caused the deaths of approximately 3.4 million people and can be transmitted from person to person. The rapid spread of the virus and the lack of a definitive treatment have necessitated strict measures during the pandemic. Many individuals have been physically and psychologically affected by the virus and the measures implemented to control its spread. Healthcare workers were the first witnesses to the psychosocial, economic, and physical losses that occurred during the pandemic and have been the most adversely affected by the process. Healthcare workers continue to experience the psychological effects of the pandemic both during and after the outbreak. Moreover, the difficulties experienced by healthcare workers in their workplaces, coupled with concerns about their families and societal challenges, further compound the situation. The increased workload and responsibilities towards both their families and patients have led to greater mental exhaustion during this period. Given the challenging nature of managing the mental health of healthcare professionals during the pandemic, this review aimed to assess the mental health issues experienced by healthcare workers from the perspectives of work, family, and society, with the goal of serving as a resource for future measures to be taken in similar situations.

Anahtar Kelimeler

COVID-19, healthcare workers, mental health, pandemic

COVID-19 Pandemisinin Sağlık Çalışanlarının Ruh Sağlığı Üzerine Etkileri

Öz

COVID-19 hastalığı tüm dünyayı etkisi altına almasıyla birlikte pandemi ilan edildi. Yaklaşık 3.4 milyon insanın ölümüne sebep olan COVID-19, solunum yolu ile insandan insana bulaşabilen bir virüstür. Virüsün hızlı şekilde yayılması ve kesin bir tedavinin olmaması pandemi döneminde sıkı önlemlerin alınmasına neden oldu. Pandemide birçok kişi virüsten ve alınan önlemler dolayı hem fiziksel hem de psikolojik olarak etkilendiler. Pandemide meydana gelen psikososyal, ekonomik ve fiziksel kayıplara ilk şahit olan sağlık çalışanları süreçten en olumsuz etkilenen kişiler oldular. Sağlık çalışanları salgının ruhsal etkilerini pandemi sırasında ve sonrasında yaşamaya devam etmektedirler. Ayrıca sağlık çalışanlarının bu dönemde iş yerindeki yaşadıkları sıkıntılara ailelerine dair endişeleri de ve toplumsal sıkıntılarda eklenmektedir. Sağlık çalışanlarının artan iş yükü ve hem ailelerine hem de hastalarına karşı sorumlulukları onları süreçte ruhsal olarak daha fazla tükenmelerine neden oldu. Pandemi döneminin sağlıkçılar açısından ruhsal olarak yönetilmesi zor bir dönem olması sebebiyle, bu derlemede sağlık çalışanlarının yaşadıkları ruh sağlığı problemlerinin iş, aile ve toplum açısından değerlendirerek gelecekte benzer durumlarda alınacak önlemler için kaynak olması amaçlandı.

Anahtar Kelimeler

COVID-19, sağlık çalışanları, ruh sağlığı, pandemi

Kaynakça

• Akcan FA, Onec K, Annakkaya A, Pehlivan M, Karaduman Z, Balbay Ö, Demircan Çakar N, Koku S, et al. Pandemi sürecinde Düzce Üniversitesi Hastanesi: Başhekimlik yönünden. Konuralp Tıp Dergisi. 2020;12(1):354- 357.
• Aslan R. Tarihten günümüze epidemiler, pandemiler ve Covid-19. Ayrıntı Dergisi. 2020;8(85):35-41.
• Lee AM, Wong JG, McAlonan GM, Cheung V, Cheung C, Sham PC, Chu CM, Wong PC, Tsang K, & Chua SE. Stress and psychological distress among SARS survivors 1 year after the outbreak. The Canadian Journal of Psychiatry. 2007;52(4), 233-240.
• Kisely S, Warren N, McMahon L, Dalais C, Henry I, Siskind D etal. Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis BMJ. 2020. 369 :m1642 DOI:10.1136/bmj.m1642.
• Güler S. Pandemi günlerinde geride kalanlar sendromu: Sağlık çalışanları üzerinde bir inceleme. OPUS–Uluslararası Toplum Araştırmaları Dergisi. 2021;17(Özel Sayı):3393-3416. DOI: 10.26466/opus.875781.
• Reardon S. Ebola's mental-health wounds linger in Africa: health-care workers struggle to help people who have been traumatized by the epidemic. Nature. 2015; 519(7541): 13-15.
• Aşkın R, Bozkurt Y, Zeybek Z. COVİD-19 pandemisi: Psikolojik etkileri ve terapötik müdahaleler. İstanbul Ticaret Üniversitesi Sosyal Bilimler Dergisi Covid-19 Sosyal Bilimler Özel Sayısı. 2020 Bahar (Özel Ek);37:304-318.
• Cullen W, Gulati G, Kelly BD. Mental health in the COVID-19 pandemic. An International Journal of Medicine. 2020;1-2. DOI:10.1093/qjmed/ hcaa11.
• Lancee WJ, Maunder RG, Goldbloom DS. Prevalence of psychiatric disorders among Toronto hospital workers one to two years after the SARS outbreak. Psychiatric Services. 2008;59(1):91-95.
• Gardner PJ, Moallef P. Psychological impact on SARS survivors: critical review of the English language literature. Can Psychol/Psychol Can. 2015;56(1):123–35.
• Lötsch F, Schnyder J, Goorhuis A, Grobusch MP. Neuropsychological long-term sequelae of Ebola virus disease survivors – a systematic review. Travel Med Infect Dis. 2017;18:18–23.
• Cabarkapa S, Nadjidai SE, Murgier J, Ng, CH. The psychological impact of COVID-19 and other viral epidemics on frontline healthcare workers and ways to address it: A rapid systematic review. Brain, Behavior, & Immunity - Health. 2020;8,1-10.
• Kaya, B. Pandeminin Ruh Sağlığına Etkileri, Klinik Psikiyatri Dergisi.
• Garcia R. Neurobiology of fear and specific phobias. Learning ve Memory. 2017;24(9):462-471. DOI:10.1101/lm.044115.116.
• Shigemura J, Ursano RJ, Morganstein J.C, Kurosawa M, Benedek DM. Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: Mental health consequences and target populations. Psychiatry and Clinical Neurosciences. 2020;74(4):281-282.
• Sakaoğlu HH, Orbatu D, Emiroglu M, Çakır Ö. Covid-19 salgını sırasında sağlık çalışanlarında spielberger durumluk ve sürekli kaygı düzeyi: Tepecik hastanesi örneği. Tepecik Eğitim ve Araştırma Hastanesi Dergisi. 2020(Ek sayı);30:1-9.
• Yumru M. COVID-19 ve sağlık çalışanlarında tükenmişlik. Klinik Psikiyatri. 2020 (Ek 1); 23:5-6. DOI: 10.5505/kpd.2020.18942.
• Güvenç R. ve Baltacı E. COVID-19 ve Sağlık çalışanlarının ruh sağlığı. COVID-19 Türk Tabipler Birliği altıncı ay değerlendirme raporu. Ankara; [Internet]. 2020. Available from: https://www.ttb.org.tr/kutuphane/ covid19-rapor_6/covid19-rapor_6_Part41.pdf.
• Öztürk MS, Yılmaz N, Demir Erbil D, Hazer O. Covid-19 pandemi döneminde hane halkındaki çatışma ve birlik-beraberlik durumunun incelenmesi. Turkish Studies. 2020;15(4):295-314.
• Çelik MY, Kiliç M. Family relationship of nurses in COVID-19 pandemic: A qualitative study. World J Clin Cases. 2022 Jul 6;10(19):6472-6482. DOI: 10.12998/wjcc.v10.i19.6472.
• Elbay RY, Kurtulmuş A, Arpacıoğlu S, & Karadere E. Depression, anxiety, stress levels of physicians and associated factors in Covid-19 pandemics. Psychiatry Research. 2020 290;113130.
• Kang L, Li Y, Hu S, Chen M, Yang C, Yang BX., Wang Y, Hu J, Lai J, Ma X, Chen J, Guan L, Wang G, Ma H, ve Liu Z. The Mental Health of Medical Workers in Wuhan, China Dealing with the 2019 Novel Coronavirus, Lancet Psychiatry. 2020 7(3), e14. DOI:10.1016/S2215- 0366(20)30047-X.
• Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during Covid-19 pandemic. The BMJ. 2020;368:3-4. DOI: https://doi.org/10.1136/bmj. m1211.
• Li W, Yang Y, Liu ZH, Zhao YJ, Zhang Q, Zhang L, Cheung T, Xiang YT. Progression of mental health services during the COVID-19 outbreak in China. International Journal of Biological Sciences. 2020;16(10):1732- 1738. DOI: 10.7150/ijbs.45120.
• Emiral E, Çevik ZA, Gülümser Ş. COVID-19 pandemisi ve intihar. ESTÜDAM Halk Sağlığı Dergisi. 2020;5:138-47.
• Tükel R. COVID-19 Pandemi Sürecinde Ruh Sağlığı, Türk Tabipler birliği, COVİD-19 Pandemisi Altıncı Ay Değerlendirme Raporu. Ankara, [Internet]. 2020. Available from: https://www.ttb.org.tr/kutuphane/ covid19-rapor_6/covid19-rapor_6_Part71.pdf.
• Havlioğlu S, Demir HA. Determining the anxiety levels of emergency service employees’ working during the COVID-19 pandemic. Harran Üniversitesi Tıp Fakültesi Dergisi. 2020;17(2):251-255.
• Zaka A, Shamloo SE, Fiorente P, Tafuri A. COVID-19 pandemic as a watershed moment: A call for systematic psychological health care for frontline medical staff. Journal of Health Psychology. 2020;25(7):883- 887. DOI:10.1177/1359105320925148.
• Ornell F, Schuch JB, Sordi AO, Kessler FHP. ‘“Pandemic fear”’ and COVID19: Mental health burden and strategies. Brazilian J Psychiatry. 2020;42(3):232–5.
• Bekaroğlu E, Yılmaz T, Yılmaz E. COVID-19 and psychological effects: A review in clinical psychology perspective. Nesne Psikol Derg. 2020;8(18):0–2.
• Shojaei SF, Masoumi R. The importance of mental health training for psychologists in COVID-19 outbreak. Middle East J Rehabil Heal Stud. 2020;7(2):1–2.
• Hiçdurmaz D, Üzar-özçetin YS. COVID-19 pandemisinde ön safta çalışan hemşirelerin ruhsal sağlığının korunması ve ruhsal travmanın önlenmesi. Hacettepe Üniversitesi Hemşirelik Fakültesi Dergisi. 2020 (Özel Sayı);7:1-7.
• Chong MY, Wang WC, Hsieh WC, Lee CY, Chiu NM, Yeh WC, Huang OL, et al. Psychological impact of severe acute respiratory syndromeon health workers in a tertiary hospital. The British Journal of Psychiatry. 2004;185:127–133.
• Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, Wu J, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Network Open. 2020;2(3).
• Liang M, Chen Q, Li Y, Guo J, Fei D, Wang L, et al. Mental health care for medical staff in China during the COVID-19 outbreak. 2020 January :19–21.
• Giuffrida A, Tondo L. 'As if a storm hit': more than 40 Italian health workers have died since crisis began. The Guardian. [Internet]. 2020 26 March. Available from: https://www.theguardian.com/world/2020/ mar/26/as-if-a-storm-hit-33-italian-health-workers-have-died-sincecrisis- began.
• Raudenská J, Steinerová V, Javůrková A, Urits I, Kaye AD, Viswanath O, Varrassi G. Occupational burnout syndrome and post-traumatic stress among healthcare professionals during the novel coronavirus disease 2019 (COVID-19) pandemic. Best Pract Res Clin Anaesthesiol. 2020 Sep ;34(3):553-560. DOI: 10.1016/j.bpa.2020.07.008.
• Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395:912-920.
• Flanagan EW, Beyl RA, Fearnbach SN, Altazan AD, Martin CK, Redman LM. The impact of COVID‐19 stay‐at‐home orders on health behaviors in adults. Obesity. 2021;29 (2):438-45.
• Ren X, Huang W, Pan H. et al. Mental health during the Covid-19 outbreak in China: a meta-analysis. Psychiatr Q. 2020;91:1033–1045.
• Ho CS, Chee CY, Ho RC. Mental health strategies to combat the psychological impact of covid-19 beyond paranoia and panic. Ann Acad Med Singapore. 2020;49(1):1-3.
• Lin CY. Social reaction toward the 2019 novel coronavirus (COVID-19). Social Health and Behavior. [Internet]. 2020;3(1): 1–2.
• Cassiani‐Miranda CA, Campo‐Arias A, Tirado‐Otálvaro AF, Botero‐ Tobón LA, Upegui‐Arango LD, Rodríguez‐Verdugo MS, Botero‐Tobón ME., et al. Stigmatisation associated with COVID‐19 in the general Colombian population. International Journal of Social Psychiatry. 2020; Advance online publication. DOI:10.1177/0020764020972445.
• Özdin S, Bayrak Özdin Ş. Levels and predictors of anxiety, depression and health anxiety during COVID-19 pandemic in Turkish society: The importance of gender. International Journal of Social Psychiatry. 2020;66 (5):504-11.
• Duan L, Zhu G. Psychological interventions for people affected by the COVID-19 epidemic. Lancet Psychiatry. 2020;7(4):300–302.
• Haider II, Tiwana F, Tahir SM. Impact of the COVID-19 pandemic on adult mental health. Pakistan Journal of Medical Sciences. 2020;36:90.
• Rubin GJ, Harper S, Williams PD, Öström S, Bredbere S, Amlôt R, Greenberg N. How to support staff deploying on overseas humanitarian work: a qualitative analysis of responder views about the 2014/15 West African Ebola outbreak. European Journal of Psychotraumatology. 2016;7(1): 30933.
• Wu P, Fang Y, Guan Z, et al. The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk. The Canadian Journal of Psychiatry. 2009;54(5):302-311. DOI:10.1177/070674370905400504.
• Liu X, Kakade M, Fuller CJ, Fan B, Fang Y, Kong J, Guan Z, Wu P. Depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic. Compr Psychiatry. 2012 Jan;53(1):15-23. DOI: 10.1016/j.comppsych.
• Su TP, Lien TC, Yang CY, Su YL, Wang JH, Tsai SL, Yin JC. Prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured sars caring unit during outbreak: A prospective and periodic assessment study in taiwan. J Psychiatr Res. 2007;41(1-2):119-130.
• McAlonan GM, Lee AM, Cheung V, Cheung C, Tsang KW, Sham PC, Chua SE, Wong JG. Immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers. Can J Psychiatry. 2007 Apr;52(4):241-7. DOI: 10.1177/070674370705200406.
• Mosheva M, Hertz-Palmor N, Dorman Ilan S, Matalon N, Pessach IM, Afek A, Ziv A, Kreiss Y, Gross R, Gothelf D. Anxiety, pandemic-related stress and resilience among physicians during the COVID-19 pandemic. Depress Anxiety. 2020 Oct ;37(10):965-971. DOI: 10.1002/da.23085.
• Salari N, Hosseinian-Far A, Jalali R, Vaisi-Raygani A, Rasoulpoor S, Mohammadi M, Rasoulpoor S, et al. Prevalence of stress, anxiety, depression among the general population during the covid-19 pandemic: A systematic review and meta-analysis. Global Health. 2020;16(1):57.
• Akman Ö, Yıldırım D. Sarıkaya A. The effect of COVID-19 pandemic on nursing students’ anxiety levels. İstanbul Gelişim Üniversitesi Sağlık Bilimleri Dergisi. 2020;(12):379-397. DOI: 10.38079/igusabder.757110.
• Arpacıoğlu S, Baltalı Z, Ünübol B. COVID-19 pandemisinde sağlık çalışanlarında tükenmişlik, Covid korkusu, depresyon, mesleki doyum düzeyleri ve ilişkili faktörler. Cukurova Medical Journal. 2021;46:88-100.
• Muller AE, Hafstad EV, Himmels JPW, Smedslund G, Flottorp S, Stensland SØ, Stroobants S., et al. The mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: A rapid systematic review. Psychiatry Res. 2020 Nov;293:113441. DOI: 10.1016/j.psychres.2020.113441.
• amnesty.org [Internet]. Londra: Global: Amnesty analysis reveals over 7,000 health workers have died from COVID-19; 2020 [cited 2020 July 19]. Available from: https://www.amnesty.org/en/latest/pressrelease/ 2020/09/amnesty-analysis-7000-health-workers-have-diedfrom- covid19/.
• tr.wikipedia.org [Internet]. Türkiye’de Covid-19 pandemisinin sağlık sektörüne etkisi; 2020 [cited 2020 July 19]. Available from: https:// tr.wikipedia.org/wiki/T%C3%BCrkiye%27de_COVID19_pandemisinin_ sa%C4%9Fl%C4%B1k_sekt%C3%B6r%C3%BCne_etkisi#:~:text=6%20 Kaynak%C3%A7a,D%C3%BCnyada%20COVID%2D19%20pandemisine%20ba%C4%9Fl%C4%B1%20sa%C4%9Fl%C4%B1k%20%C3%A7al%C4%B1%C5%9Fanlar%C4%B1n%C4%B1n%20%C3%B6l%C3%BCmleri,sa%C4%9Fl % C 4 % B 1 k % 2 0 %C3%A7al%C4%B1%C5%9Fan%C4%B1n%C4%B1n%20 %C3%B6ld%C3%BC%C4%9F%C3%BCn%C3%BC%20ortaya%20 kondu.
• Bandyopadhyay S, Baticulon RE, Kadhum M, Alser M, Ojuka DK, Badereddin Y, Kamath A., vd. (2020). Infection and mortality of healthcare workers worldwide from COVID-19: a systematic review. BMJ Glob Health.,5(12):e003097. DOI: 10.1136/bmjgh-2020-003097.
• The Lancet. COVID-19: protecting health-care workers. Lancet. 2020 Mar 21;395(10228):922. DOI: 10.1016/S0140-6736(20)30644-9.
• Yılmaz Z, İstemihan F, Arayıcı S, Yılmaz S, Güloğlu B. COVID-19 Pandemi Sürecinde Bireylerdeki Anksiyete ve Umutsuzluk Düzeylerinin İncelenmesi . Kriz Dergisi. [Internet]. 2020 28 (3), 135-150.
• Yıldız İ, Çıkrıkçılı U, Yüksel Ş. Karantinanın ruhsal etkileri ve koruyucu önlemler. Türkiye Psikiyatri Derneği. Ankara, [Internet]. 2020. Available from: https://psikiyatri.org.tr/TPDData/Uploads/files/KarantinaCOVID.pdf.
• Reynolds DL, Garay J, Deamond S, Moran MK, Gold W, Styra R. Understanding, compliance and psychological impact of the SARS quarantine experience. Epidemiol Infect. 2008;136:997-1007.
• Bai YM, Lin CC, Lin CY, Chen JY, Chue CM, Chou P. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv. 2004; 55(9): 1055-1057. DOI:10.1176/appi.ps.55.9.1055.
• Braunack-Mayer A, Tooher R, Collins JE, Street JM, Marshall H. Understanding the school community’s response to school closures during the H1N1 2009 influenza pandemic. BMC Public Health. 2013;13(1):1-5. DOI:10.1186/1471-2458-13-344.
• Gómez-Durán EL, Martin-Fumadó C, Forero CG. Psychological impact of quarantine on healthcare workers Occupational and Environmental Medicine 2020;77:666-674.
• Baki S, Piyal B. Covid-19 pandemisi ve benzeri olağanüstü durumlarda sağlık çalışanları açısından iş-aile çatışması. Sağlık ve Toplum. 2020;30(Özel Sayı):119 - 123.
• Shechter A, Diaz F, Moise N, Anstey DE, Ye S, Agarwal S, Birk JL., et al. Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic. Gen Hosp Psychiatry. 2020 Sep-Oct;66:1-8. DOI: 10.1016/j. genhosppsych. 2020.06.007.
• Gürer A, Gemlik HN. Covid-19 pandemisi sürecinde sahada olan sağlık çalışanlarının yaşadıkları sorunlar ve çözüm önerileri üzerine nitel bir araştırma. Sağlık Hizmetleri ve Eğitimi Dergisi. 2020;4(2):45- 52 . DOI: 10.29228/JOHSE.3.
• Fan J, Hu K, Li X, Jiang Y, Zhou X, Gou X, Li X. A qualitative study of the vocational and psychological perceptions and issues of transdisciplinary nurses during the COVID-19 outbreak. Aging (Albany NY). 2020 Jul 3;12(13):12479-12492. DOI: 10.18632/aging.103533.
• Johal SS. Psychosocial impacts of quarantine during disease outbreaks and interventions that may help to relieve strain. Journal of the New Zealand Medical Association. 2009;122:53-58.
• Nakışci Kavas B, Develi A. Çalışma yaşamındaki sorunlar bağlamında Covid-19 pandemisinin kadın sağlık çalışanları üzerindeki etkisi. Uluslararası Anadolu Sosyal Bilimler Dergisi. 2020;4(2):84-112.
• Qureshi, KA, Merrill JA, Gershon RR, Calero-Breckheimer A. Emergency preparedness training for public health nurses: a pilot study. Journal of Urban Health. 2020;79(3): 413-416.
• Brewin C, Andrews B, Valentine J. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology. 2000;68(5):748–766. DOI:10.1037//0022-006x.68.5.748.
• Tekin S, Glover N, Greene T, Lamb D, Murphy D, Billings J. Experiences and views of frontline healthcare workers’ family members in the UK during the COVID-19 pandemic: a qualitative study. European Journal of Psychotraumatology. 2022 13:1-11.
• Davidson J, Smith R, Kudler H. Familial psychiatric illness in chronic posttraumatic stress disorder. Comprehensive Psychiatry. 1989;30(4):339–345. DOI:10.1016/0010-440x(89)90059-x doi:10.1037/0033-2909.129.1.52.
• Selimbasic Z, Sinanovic O, Avdibegovic E, Hamidovic M. Behavioral problems and emotional difficulties at children and early adolescents of the veterans of War with post-traumatic stress disorder. Medical Archives. 2016;70(5):348. DOI:10.5455/ medarh.2016.70.348-353.
• Galovski T, Lyons J. Psychological sequelae of combat violence: A review of the impact of PTSD on the veteran’s family and possible interventions. Aggression And Violent Behavior. 2004;9(5):477–501. DOI:10. 1016/s1359-1789(03)00045-4.
• Alrutz A, Buetow S, Cameron L, Huggard P. What happens at work comes home. Healthcare, 2020;8(3), 350–362. DOI:10.3390/ healthcare8030350.
• Friese K. Cuffed together: A study on how law enforcement work impacts the officer’s spouse. International Journal of Police Science & Management. 2020;22(4):407–418. DOI:10.1177/1461355720962527.
• Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: A systematicreview and meta-analysis. Social Science & Medicine. 2010;71(12):2150–2161.
• Karasu F, Çopur E. COVID-19 vakaları artarken salgının ön safındaki bir yoğun bakım hemşiresi: “Cephede Duran Kahramanlar” olgu sunumu. Yoğun Bakım Hemşireliği Dergisi. 2020;24(1):11-14.
• Simmons, L.A., Yang, N.Y., Wu, Q., Bush, H.M. and Crofford, L.J. “Public and Personal Depression Stigma in a Rural American Female Sample”. Archives of Psychiatric Nursing. 2015; 29: 407-412.