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A study of depression disclosure among Latino older adults in Los Angeles

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A study of depression disclosure among Latino older adults in Los Angeles

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A STUDY OF DEPRESSION DISCLOSURE AMONG LATINO OLDER ADULTS
IN LOS ANGELES

By

Dahlia Fuentes

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(SOCIAL WORK)

August 2014

ii

DEDICATION
This dissertation is dedicated to my brother, Daniel Fuentes, whom I greatly admire for
his immense courage and perseverance despite all tribulations. I thank him for his openness and
trust, as well as the welcoming heart and mind that allow me to open up and trust in return.

iii

ACKNOWLEDGEMENTS
This dissertation could not have been completed without the support from many
individuals. First, I would like to thank my research committee —Drs. Lawrence Palinkas, María
Aranda, and Lourdes Baezconde-Garbanati— for their guidance, care, and motivation
throughout my learning process. I appreciate their knowledge and wisdom, as well as their time
to share and teach beyond research skills.
Secondly, I would like to thank other professors and mentors whose passion for social
justice and human worth has inspired me to enter into the field of social work and focus my
research on aging, mental health, and minorities. Although the list is not exhaustive, I am
especially grateful to Drs. Concepción Barrio, Piedad Garcia, and Rodrigo Muñoz. Their arduous
commitment to improving the lives of others is a true inspiration.
I would also like to acknowledge my friends and colleagues within and outside of the
USC School of Social Work community who have helped make this long and oftentimes difficult
process more pleasant: Luz Donis, Wendy Hileman, Beth Green, Elisa Castro, Edith Mohler,
MinKyoung Rhee, Rohini Pahwa, and Mercedes Hernandez. I couldn’t ask for better
cheerleaders; thank you for all of your love and support.
Finally, I would like to express my gratitude to my family who has made countless
sacrifices for my education and personal growth. I especially want to thank my partner and
spouse, Luis Lechuga, for his love and humor that fill my life with joy. I also appreciate my
mother, my aunt, and the memory of my loving grandmother for keeping me grounded in my
cultural roots and for reminding me of the meaning of this work that I do.

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TABLE OF CONTENTS

DEDICATION ii
ACKNOWLEDGEMENTS iii
LIST OF TABLES vi
LIST OF FIGURES vii
ABSTRACT viii
CHAPTER ONE: INTRODUCTION 1
Background of the problem 1
Purpose and specific aims of the study 4
Significance of the study 4
Theoretical underpinnings 5
Methodology 7
Organization of the study 8

CHAPTER TWO: LITERATURE REVIEW 10
Stigma, mental illness, and disclosure 10
Recipients of disclosure: Individuals and the social network 15
Consequences of disclosing a mental illness: Benefits and costs 20
Predictors of disclosure: Personal characteristics, barriers, and facilitators 25

CHAPTER THREE: METHOD 34
Data source 34
Recruitment of the sample 34
Development and translation of the study materials 36
Data collection 36
Data analysis 40

CHAPTER FOUR: RESULTS 47
Characteristics of the study participants 47
Characteristics of the network alters 49
Size and composition of the study participants’ egocentric networks 49
Disclosure patterns by participant demographics 55
Disclosure patterns by participants’ network characteristics 58
Depression disclosure, perceived stigma, and perceived burden to others 60
A conceptual model of depression disclosure among older Latinos 67

CHAPTER FIVE: DISCUSSION 84
Review of findings 84

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Implications for social work practice 92
Limitations and suggestions for further study 94
Conclusion 97

REFERENCES 99

FOOTNOTES 123
APPENDIX A: Interview Guide (English) 124
APPENDIX B: Interview Guide (Spanish) 135

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LIST OF TABLES
Table 1: Demographics and other characteristics of the study participants 48

Table 2: Size of participants’ social support networks according to participant and
alter characteristics 53

Table 3: Number and percentage of the study participants that identified at least one
person that… 54

Table 4: Correlation matrix of variables describing participant demographics and
depression disclosure to his/her network 57

Table 5: Correlation matrix of variables describing the size, composition, relationships,
and disclosure within the egocentric networks 59

Table 6: Correlation matrix of variables describing stigma, burden, and depression
disclosure within the egocentric networks 61

Table 7: Summary of hierarchical regression analysis for variables predicting the
proportion of network that the participant has disclosed to about his/her depression 64

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LIST OF FIGURES
Figure 1: Conceptual model of depression disclosure among Latino older adults 83

viii

ABSTRACT
Self disclosure has been defined as the process of making the self known to others, and usually
entails the act of verbally revealing personal information about oneself. Although disclosure of a
mental illness can have deleterious effects, such as the stigmatization that results in
discrimination, benefits have also been documented. Disclosure has been found to improve self-
esteem, to decrease distress related to secrecy and self-stigmatization, and may increase quality
of life. Moreover, disclosure to family and friends has been found to influence care and increase
retention among individuals with other stigmatized identities. This is of special relevance for
Latino older adults, as in the U.S. the treatment gap is largest among traditionally underserved
groups such as older adults and racial/ethnic minorities. However, mental illness disclosure
among Latino older adults has not yet been examined. The goal of this study was to develop a
conceptual model of depression disclosure that is based on the experiences of older Latinos.
Data were collected from 35 Latino older adults who were receiving care at community Adult
Day Healthcare Centers (ADHCs) and who were also participating in an NIMH-funded
randomized control depression intervention study titled “Enhanced Geriatric Depression
Treatment in Adult Day Health Care” (i.e., Programa Mano Amiga, PMA). This cross-sectional
exploratory study utilized a mixed method approach, where network questions were embedded
within the predominant qualitative methodology. Correlation analyses show that the participant’s
age and education were significantly related to the proportion of the participant’s network that
was disclosed to. Older participants and higher-educated participants disclosed to a smaller
proportion of their social support network. Moreover, disclosure to the network was significantly
related to providing emotional support. As the proportion of the network that the participant
provided emotional support to increased, so did the proportion of alters within the network that

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were disclosed to about depression. Correlation analyses also demonstrated that self perceived
burden –but not perceived stigma– was significantly related to participant disclosure of his/her
depression. Specifically, the proportion of the network that participants perceive might be
burdened by his/her depression was significantly related to the proportion of the network that the
participants disclosed to. The analyses of the qualitative data revealed a heuristic model of the
depression disclosure process that identified eight general themes contained in three separate but
interrelated phases of disclosure: (a) determinants of disclosure, (b) the disclosure event, and (c)
consequences of disclosure. With regard to culture, the terms used by participants to describe to
others what they were feeling (e.g., to describe their depression) influenced their ability to
verbally communicate with others (i.e., disclose) about the depression. Overall, this study
highlights the complexity of the process of self disclosure that often entails a combination of
verbal and nonverbal cues which may be culturally bound not only by the Latino culture but also
by the culture of older adulthood. These results drawn from the emic perspective of Latino older
adults can inform the development of culturally-sensitive strategies to support older Latinos who
face the dilemma of disclosure.

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CHAPTER ONE: INTRODUCTION
Background of the Problem
Depression is a common and debilitating illness that is associated with losses in health-
related quality of life (Pyne et al., 1997; Unützer et al., 2000), and is considered to be one of the
leading causes of disease burden and disability in the United States and abroad (Chapman &
Perry, 2008; McKenna, Michaud, Murray, & Marks, 2005; Moussavi et al., 2007; WHO
Department of Mental Health and Substance Abuse, 2011). In the U.S., an estimated 2.3% of
older adults report a 12-month prevalence of major depressive disorder (Gum, King-Kallimanis,
& Kohn, 2009), and as many as 15-20% experience significant depressive symptoms (Gallo &
Lebowitz, 1999; Steffens, Fisher, Langa, Potter, & Plassman, 2009). Depression has a strong
tendency to recur in older adults (Cole, 1997; Stek, Exel, Tilburg, Westendorp, & Beekman,
2002), and some research suggests that their risk of recurrence is greater compared to younger
individuals (Mueller et al., 2004). While they currently make up an estimated 18.5% of the U.S.
population in 2010, older Americans (ages 60+) are projected to comprise over one fourth of the
total population by 2050 (U.S. Census Bureau, 2011, 2012). With this imminent burgeoning of
the older adult population, geriatric depression is an increasingly important public health
concern.
Geriatric depression is a major concern for Latinos as well, as depression is one of the
most prevalent mental disorders not only among older adults, but also among racial and ethnic
minorities (González, Tarraf, Whitfield, & Vega, 2010; Jimenez, Alegría, Chen, Chan, &
Laderman, 2010; U.S. Department of Health and Human Services, 2001). Although Latinos are
currently characterized as a younger population in comparison to other ethnic groups in the U.S.,
there is an impending growth of the Latino older adult population (National Research Council,

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2006; U.S. Census Bureau, 2012). Latinos are currently the fastest-growing racial/ethnic
minority group in the United States, comprising approximately 16% of the U.S. population, or
50.5 million in number according to 2010 Census data (Ennis, Rios-Vargas, & Albert, 2011; U.S.
Census Bureau, 2012). In comparison to the proportion of older adults ages 60 and above found
in the general population (18.4%), older Latinos comprised only 8.6% of the Latino population
and only 7.5% of the older adult population (U.S. Census Bureau, 2012). However, as the Latino
population continues to increase and age, the older Latino population will increase as well (U.S.
Census Bureau, 2012; Vincent & Velkoff, 2010). By 2050, an estimated 22.6 million Latinos
will comprise approximately 20% of the population age 60 and above, which will make Latinos
the largest minority group among the older adult population in the United States (U.S. Census
Bureau, 2008). These demographic shifts will result in an increased number of Latino older
adults who may be at risk for depression.
Evidence-based treatments for geriatric depression exist (Bartels et al., 2002; Nelson,
Delucchi, & Schneider, 2008; Scogin, 2005; Wilson, Mottram, & Vassilas, 2008). However, the
existence of depression treatment does not always translate to equitable accessibility and service
utilization. In a study of the World Health Organization, the global treatment gap for major
depression was estimated to be 56.3%, meaning that over 56% of individuals with major
depression remain untreated although treatment exists (Kohn, Saxena, Levav, & Saraceno,
2004). Furthermore, there are racial and ethnic disparities in the utilization of mental health
services (Alegria et al., 2002; Chen & Rizzo, 2010; Solway, Estes, Goldberg, & Berry, 2010), in
the treatment for mental illness (Akincigil et al., 2012; Alegria et al., 2008; Cook, McGuire, &
Miranda, 2007; Sclar, Robison, & Skaer, 2008), and in participation of research that ascertains
the effectiveness of the treatment (Aisenberg, 2008; Fuentes & Aranda, 2012; Miranda,

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Nakamura, & Bernal, 2003). Indeed, in the United States the aforementioned treatment gap was
largest among traditionally underserved groups such as older adults and racial/ethnic minorities
(Wang et al., 2005). Hence, improvements in the mental health care and accessibility among
racial and ethnic minorities in general - and Latinos specifically – have become a national
priority as evidenced by numerous initiatives, which include the National Congress for Hispanic
Mental Health (SAMHSA, 2000), the formation of the National Latino Behavioral Health
Association (López, 2002), and the release of the landmark report on disparities in mental health
care by the U.S. Surgeon General (U.S. Department of Health and Human Services, 2001). In
sum, strategies to increase mental health outcomes, as well as the access and retention into
existing treatment are of critical importance for Latino older adults.
Self disclosure has been defined as the process of making the self known to others
(Jourard, 1971; Jourard & Lasakow, 1958), and usually entails the act of verbally revealing
personal information about oneself (Cozby, 1973). Although disclosure can have deleterious
effects, such as the stigmatization that results in discrimination (Pandya, et al., 2011), many
benefits have also been documented. For example, disclosure of a mental illness has been found
to improve self-esteem and decrease distress related to secrecy and self-stigmatization (Corrigan,
et al., 2010; Pachankis, 2007; Nicolas Rüsch, Angermeyer, & Corrigan, 2005; Wegner & Lane,
1995). Disclosure has been described as therapeutic (Hellemans et al., 2011; Ralph, 2002), and it
may also increase quality of life (Corrigan, et al., 2010). Importantly, disclosure to family and
friends has been found to influence care and increase retention among individuals with other
stigmatized identities (Wohl et al., 2011). While there has been an increase in the amount of
research on the topic of illness disclosure, mental illness disclosure among Latino older adults
has not yet been examined.

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Purpose and Specific Aims of the Study
This study addresses the research gap that exists on the experiences of Latino older adults
in self disclosing about their depression to people who are important to them such as their
network of social support. Utilizing mixed methods, the purpose of this study is to develop a
conceptual model of depression disclosure that is based on the experiences of older Latinos
whom are participating in a randomized behavioral trial of geriatric depression care. The
specific aims of this study are the following:
1. To quantitatively examine the relationship between the participant demographics and
depression disclosure to the egocentric networks.
2. To quantitatively examine the relationship between the structure (i.e., size and
composition) of the egocentric networks and participants’ depression disclosure to their
network.
3. To examine the relationship between participants’ perceived stigma, perceived burden
on others, and disclosure of depression to their network.
4. To qualitatively examine the disclosure process through which older Latinos
communicate to members of their support network and important others that they have
depression.
Significance of the Study
There has been a recent increase in the amount of research on the topic of illness
disclosure, and social support has been found to be an important correlate of disclosure in
general (Fekete, 2009; Zea, Reisen, Poppen, & Echeverry, 2005). Moreover, research shows that
individuals with severe mental illness with certain aspects of the social support network (e.g.,
larger size of and greater satisfaction with social support network) are more likely to report

5

process perspectives of mental health recovery such as hope and being more oriented toward
goals and success (Corrigan & Phelan, 2004). This has important implications for older adults
and Latinos in the U.S., as these groups place great value on their social networks of family and
friends (Golding & Baezconde-Garbanati, 1990; Keefe, Padilla, & Carlos, 1979; Marín & Marín,
1991; Mulvaney-Day, Alegría, & Sribney, 2007; Sabogal, Marín, Otero-Sabogal, Marín, &
Perez-Stable, 1987). By not studying individuals’ mental illness disclosure to members of their
support networks, we could potentially be missing an opportunity to improve depression care
outcomes and increase access and retention in depression treatment. Therefore, greater attention
to the topic of older Latinos’ mental illness disclosure among members of their support network
(such as family and friends) is warranted.
Theoretical Underpinnings
This dissertation is guided by Bronfenbrenner’s (1979) ecological theory of human
development, as well as Kleinman’s (1978) cultural explanatory model. Bronfenbrenner’s
ecological theory (1979) identifies five factors of the environment that individuals interact with
which impact growth and development (i.e., micro-, meso-, exo-, macro-, and chrono-systems).
The microsystem of the environment refers to institutions and groups that the individual most
immediately comes in contact with, which includes family, friends, and peers. The mesosystem
refers to the interconnections between the microsystems (e.g., relationships between the
individual’s family and peers, etc.), while the exosystem involves linkages between two or more
settings –one of which is not the immediate context. The macrosystem describes the culture (i.e.,
attitudes and ideologies) in which the individuals live, and the chronosystem refers to transitions
or patterning of events that occur over a life course. In sum, this theory suggests that individuals
do not exist in a vacuum; individuals are embedded in these various systems of the social

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environment, which, in turn, have influence on individuals’ growth, development, decisions, and
relationships. In this dissertation, Bronfenbrenner’s ecological theory highlights the socio-
cultural context of older adults with depression as they interface with family, friends, and other
individuals in their support network, community, and organizational entities (e.g., healthcare
providers and researchers).
According to Arthur Kleinman’s explanatory models (1978), cultures define appropriate
and inappropriate responses to specific illnesses. Specifically, explanatory models contain
explanations of any or all issues relating to illness: etiology, onset of symptoms,
pathophysiology, course of sickness, and treatment (p. 87-88). They help explain cross-cultural
and ethnic differences in the manner in which illnesses such as depression are experienced and
reacted to (Kleinman & Good, 1985). Although research has explored explanatory models of
depression among Latinos (Cabassa, Hansen, Palinkas, & Ell, 2008; Cabassa, Lester, & Zayas,
2007; Guarnaccia, Lewis-Fernandez, & Marano, 2003; Pincay & Guarnaccia, 2007), the existing
research has not examined older Latinos’ experience with depression disclosure. In this present
study, Kleinman’s explanatory model highlights the experience of being Latino and of being an
older adult in relation to their understanding of having depression. The explanatory model also
highlights their older adulthood and Latino culture as it relates to how they react to depression
(i.e., their disclosure behavior). In sum, by way of these two theories cultural and social contexts
serve as the lens through which specific groups understand and react to their illness experience.
Accordingly, disclosure may vary in relation to the manner in which depression is culturally and
socially understood.
This dissertation also draws from existing literature on stigma, mental illness, and
disclosure; which is more thoroughly reviewed in Chapter Two. Briefly, self disclosure is a

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multidimensional behavior involving numerous cognitive stages that may have varying
consequences (Chaudoir & Fisher, 2010; Limandri, 1989; Omarzu, 2000). Dimensions of
disclosure include content (topic), target or recipient (persons being disclosed to), breadth
(number of topics), depth (intimacy), duration (length or amount of time), and context, as well as
the characteristics of the discloser (Cozby, 1973; Goodstein & Reinecker, 1974), and these may
vary according to the goal or purpose of the disclosure (Omarzu, 2000). Existing models of the
disclosure decision process describe stages in which disclosure unfolds. In Omarzu’s (2000)
model, the first step is the activation of a specific disclosure goal (i.e., approval, intimacy, relief,
identity, or control) and through cues the individual evaluates whether the goal is accessible. The
individual then evaluates whether disclosure is an appropriate strategy and then identifies a
target. The third and final stage entails the evaluation of risk and utility of the disclosure.
Chaudoir and Fisher’s (2010) model of disclosure processes goes beyond disclosure decision-
making, and also characterizes the disclosure event and consequences or outcomes.
While the purpose of this study is to build theory through the development of a
conceptual model of depression disclosure that is based on the experiences (e.g., social and
cultural context) of older Latinos with depression, these existing theories and models are useful
in providing sensitizing concepts (Blumer, 1954; Bowen, 2006) that can be incorporated as
probes in the interview guide of this exploratory study.
Methodology
This dissertation is a cross sectional study designed to understand depression disclosure
among 35 Latino older adults who were receiving care at community ADHCs and who were also
participating in an NIMH-funded randomized control depression intervention study titled
“Enhanced Geriatric Depression Treatment in Adult Day Health Care” (i.e., PMA). The data

8

were collected by the author and three research assistants trained in qualitative methods. The
study utilizes a mixed method approach; specifically the embedded design described by Creswell
and Clark (2007) which allows both qualitative and quantitative network data to be collected
simultaneously. In this study network questions were embedded within the predominant
qualitative methodology to provide a supportive, but secondary role in this exploratory study.
Organization of the Study
This dissertation consists of five chapters. Chapter One presents the background of the
problem. Then the purpose and specific aims of the study are presented to highlight the
significance of this research. Theoretical frameworks that guide this study, which include
Bronfenbrenner’s (1979) ecological theory of human development and Kleinman’s (1978)
cultural explanatory model, are then briefly reviewed. Existing conceptual models of disclosure
are also briefly reviewed. Finally, the methodology of the overall project is introduced.
Chapter Two includes the thorough literature review on the various concepts relating to
the research aims of this study. The first section of the literature review examines stigma, mental
illness, and disclosure. The second section of Chapter Two reviews literature on the recipients of
disclosure, highlighting research that focuses on whom persons with mental illness are more
likely to disclose, as well as the targets/recipients of disclosure in specific settings (e.g.,
workplace and healthcare). The third section of Chapter Two reviews the consequences of
disclosing a mental illness. These benefits and costs of disclosing a mental illness are thoroughly
reviewed. Finally, the fourth and last section of this chapter reviews the literature on predictors
of disclosure. Research that focuses on the personal characteristics of the discloser is presented.
Research that highlights additional determinants that serve as barriers and facilitators to
disclosing is also reviewed.

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Chapter Three more thoroughly explains the methodology that was briefly presented in
the introduction. It includes an overview of the data source and the overall study (i.e., the
Programa Mano Amiga, PMA) from which this dissertation was made possible. The
development of materials and translation of the study materials, as well as data collection are
described. Finally, the data analysis is explained: first by methodology, and then by specific aim.
Chapter Four presents the results for this study. First, data that describes the study
participants, the network alter, and the size and composition of the egocentric networks is
presented. Then the results that address each specific aim are presented sequentially. First,
disclosure patterns by participant demographics are presented. Second, disclosure patterns by
network characteristics are described. Third, patterns describing disclosure, perceived stigma,
and perceived burden on others are presented. Finally, the disclosure process through which
older Latinos communicate their depression to their important others is described. The overall
conceptual model is finally presented.
Chapter Five presents the discussion of the findings, where each aim is discussed
separately. The chapter concludes by presenting the research and practice implications of this
study, and discussing limitations of the research.

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CHAPTER 2: LITERATURE REVIEW
This chapter reviews existing literature on the topic of disclosure, with special attention
provided to research of self disclosure among older adults and ethnic and racial minorities in the
United States. Considering that the majority of mental illness disclosure research has taken place
within the frameworks of stigma and discrimination, this chapter starts off by describing the
relationship between stigma, mental illness, and disclosure. This sets the stage for the second
section of this chapter, which focuses on the targets/recipients of disclosure in nonspecific
(general) and specific (workplace or healthcare) settings. Specifically, the second section
summarizes literature that describes to whom persons with mental illness are disclosing to, whom
they are most likely to disclose to, and these disclosure recipients’ characteristics. The third
section of this chapter summarizes literature describing the consequences of disclosing a mental
illness. Consequences include both risks and benefits of disclosure. The fourth section of this
chapter describes what is known about barriers and facilitators to disclosure (i.e., when and why
individuals might choose to disclose about their mental illness to others). This section includes
what is known about social support and self perceived burden in relation to the disclosure of
mental illness. Together, these four sections shed light on the dynamics of disclosure and how
individuals disclose about their mental illness to others.
Stigma, Mental Illness, and Disclosure
Stigma. Originally defined by Erving Goffman (1963) as an “attribute that is deeply
discrediting”, which reduces the bearer “from a whole and usual person to a tainted, discounted
one” (p. 3) stigma has also been defined as a “mark” that identifies the individual as carrying a
condition that is considered deviant by a society (Jones et al., 1984). Stigma can be understood
as the convergence of interrelated components such as labeling, stereotyping, separation, status

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loss, and discrimination that unfold in situations involving power (Link & Phelan, 2001), and
more succinctly can be understood in terms of the following three components: stereotype (i.e.,
the beliefs about a group), prejudice (i.e., the agreement with the belief), and discrimination
(Corrigan & Watson, 2002a). Stigma manifests at the individual and structural levels of society,
through individuals’ opinions and actions as well as social policies that discriminate against the
bearers of stigmata.
Stigma and mental illness. Mental illness has long been the matter of stigmatization
(Angermeyer & Matschinger, 1994; Corrigan & Penn, 1999; Goffman, 1963). In a sociological
paradigm, structural levels of mental illness stigma have been conceptualized as discrimination
caused by intended as well as unintended consequences of media, politics, and economic forces
(Corrigan, Markowitz, & Watson, 2004; Link & Phelan, 2001). In their article, Corrigan and
colleagues (2004) explain how stigma intentionally discriminates against people with mental
illness through news media that sensationalizes violence associated with mental illness and also
through laws that restrict voting, marriage, and child custody among persons with mental illness.
Similarly policies and procedures exist that inadvertently diminish opportunities among persons
with mental illness, such as the unintended consequences of the 1996 Mental Health Parity Act
which resulted in fewer financial resources for psychiatric disorders for people employed by
small businesses after exemptions were considered (Levinson & Druss, 2000). As such,
structural-level stigma manifests through political and economic forces that generate social
structures that promote or maintain discrimination against persons with mental illness (Link &
Phelan, 2001).
In individual-level psychological paradigms, stigma research focuses on processes that
may lead individuals in society to stigmatize (i.e., public stigma) as well as on internal processes

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that lead individuals to feel stigmatized (i.e., self or internalized stigma). Corrigan and Watson
(2002b) have defined public stigma as “the reaction that the general public has to people with
mental illness” and ways in which they show prejudice and discrimination against them (p.16).
In their review of psychological effects of social stigma, Major and O’Brien (2005) proposed an
identity threat model of stigma that suggests that individuals whom are stigmatized are not
“passive victims of other’s negative stereotypes, prejudicial attitudes, and discriminatory
behaviors”, but their construal of these mechanisms also “plays key mediating role in their
responses to stigma” (p. 411). As such, self stigma has been described as the belief in negative
stereotypes about mental illness and the application of those beliefs to oneself, thereby
diminishing one’s self-esteem and undermining one’s self-efficacy (Corrigan & Watson, 2002a,
2002b; Corrigan, Watson, & Barr, 2006; Link, Struening, Neese-Todd, Asmussen, & Phelan,
2001). In this way, self stigma has been presented as a model with dimensions of stereotype
agreement, self-concurrence, and self-esteem decrement (Corrigan, et al., 2006; Link, et al.,
2001).
With regard to public stigma, some research indicates that ethnic minorities are less likely
to endorse stigma by supporting prejudicial attitudes (e.g., authoritarianism and benevolence)
about mental illness in comparison to non-Hispanic Whites (Corrigan, Edwards, Green, Diwan,
& Penn, 2001), while other studies indicate greater prejudice toward people with mental illness
among certain minorities groups (Anglin, Link, & Phelan, 2006; Rao, Feinglass, & Corrigan,
2007; Whaley, 1997). African American respondents were more likely than non-Hispanic White
respondents to believe that persons with mental illness would do something violent to others
(Anglin, et al., 2006), and also perceived persons with mental illness as significantly more
dangerous than the non-Hispanic White respondents (Whaley, 1997). Asian American and

13

Hispanic respondents perceived persons with mental illness as significantly more dangerous than
the non-Hispanic White respondents regardless of the level of contact with persons with mental
illness (Whaley, 1997). In a sample of older adults with depression, there were no significant
differences on perceptions of public stigma between African American and non-Hispanic White
participants (Conner et al., 2010).
Studies on racial/ethnic differences in self-stigma report mixed results. One study has
shown that African American older adults with depression were more likely than their non-
Hispanic White counterparts to experience internalized stigma (Conner, et al., 2010), while
another study reported no significant differences between the two racial groups in shame and
embarrassment about having a mental illness (Jimenez, Bartels, Cardenas, & Alegría, 2013).
However, in the latter study, greater proportions of Latino and Asian-American older adults
expressed ‘very’ or ‘extremely’ to questions about shame and embarrassment of having a mental
illness compared to non-Hispanic Whites (40.3% of Latinos, 25.9% of Asian-Americans, and
15.3% of non-Hispanic Whites). Furthermore, a greater proportion of Latino older adults
(40.3%) compared to non-Hispanic White older adults (25.9%) felt that people would think
differently of them if they sought mental health treatment (Jimenez, et al., 2013).
Strategies to manage self-stigma may include approaches that either hide the mental
illness or affirm the person with mental illness (Corrigan & Rao, 2012; Freidl, Lang, & Scherer,
2003; Link, Mirotznik, & Cullen, 1991; Rüsch, et al., 2005; Rüsch et al., 2009; Rüsch, Lieb,
Bohus, & Corrigan, 2006). These strategies to manage mental illness self-stigma, in effect, have
to do with the issue of disclosure, which is the focus of the following section.
Stigma and disclosure. Coping orientations that confront discrimination and affirm the
person with mental illness include educating and challenging those who stigmatize (Link,

14

Struening, Neese-todd, Asmussen, & Phelan, 2002; Rüsch, et al., 2005; Rüsch, et al., 2006).
Corrigan and colleagues (2010) have developed the Coming Out with Mental Illness Scale to
measure disclosure or coming out as a stigma management approach that affirms the person with
mental illness. There are also self-stigma coping orientations that hide the mental illness; these
include secrecy, withdrawal or avoidance, and distancing from the stigmatized group (e.g., I’m
not like them) (Link, et al., 1991; Rüsch, et al., 2009). However, not all mentally ill persons
react to public stigma —meaning that not everyone internalizes the public stigma— in the same
manner. For example, Corrigan and Watson (2002b) describe a paradox of self-stigma, where
personal reaction to mental illness stigma is righteous anger instead of the expected loss of self
esteem.
Ways in which people might disclose their mental illness has been classified into
different levels. These are: (a) social avoidance (i.e., where the person with the mental illness
stays away from any situation where others may find out about their mental illness); (b) secrecy
(i.e. where the person may choose not to avoid social situations but instead keep their
experiences with mental illness secret); (c) selective disclosure, which implies disclosure to a
select group of people and secrecy toward another group of people; (d) indiscriminate disclosure,
where the person makes no active effort to conceal the mental illness; and (e) broadcasting,
which implies a deliberate seeking out of people for purpose of sharing of one’s experiences with
mental illness (Corrigan & Matthews, 2003; Herman, 1993). It is not to be implied that people
with mental illness will fit into only one of these categories throughout their lives.
Goffman (1963) distinguished between the discredited and the discreditable groups,
where the discredited were those who suffered stigma due to observable traits such skin color or
obvious symptoms of leprosy and the discreditable were those who’s stigmatized traits (such as

15

homosexuality or a mental illness) was not readily visible. Thus having a discreditable stigma
(i.e., a concealable stigmatized identity) allows for the ability or dilemma of having to make
decisions related to disclosure —to whom, when, and how to disclose— if disclosure is to occur
at all. However as previously mentioned, some individuals express no reaction or ignore the
effects of public prejudice altogether; they do not internalize this public stigma (Corrigan &
Watson, 2002b). Therefore, mental illness disclosure is not exclusively a function of stigma.
There are other reasons why individuals choose whether or not to disclose their mental illness, or
whom to tell. The following section describes the targets or recipients of such disclosure.
Recipients of Disclosure: Individuals and the Social Network
In this section, recipients of disclosure are defined as the persons who receive the
information regarding another individual’s mental illness. Recipients of disclosure can also be
referred to as targets. However, a target implies intention, while a recipient may be disclosed to
intentionally or unintentionally (e.g., accidentally). Moreover, it is important to mention that
disclosure is not always a choice. Oftentimes, a person’s mental illness may be unwillingly
disclosed via symptom manifestation or by the outing on behalf of other individuals. With this
stipulation in mind, the remainder of this section on the recipients of disclosure will focus on
disclosure dynamics in situations when persons with mental illness have a choice in deciding
whether or not to disclose and who to tell. Moreover, the literature describing the
targets/recipients of disclosure will be reviewed based on the following: (a) studies that examine
disclosure of the mental illness across different recipients in a variety of settings or nonspecific
settings and describe the most common recipients of disclosure (i.e., describe to whom persons
with mental illness are most likely to disclose to); and (b) studies that examine disclosure in only
one setting (i.e., in primary care setting or at their workplace). The first set of studies tends to

16

generally describe to whom persons with mental illness are most likely to self disclose to. The
second set of studies focus on the patterns of mental illness disclosure within specific settings.
To whom are persons with mental illness more likely to disclose? There are several
studies that have examined mental illness disclosure patterns across different types of
targets/recipients in non-specific or a variety of settings to find out who are the most likely
recipients of mental illness disclosure. These studies tend to categorize the recipient by relation
or by recipients’ personal characteristics. For example, targets of mental illness disclosure tended
to be persons who were supportive, understanding, and trusting (Brohan et al., 2012; Chen, Lai,
& Yang, 2013; Fisher, 1995; Jones, 2011; Perry, 2011; Ralph, 2002; Wheat, Brohan, Henderson,
& Thornicroft, 2010). Chen and colleagues (2013) described Chinese immigrants’ “circle of
confidence” composed of a combination of family, close friends, mental health professionals,
and others whom are part of the inner circle of the guanxi network which is “the personalized
network of people of any type of relationship who exchange support, resources, benefits/gains,
and opportunities” (p. 380). Trusted peers or a community of peers who had gone through
similar experiences of having a mental illness and were in the process of recovery were also
common targets/recipients of disclosure (Corrigan, Kosyluk, & Rüsch, 2013; Corrigan, Sokol, &
Rüsch, 2013; Fisher, 1995; Ralph, 2002). Further, Fisher (1995) recommends selecting targets
who are “tolerant, understanding, and fearless about the experiences”, as it is valuable to process
or reexamine your own experiences, thoughts, and feelings of past episodes with a trusted peer
(p. 55).
While these studies identified targets/recipients of mental illness disclosure based on
personal characteristics, other studies identified or described targets of disclosure based on
relation. With regard to relation, family (i.e., spouses, significant others, parents, other relatives)

17

and friends seem to be the most likely recipients of disclosure (Bos, Kanner, Muris, Janssen, &
Mayer, 2009; Chen, et al., 2013; Pandya, et al., 2011). In a survey of 500 Dutch clients of an
outpatient mental health institute, 90% reportedly disclosed to at least some family,
approximately 88% disclosed to at least some friends, and 74% disclosed to at least some
acquaintances (Bos, et al., 2009). In this study, 96.8% reportedly disclosed to their partner,
88.8% disclosed to their mother and 84.2% disclosed to their father. In a separate study of
individuals with schizophrenia recruited via a website and email list of the National Alliance of
Mental Illness (NAMI), nearly the entire sample (97%) was at least somewhat open about their
schizophrenia diagnosis with their doctors, while 86% were at least somewhat open to parents or
friends (Pandya, et al., 2011). Using an openness rating scale ranging from 1 (not open at all) to
4 (completely open regarding diagnosis), it was found that this sample was most open about their
diagnosis with doctors than with their spouse or significant other, parents, or friends (Pandya, et
al., 2011). The lowest mean openness scores were attributed to neighbors (M=1.7, SD=0.7), law
enforcement (M=2.0, SD=1.1), and people from place of worship (M=2.0, SD=1.1). Only 39%
mentioned that they were at least somewhat open about their schizophrenia with somebody from
their place of worship. A low rate of depression symptom disclosure to clergy was similarly
observed among participants in a study of diabetes and depression (Wagner, Perkins, Piette,
Lipton, & Aikens, 2009). African Americans were 5.9 times less likely than whites to have
discussed their depressive symptoms with anyone, although there were no racial differences in
disclosure specifically to clergy, family members, or friends (Wagner, et al., 2009).
Disclosure targets/recipients in the workplace and healthcare settings. The issue of
mental illness disclosure at the workplace became very important with the enactment of the
American Disabilities Act of 1990 (United States Code, 1990), which prohibits discrimination

18

based on disabilities, including a mental illness. Since disclosure to the employer is necessary for
protections and accommodations to be made, disclosure at the workplace has become a common
dilemma among people with a mental illness (Peterson, Currey, & Collings, 2011; Wheat, et al.,
2010). A literature review of 23 studies on workplace disclosure found that between 35% to 87%
of study participants disclosed their mental illness to somebody in the workplace (Jones, 2011).
Within this setting, disclosure targets/recipients include supervisors and co-workers/peers,
although disclosure was more common with supervisors (Ellison, Russinova, MacDonald-
Wilson, & Lyass, 2003; Granger, 2000; Jones, 2011; Rollins, 2002). When considering
disclosure in the workplace, persons with mental illness seek people who are supportive (Brohan,
et al., 2012; Dalgin & Gilbride, 2003; Rollins, Mueser, Bond, & Becker, 2002). In supportive
vocational programs specifically designed for persons with mental illness, it was not always
necessary to directly disclose to employers or co-workers since mental illness was a requirement
for accessing those supportive programs (Banks, Novak, Mank, & Grossi, 2007; Granger, Baron,
& Robinson, 1997; Jones, 2011). In these situations, the recipients of disclosure were usually the
supportive vocational program staff members in charge of coordinating the employment
placements.
There is an abundance of studies that examine issues of disclosure specifically to
healthcare providers (Bushnell et al., 2005; Corrigan, Swantek, Watson, & Kleinlein, 2003; Dew
et al., 2007; O'Connor, Rosewarne, & Bruce, 2001; Prior, Wood, Lewis, & Pill, 2003; Probst,
Laditka, Moore, Harun, & Powell, 2007; Sankar, 2005; Wagner, et al., 2009). However, the
majority of these studies are actually examining the disclosure of symptoms or emotional
problems rather than the disclosure of an actual diagnosis, and are in the context of seeking
specialty psychiatric care (Bushnell, et al., 2005; Corrigan, et al., 2003; Dew, et al., 2007;

19

O'Connor, et al., 2001; Prior, et al., 2003; Probst, et al., 2007; Wagner, et al., 2009). Further, the
focus of some research has been on the concealment rather than on disclosure to providers (Cape
& McCulloch, 1999; Okuyama et al., 2008).
Among the studies reviewed, there was wide variation in the proportion of participants
who had disclosed psychiatric symptoms to a healthcare provider. Nearly two-thirds of older
adult patients with mild depressive episode had reported one or more symptoms to their
physician, as had 47% with moderate depression and 75% with severe depressive illness
(O'Connor, et al., 2001). Overall, 51.8% of participants in the study by Probst and colleagues
(2007) disclosed their depressive symptom to their physician or other practitioner in the past
year, while in the study by Wagner and colleagues (2009) these rates differed based on type of
provider. In the latter study, discussions about depression symptoms were more likely to take
place with a counselor (71%) or a family physician (61%) than with a psychiatrist (35%), other
physician (6%), or pharmacist (0%). As expected, studies reporting on disclosure of actual
diagnoses (rather than symptoms) have found that disclosure to healthcare providers is quite
common. As an example, Pandya and colleagues (2011) found that 97% of the participants with
schizophrenia were reportedly at least somewhat open about their schizophrenia diagnosis with
their doctors.
In general, research has demonstrated a reluctance among minorities and older adults to
talk about emotional or psychological problems with their physicians (Harman & Reynolds,
2000; O'Connor, Rosewarne, & Bruce, 2001; Probst, Laditka, Moore, Harun, & Powell, 2007;
Wagner, Perkins, Piette, Lipton, & Aikens, 2009). In a study using a nationally representative
sample, lower proportions of Hispanics and African Americans reportedly communicate
depressive feelings to their provider in comparison to non-Hispanic Whites (Probst, et al., 2007).

20

Moreover, African Americans who screened positive for depression were significantly less likely
than Hispanics and non-Hispanic Whites to communicate with a physician or other practitioner.
With regard to older adults, disclosure to doctors about their depression symptoms is more likely
to occur when they cannot count on family and friends (Corrigan, et al., 2003). This latter study
suggests the reliance on the social network (e.g., family and friends) for communicating about
mental illness or symptoms. The majority of these studies highlight the importance of support as
a qualification when selecting the disclosure target.
Consequences of Disclosing a Mental Illness: Benefits and Costs
Currently, much of what is known regarding the consequences of mental illness
disclosure has been drawn from the coming out experience of gay men and lesbians and from
research on mental illness disclosure at the workplace. This section reviews literature on the
costs and benefits of mental illness disclosure. These consequences of disclosure are described
across different settings and across disclosure recipients.
Positive consequences of disclosing. Research shows that individuals who disclose a
stigmatized illness can experience improvements in psychological well-being and interpersonal
relationships (Corrigan et al., 2009; Corrigan & Matthews, 2003; Ralph, 2002). At the
intrapersonal level, disclosure has been found to be associated with physical and psychological
health (Jourard, 1959, 1971). Self disclosure may decrease distress that is related to secrecy or
the concealment of an illness (Jourard, 1959, 1971; Pachankis, 2007). The secrecy cycle is a set
of cognitive processes that lead to obsessive preoccupation with a secret (e.g., the secret of
having a mental illness) (Lane & Wegner, 1995), which, in turn, could be harmful and lead to
psychopathology (Wegner & Lane, 1995). Self disclosure negates the need for secrecy, therefore
avoiding the secrecy cycle. Hence, self disclosure has been described as therapeutic, as it

21

provides a sense of freedom or catharsis and promotes empowerment and emotional wellness
(Hellemans, et al., 2011; Ralph, 2002). With regards to the self disclosure of a mental illness,
research has shown disclosure to be positively related to self-esteem, quality of life, and
empowerment (Bos, et al., 2009; Corrigan, et al., 2010), and negatively associated with self-
stigma (Rüsch, et al., 2005). Specifically, disclosure mediates (reduces) the association between
self stigma and quality of life (Corrigan, et al., 2010) and moderates the relationship between
stigma and self-esteem (Bos, et al., 2009). In this sense, perceived stigma is strongly and
negatively related to self-esteem when participants are more open about their mental illness;
however, the relationship between stigma and self-esteem becomes weaker for participants who
are less open about their mental illness with others (Bos, et al., 2009).
Moreover, research suggests that disclosure of a stigmatized illness can improve service
utilization. Specifically, among ethnic minority participants with HIV, disclosure to family and
friends was found to influence care and increase retention in services (Wohl, et al., 2011).
Improvements in access and retention in services is especially relevant for ethnic minorities and
older adults, as these groups tend to experience limited access to care (Alegria, et al., 2002;
Alegria, et al., 2008).
Self disclosure of a stigmatized illness has also been shown to improve interpersonal
relationships at the personal and professional levels. Numerous studies have found HIV status
disclosure to be positively related to social support, where those who disclose (especially to
mothers and friends) tend to report more social support (Kadushin, 2000; Simoni, Demas,
Mason, Drossman, & Davis, 2000; Zea, et al., 2005). Moreover, in a sample of Latino gay and
bisexual men, disclosure of HIV status was found to improve the quality of the social support,
which, in turn, had beneficial effects on psychological well-being (Zea, et al., 2005). Among

22

persons with mental illness, self disclosure of the mental illness resulted in more supportive
family and friends, in their increased interest in the mentally ill person’s condition or diagnosis,
and in encouragement toward recovery (Chen, et al., 2013; Pandya, et al., 2011; Ralph, 2002).
Examples of support and care included hospital visits, reminders regarding medication-taking,
consoling phone calls and visits, and financial assistance. In a study where adults with
schizophrenia were asked if they were treated better, worse or the same by specific individuals
after disclosing their mental illness, 34% reported being treated better by parents, 25% reported
being treated better by their spouse/significant other, and 20% reported being treated better by
extended relatives (Pandya, et al., 2011). Nineteen percent reported better treatment from friends,
while 15% reported being treated better by neighbors.
At the professional level, disclosure at the workplace has also been shown to improve
interpersonal relationships. Specifically, for some individuals disclosure of a mental illness
resulted in supportive relationships with supervisors and coworkers, as it allowed employees to
be more open about day-to-day affairs and honest when requesting time off for appointments
with mental health providers (Banks, et al., 2007; Corrigan, Kosyluk, et al., 2013; Jones, 2011;
Rollins, et al., 2002; Wahl, 1999). There was less worry about hiding the mental illness from
supervisors or coworkers. Other benefits of disclosure at the workplace include increased
accommodations and increased job tenure (Banks, et al., 2007; Fabian, Waterworth, & Ripke,
1993; Jones, 2011; Kirsh, 2000).
Importantly, the act of disclosing opens up the opportunity for a reciprocated disclosure.
In other words, through the process of disclosing about your mental illness you may learn of
others who have gone through or are undergoing similar experiences. Hence, disclosures can
lead to opportunities for mutual support or mutual aid (i.e., helping or offering assistance to

23

peers), which in turn has been found to bolster self-esteem, self confidence, and hope (Corrigan
et al., 2005; Corrigan, Sokol, et al., 2013; Hsiung et al., 2010; Rappaport, 2000). On a societal
level, self disclosure of a mental illness has the potential to reduce social stigma since self
disclosure allows for others/colleagues to be educated about mental illness, and allows for the
opportunity to alert them when they are being offensive (Corrigan, Kosyluk, et al., 2013).
Moreover, research shows that negative attitudes about mental illness are influenced by the
person’s familiarity (level of contact) with mental illness (Corrigan, Edwards, et al., 2001;
Corrigan et al., 2001). Since contact implies disclosure, self disclosure may be a vital strategy for
debunking social stigma.
Negative consequences of disclosing. Disclosure of a mental illness can also result in
negative consequences related to stigma at both the intrapersonal and interpersonal levels.
Research suggests that at the intrapersonal level, indiscriminate and selective disclosure can
produce more harm than good with respect to demoralization and subjective distress (Bos, et al.,
2009; Link, et al., 1991). It must be noted, though, that secrecy (i.e., complete concealment of
the mental illness) led to similar effects (Link, et al., 1991). Specifically in the study by Link and
his colleagues (1991), the two different forms of disclosure did not diminish the effect of
devaluation (from being labeled as a psychiatric patient) on demoralization, which included
domains of helplessness-hopelessness, sadness, low self-esteem, and confused thinking.
At the interpersonal level, negative consequences of disclosure can range from subtle
differences in the way others treat you to overt discrimination and bullying (Chen, et al., 2013;
Jones, 2011; Pandya, et al., 2011). Upon being labeled as having a mental illness, individuals
experienced alienation, social avoidance, negative comments, and criticism from others (Link,
Cullen, Struening, Shrout, & Dohrenwend, 1989; Link, Cullen, Frank, & Wozniak, 1987; Wahl,

24

1999). Moreover, some individuals have reported being treated ‘differently’, as dangerous,
incompetent, or lacking intelligence (Chen, et al., 2013; Pandya, et al., 2011). In a nationwide
study of persons with schizophrenia, nearly one third of the participants reported being treated
worse by extended family and neighbors after disclosure (Pandya, et al., 2011). In a separate
study that included individuals with schizophrenia from 27 countries, 47% of the sample
experienced negative discrimination in making or keeping friends, and 29% of them experienced
negative discrimination when finding a job (Thornicroft, Brohan, Rose, Sartorius, & Leese,
2009). Mental illness disclosure was also not effective in diminishing negative labeling effects
(e.g., devaluation) on unemployment among individuals with major depression and
schizophrenia (Link, et al., 1991).
At the workplace, costs of mental illness disclosure also include having competence
questioned and exclusion from events or cooperative projects (Corrigan, Kosyluk, et al., 2013;
Jones, 2011; Pandya, et al., 2011; Wahl, 1999). One employee reported that after disclosing her
mental illness her boss treated her as stupid and incompetent (Baron, 2002, p. 43). Mental illness
disclosure has resulted in less supportive and stronger stigmatizing reactions on behalf of
colleagues (Bos, et al., 2009). Some individuals have reportedly left their jobs after experiencing
unjust treatment plagued with stigma and prejudice (Kirsh, 2000). Common stigmatizing
behaviors toward employees with mental illness include micro-management, over-attribution of
mistakes to illness, restricting opportunities for promotion, gossip, and social exclusion
(Corrigan & Lundin, 2001; Kirsh, 2000). Even from the employers’ perspective, research has
found that disclosure of a mental illness places job applicants at a disadvantage in securing
employment compared to applicants with a physical disability or no disability (Brohan, et al.,
2012; Koser, Matsuyama, & Kopelman, 1999). In general, these adverse consequences of

25

disclosure describe stigmatization (Corrigan, Larson, Hautamaki, et al., 2009; Corrigan &
Matthews, 2003).
In sum, disclosure of a mental illness can have positive outcomes as well as deleterious
effects which can severely impact a person’s life. When evaluating whether or not to disclose
about their mental illness, individuals may take notice of others’ experiences and outcomes of
their disclosures. However, there are other elements that may influence whether or not an
individual will disclose. These predictors of mental illness disclosure are the focus of the
literature reviewed in the following section.
Predictors of Disclosure: Personal Characteristics, Barriers, and Facilitators
There are numerous factors that may influence whether or not an individual will disclose
his/her mental illness to others. Disclosure decisions among persons with mental illness may
vary by personal characteristics, such as an individual’s race/ethnicity, age, gender, or marital
status. Individuals also make disclosure decisions by assessing the perceived costs and benefits
of disclosing (Valle & Levy, 2009; Zea, Reisen, Poppen, Bianchi, & Echeverry, 2007). These
perceived costs or benefits of disclosure may be informed by others’ opinions and perceptions
regarding the stigmatized illness, by observing others’ disclosure experiences, or even by their
own experience with other similar types of disclosures (Afifi & Steuber, 2009; Brohan, et al.,
2012; Greene, 2009; Ralph, 2002). Perceived costs may be seen as barriers to disclosure, while
perceived benefits may be interpreted as facilitators. In this section, predictors of self disclosure
(i.e., personal characteristics, barriers, and facilitators) are reviewed.
Personal characteristics as predictors of disclosure. There are personal characteristics
that may influence disclosure decisions, and this may vary according to type of disclosure (e.g.,
disclosure of a diagnosed mental illness to others vs. disclosure of symptoms to a provider).

26

Personal characteristics may include individuals’ race or ethnicity, age, gender, and marital
status. Individuals who disclose symptoms of depression to a healthcare provider are typically
younger, are females, and are married (O'Connor, et al., 2001; Probst, et al., 2007). Probst and
her colleagues (2007) found that a significantly lower proportion of older adults (who screened
positive for depression) communicated their feelings with a non-physician practitioner compared
to three younger age groups. Approximately 50% of the older adults reported feelings of
depression to a physician. Further in Probst’ study (2007), 54.4% of females and 46.3% of males
reported depression symptoms to their physician; disclosure was also highest among married
participants. Among older adults ages 70+ in Australia, female gender was found to be a
significant factor to the disclosure of depression symptoms to physicians; marital status did not
show any significant effects in disclosure among this sample (O'Connor, et al., 2001). In the
United States, older adults with some level of depression were more likely to disclose his/her
symptoms to a provider if he/she experienced less satisfaction with others and could not count on
family and friends (Corrigan, et al., 2003).
However, some studies on the disclosure of a diagnosed mental illness have reported
contrary or different findings to what is found among persons reporting their symptoms to
providers. For example, individuals who disclose their mental illness at the workplace are
significantly more likely to be males (Jones, 2011; Pandya, et al., 2011). In a separate study,
females were more likely to endorse reasons for staying in the closet (i.e., conceal) compared to
males (Corrigan, et al., 2010). Results from an unadjusted stepwise linear regression analyses
found that gender, race, and marital status did not predict average openness scores (i.e.,
disclosure) of individuals with schizophrenia; however marital status significantly predicted
overall level of openness after controlling for gender, race, physical health, income, and

27

employment (Pandya, et al., 2011). Contrarily, Corrigan and his colleagues (2010) found no
significant differences in disclosure among those who were married compared to those who were
not.
With regard to race and ethnicity, findings have been mixed. In a study conducted by
Corrigan and his colleagues (Corrigan, et al., 2010), the African American participants were
more likely to identify and endorse the benefits of being out in comparison to non-Hispanic
White participants. Yet studies on the disclosure of symptoms in healthcare settings, racial
minorities were less likely to disclose mental illness symptoms to their providers in comparison
to non-Hispanic Whites (Probst, et al., 2007; Wagner, et al., 2009). For example, African
American and White participants with elevated depressive symptoms who are also receiving care
for diabetes found that African Americans were nearly 6 times less likely than White participants
to have ever discussed depression with their primary care physician (Wagner, et al., 2009).
Similarly, another study showed that Whites and Hispanics were more likely than African
Americans to report depression symptoms to a physician (54.4%, 48.0%, and 35.7%,
respectively); African Americans were less likely to report depressive symptoms in comparison
to Whites even after controlling for demographic, health, and resources (Probst, et al., 2007). At
the workplace, disclosure is significantly more likely among older, non-Hispanic White workers
(Jones, 2011; Rollins, et al., 2002).
Barriers to disclosure. Factors that discourage individuals from disclosing information
about their illness, or that encourage concealment of an illness, are considered to be barriers to
disclosure. In general, there are many barriers to illness disclosure. When the illness is not yet
diagnosed and symptoms are not recognized, a barrier to its disclosure may naturally be the lack
of awareness with regard to the illness (Dew, et al., 2007; Prior, et al., 2003). However, when an

28

illness is diagnosed, barriers to the self disclosure of the illness may include the need for privacy,
control, and the perceived worry or burden on others (Brohan, et al., 2012; Cahill, Lewis, Barg,
& Bogner, 2009; Chen, et al., 2013; Ralph, 2002). However with regard to the disclosure of a
mental illness, there is no other barrier that has been most written about than the stigma that is
related to mental illness (Brohan, et al., 2012; Chen, et al., 2013; Corrigan, Larson, Hautamaki,
et al., 2009; Dalgin & Gilbride, 2003; A. Jones, 2011; Ralph, 2002; Wahl, 1999). Indeed, some
believe that perhaps a focus on stigma has tended to obscure the influence of other equally
important factors that are likely to affect the issue of disclosure (Prior, et al., 2003).
Some individuals are hesitant to disclose about their mental illness to others due to the
belief that illness is private (Brohan, et al., 2012). This need or desire for privacy refers to the
belief that information about mental illness is personal and too intimate to share with others
(Auerbach & Richardson, 2005; Dalgin & Gilbride, 2003), especially those outside of the
immediate family (Chen, et al., 2013). It may not necessarily be related to perceived stigma of
having a mental illness, but may be merely a function of being a private person. For other
individuals, secrecy has more to do with the issue of personal control (Dew, et al., 2007; Ralph,
2002). For example, once they are on the path to recovery, some people may not want to be
reminded of the times when their lives were so out of control (e.g., due to illness), and perhaps
their difficult experiences with seclusion and restraints. Hence, they hesitate to disclose about
their mental illness in order to not be reminded of that difficult time in their lives.
Other individuals may hesitate to disclose their mental illness due to the perceived worry
or burden that it may cause onto others. In a study of Chinese immigrants, participants did not
disclose about their mental illness for reasons of not wanting to bother people because those who
knew would be culturally obligated to visit them or want to help (Chen, et al., 2013). Some

29

participants opted for concealment of their mental illness in order to avoid getting others upset.
Studies have found that fear of burdening family members and other caregivers has an impact on
illness disclosure among persons with terminal illness and older adults in general (Cahill, et al.,
2009; Horne & Payne, 2004). They don’t want to complicate the already-busy lives of their adult
children. Self perceived burden may be especially relevant to older adults, considering
diminished functioning and additional assistance required with activities of daily living, finances
and other areas of life. As such, research indicates that perceived burdensomeness occurs more
often among older adults compared to younger adults (Foster, 2003). Further, among older adults
in a primarily non-Hispanic White sample, perceptions of burden on a spouse are relatively more
severe than the perceptions of burden on a child (Jahn, Van Orden, & Cukrowicz, 2013).
Anticipated discrimination and perceived stigma were commonly cited barriers to
disclosure across several studies focused on mental illness (Brohan, et al., 2012; Chen, et al.,
2013; Corrigan, Larson, & Ruesch, 2009; Peterson, et al., 2011; Ralph, 2002; Thornicroft, et al.,
2009; Wahl, 1999). Stigma-related barriers to mental illness disclosure among employees at the
workplace include the expectation of not being hired, unfair treatment by the supervisor and
colleagues, loss of credibility in the eyes of others, fear of being stereotyped, gossip, and
rejection/alienation (Brohan, et al., 2012; Peterson, et al., 2011; Ralph, 2002; Wheat, et al.,
2010). Anticipated discrimination by employers was described as a lack of opportunity for
advancement and the need to work harder than others to prove one’s worth (Dalgin & Gilbride,
2003). According to Ralph (2002), observations of others’ painful experiences of subtle stigma-
laced day-to-day interactions are the most feared by people who have not disclosed their mental
illnesses. For them, disclosure was described as “the difference between being viewed as a
competent, productive, and accepted person, or being viewed with disbelief in your ability to do

30

a task or complete a job” (Ralph, 2002, p. 166). A global cross-sectional study of persons with
schizophrenia found that anticipated discrimination affected 64% of the participants in applying
for work, training, or education, and 72% felt the need to conceal their diagnosis from others
(Thornicroft, et al., 2009).
Internalized and perceived stigma was described as a barrier to mental illness disclosure
not only in the workforce, but across settings and populations. The fear of alienation, rejection,
disapproval, and avoidance have been found to impede disclosure (Chen, et al., 2013; Corrigan,
Larson, Hautamaki, et al., 2009; Corrigan & Matthews, 2003), while secrecy has long been
identified as a strategy for coping with stigma in populations with mental illness (Link, et al.,
1991; Wahl, 1999). In the qualitative study on Chinese immigrants with mental illness, Chen and
her colleagues (2013) described their personal and familial concerns of losing face. This shame
of having a mental illness sometimes resulted in the family members’ opposition to disclosure.
Further, an empirical study with a sample consisting of 57% African Americans and 34% non-
Hispanic White individuals with schizophrenia found that internalized (self) stigma resulting
from believing the negative stereotypes about mental illness was negatively associated with
benefits of being out (e.g., an indicator of disclosure; Corrigan, et al., 2010). In a sample of 500
clients of Dutch mental health institute with outpatient services, perceived stigmatization was
negatively related to self disclosure (r = -.32, p < .001; Bos, et al., 2009).
Facilitators to disclosure. Factors that assist individuals in deciding to disclose about
their mental illness are considered to be facilitators to disclosure. Some facilitators could be
categorized into intrinsic vs. extrinsic motivators for disclosure. Intrinsic motivators to disclose a
mental illness may include altruism, the desire to be true to themselves, and the desire to
alleviate the stress related to concealment (Brohan, et al., 2012; Garcia & Crocker, 2008;

31

Peterson, et al., 2011; Ralph, 2002). Having an altruistic motivation to disclose means that the
individual discloses only when he/she perceives that his/her own experience with a mental illness
will help another person going through a similar experience (Brohan, et al., 2012; Peterson, et
al., 2011). In other words, at the heart of these individuals’ mental illness disclosure is the desire
to help others. Garcia and Crocker (2008) similarly described ecosystem motivations to
disclosure of depression, which are disclosure motivations that are concerned with contributing
or supporting others. The desire to be true to oneself is a facilitator to disclosure that has much to
do with issues of honesty and pride with regards to self identity (Brohan, et al., 2012). In their
qualitative study of employed New Zealanders, Peterson and her colleagues (2011) similarly
described “moral pressures” and the genuine feeling that self disclosing about one's own mental
illness is the “right thing to do” (p. 146). For some individuals, disclosure may be facilitated
when concealment becomes too stressful and there is a need for catharsis (Afifi & Steuber, 2009;
Brohan, et al., 2012; Kirsh, 2000; Pachankis, 2007). For others, disclosure is facilitated by the
need for emotional support (Brohan, et al., 2012). One study found that the most commonly
selected reason for disclosing a mental illness at the workplace was to obtain support from others
(Banks, et al., 2007). In these situations, people disclosed for the purpose of fulfilling a need for
support, and they seek individuals whom are likely to provide that support. Comfort and
happiness were also identified as facilitators that promoted disclosure (Corrigan, Larson,
Hautamaki, et al., 2009).
There are also extrinsic factors that motivate individuals to disclose their mental illness.
These include legal and practical pressures, support from others, and the need to address
symptoms and explain unusual behavior (Brohan, et al., 2012; Chen, et al., 2013; Jones, 2011;
Ralph, 2002; Wheat, et al., 2010). At workplace settings, legal pressures to disclose can occur

32

when completing health questionnaires during the employment application process since in these
situations individuals are required to answer truthfully to questions regarding a history of mental
illness (Peterson, et al., 2011). Moreover, persons with mental illness are inclined to disclose
when there are practical pressures such as the need for workplace adjustments (Brohan, et al.,
2012; Jones, 2011; Peterson, et al., 2011). Workplace adjustments may include transfers to less
stressful duties and increased schedule flexibility for psychiatric appointments or for
hospitalizations if relapse occurs.
Research has shown that having support from others is an important facilitator —or in
some cases a requirement— to the disclosure of stigmatized identities, including mental illness
(Chen, et al., 2013; Dalgin & Gilbride, 2003; Derlega, Winstead, Greene, Serovich, & Elwood,
2004; Rice, Comulada, Green, Arnold, & Rotheram-Borus, 2009; Smith, Rossetto, & Peterson,
2008; Valle & Levy, 2009). Across settings (e.g., workplace, healthcare, home, other),
individuals are more likely to disclose their mental illness or symptoms to people whom they
trust to be supportive and understanding (Brohan, et al., 2012; Chen, et al., 2013; Dew, et al.,
2007; Fisher, 1995; Jones, 2011; Perry, 2011; Ralph, 2002; Wheat, et al., 2010). Among Chinese
immigrants with mental illness, a self-identified circle of confidence and the appraisal of
affection and trust were two important and significant factors on decisions about disclosure
(Chen, et al., 2013). Among a sample of African Americans with HIV, the most commonly cited
motivator for disclosing their HIV status was perceived increase in social support (Valle & Levy,
2009).
Individuals also elect to disclose a mental illness in order to explain unusual behavior and
to educate others about the mental illness in the event that a crisis occurs (Brohan, et al., 2012;
Jones, 2011; Joyce, McMillan, & Hazelton, 2009). This is of special concern at the workplace

33

where individuals want to avoid having their symptoms misattributed to laziness or illicit drug
use (Michalak, Yatham, Maxwell, Hale, & Lam, 2007). A national mail survey of working
professionals and managers with mental illness found that nearly approximately one half of
disclosures in this sample occurred as a response to explain symptoms or hospitalizations
(Ellison, et al., 2003).
In sum, this chapter reviewed research on the intersection of stigma, mental illness, and
disclosure, and then focused on dimensions such as disclosure recipients, experienced and
perceived consequences of disclosure as well as other facilitators and barriers that influence
individuals’ decisions to disclose. Together, these dimensions convey the dynamics of
disclosure. While there is a growing amount of research on the topic of mental illness disclosure
within the social network, there are very few studies that inform the experience of mental illness
disclosure among racial/ethnic minorities and older adults. With very few exceptions, much of
what is known regarding illness disclosure among racial/ethnic minorities is from the HIV
literature, and thus far no studies have been found that inform of the experiences relating to
depression disclosure among Latino older adults. This dissertation aims to address this gap.

34

CHAPTER 3: METHOD
Data Source
This dissertation is a cross sectional study designed to understand depression disclosure
among 35 Latino older adults who were receiving care at community ADHCs and who were also
participating in an NIMH-funded randomized control depression intervention study titled
“Enhanced Geriatric Depression Treatment in Adult Day Health Care” (i.e., Programa Mano
Amiga, PMA). The data were collected by the author and three research assistants via semi-
structured qualitative interviews that included a semi-structured network survey.
Recruitment of the Sample
Sampling. The data for this dissertation were derived from data that had been collected
for the aforementioned PMA study. Random sampling methods were utilized to yield 35 Latino
older adults from the pool of 100 participants in the Programa Mano Amiga study.
Programa Mano Amiga (PMA). The PMA study was a randomized controlled trial
(RCT) funded by the National Institute of Mental Health and conducted by Drs. María P. Aranda
and Kathleen Ell from the University of Southern California in cooperation with AltaMed Health
Services Corporation. The purpose of the PMA study was to identify best ways to treat severe
depression in older Latinos. It was specifically intended to determine if a particular type of
counseling called Problem Solving Treatment
1
(PST) was more effective in alleviating severe
depression than Enhanced Usual Care (EUC).
The following criteria were required for participation:
1. Latino descent (English- or Spanish-speaking)
2. 60 years of age or older

35

3. Met criteria for Major Depression, as ascertained by the Structured Clinical Interview
for DSM-IV (SCID) which was conducted by the study personnel
After informed consent processes were conducted and diagnostic criteria of severe
depression were confirmed, participants completed a baseline assessment and were randomized
into either one of the two study arms (i.e., EUC or PST). Participants randomized to the
intervention arm participated in 8 to 9 weekly individual counseling sessions of PST provided by
a trained and supervised social worker that was part of the research team and not AltaMed staff.
Participants randomized to the EUC received the typical care that is received by older adults who
utilize adult day health care services, plus educational material on depression and quarterly
monitoring of depression symptoms by the AltaMed social worker. Demographic information
was collected during the diagnostic and baseline interviews, which includes participants’ age,
preferred language, nativity, marital status, and years of education.
PMA participants provided permission for medical chart extraction and completed
follow-up assessment interviews at 4 and 8 months post baseline. Gift card compensation was
offered for each of those assessments. A recruitment target of 100 participants was reached,
although approximately 5% of these participants died or became lost to follow-up. Eight-month
outcomes interviews were completed with the remaining participants.
After completion of the 8-month assessments, random sampling methods were used to
recruit 35 participants for a face-to-face qualitative interview which included the semi-structured
network survey. The purpose of this portion of the PMA study was to provide an in-depth
understanding of participants’ experiences with depression and disclosure, their experiences in
the study, and their suggestions on how to improve depression care.

36

In summary, the sample for this dissertation consists of the 35 randomly-selected PMA
participants who completed the qualitative interviews. Data utilized for this dissertation was
derived from the PMA qualitative interviews, which contained an embedded network survey.
Data for this dissertation also included demographic and diagnostic information that was
collected during the diagnostic interview.
Development and Translation of Study Materials
The interview guide for the qualitative interviews was developed jointly by the PMA
Principal Investigator (Aranda), the author of this dissertation (Fuentes), and two additional
doctoral-level research assistants. It contained a combination of closed questions as well as open-
ended questions with probes. The interview guide also contained a network survey. These study
materials were translated from English to Spanish prior to data collection. Translations were
presented and discussed by three team members to ensure language equivalence. Problematic
translations were modified by reaching consensus between the team members involved. The
interview guide was pilot-tested with three participants. Modifications were made to clarify any
questions and probes that seemed unclear, and thus improve the utility of the interview guide.
Refer to Appendix A for the interview guides in English and Spanish.
Data Collection
The PMA study was approved by the USC Institutional Review Board (IRB). This
dissertation falls within the scope of the IRB-approved protocol. Informed consent procedures
were repeated in situations where the original consent to participate in the PMA study had been
provided by the participant more than one year prior to the date of the qualitative interview. All
data were self-reported and collected during the PMA during face-to-face interviews by team
members of the PMA study. Interviews with Spanish-speaking participants were conducted by

37

bilingual, Spanish-speaking researchers. The interviews took place at the participants’ home or
their AltaMed ADHC site, and averaged 90 minutes in duration. All interviews were audio-
recorded and transcribed in the language in which they were conducted. Additionally, data from
the network surveys were recorded in pencil and paper format. There was no monetary
compensation provided to participants for their participation in the qualitative interviews. The
content of the interview was divided into the three parts described here.
Part 1: Depression and the PMA study. Using the semi-structured interview guide,
participants were asked about their depression knowledge, their experiences with depression,
their experiences in the study, and their suggestions on how to improve depression care. They
were also asked questions regarding sociocultural and contextual issues. While most of the
questions were open-ended, other questions were closed-ended and included many probes. For
example, to find out about their overall impression of the PST sessions, participants were asked
the following open-ended question, “If someone asked you what the sessions were about, what
would you tell them?” They were also asked, “If someone asked if you liked these sessions or
not, what would you tell them?” In the latter question, most participants would answer yes or no,
indicating whether they liked the sessions or didn’t like the sessions. Hence, follow-up probes
asked participants to provide examples of why they liked the sessions and/or examples of why
they didn’t like the sessions. Refer to Appendices A and B for the Interview Guides in English
and Spanish.
If they had been randomized to the Problem Solving Treatment intervention, they were
also asked to describe what they remember about the PST. Additionally, participants were asked
to describe their disclosure to family members with regards to their participation in the research
study.

38

Part 2: Social support network and the alters’ attributes. Social support network data
were collected as part of the face-to-face interview, using a modified version of Barrera’s (1981)
Arizona Social Support Interview Schedule (ASSIS). The ASSIS consists of a series of questions
to assess seven dimensions of a social support network, including (a) private feelings, (b)
material aid, (c) advice, (d) positive feedback, (e) physical assistance, (f) social participation, and
(g) negative interactions. The ASSIS also taps into (a) the perceived social support, (b) the
utilized social support, and (c) the need for social support for the first six of the seven
dimensions. The original ASSIS was modified for the PMA study to include only the dimensions
of perceived private feelings and perceived physical assistance, which were found to be of most
relevance among a similar sample (i.e., Latino older adults who receive services at AltaMed
Corp.) from a previous study conducted by the Principal Investigator of the PMA study (Aranda,
Lee, & Wilson, 2001). The social support network survey was further modified to also include
questions to assess reciprocal relationships of support. Specifically, participants in this study
were first asked to provide the first names, nicknames, or initials of:
1. Individuals who the participant talks to about things that are very personal and private;
2. Individuals who go to the participant to talk about things that are very personal and
private;
3. Individuals who the participant could call on for time and energy to help take care of
things that s/he needs to do; and
4. Individuals who call on the participant for her/his time and energy to help take care of
things.
In this study, the social support dimension of private feelings, which is derived from the
first two questions listed above, was instead labeled as emotional support. For each participant,

39

the names provided for the four network questions were compiled to generate a list of all
nonduplicated persons that provide and/or receive emotional support and/or physical assistance
to each participant. Thus, for each participant this comprehensive list of individuals composed
his/her aggregate support network.
Second, the participant was asked attribute data for each of the individuals (i.e., network
alters) mentioned in the aggregate support network. Specifically, participants were asked the
following questions for each network alter:
1. Socio-demographic information, such as each alter’s gender and the relation to the
participant (e.g., son, daughter, sibling, friend, provider, minister/pastor, etc)
2. Whether or not the alter belongs to the same AltaMed ADHC site
3. Self disclosure: Whether or not the alter knows that the participant has depression,
and if so, who told the alter of the participant’s depression
4. Burden: Whether or not the participant thinks that her/his depression is a bother or
burden to the alter
5. Stigma: Whether or not the participant feels that talking about her/his depression with
the alter is shameful or embarrassing
Part 3: Depression disclosure. Each participant was asked questions with follow-up
probes regarding any additional recipients of depression disclosure, factors that influence
disclosure, and any details to describe their process of disclosure. For example, to find out more
about influential factors of disclosure decisions, participants were asked, “Please describe how
your depression was disclosed or communicated to family members/caregivers and others who
are important to you?” Possible probes included:

40

1. Direct or indirect (roundabout) communication? (e.g., found out from you directly,
from others, or other way?)
2. What words were used, if any? (e.g., verbal language, non-verbal/ body language)
3. What was context of the conversation or situation? (e.g., spontaneous or planned talk)
4. How did the process of disclosing differ by type of person/relation, if at all?
The interviews were designed to be sufficiently open-ended to enable the participant to
elaborate on issues that she/he considers important or relevant to her/his experience with the
disclosure of depression. Oftentimes in this section, participants compared and contrasted or
simply made some direct reference to their disclosure experience with one or more of the alters
in the aggregate social support network.
Data Analysis
This section describes the methods utilized for analysis of the qualitative and network
data, separately. The primary source of data that was used to accomplish each aim is then
outlined.
Analysis of the qualitative data. Interview transcripts were analyzed using a
methodology of “Coding Consensus, Co-occurrence, and Comparison” outlined by Willms et al.
(1990) and rooted in grounded theory (i.e., theory derived from data and then illustrated by
characteristic examples of data; Glaser & Strauss, 1967). To condense the data into analyzable
units, the transcripts were first open-coded independently by three PMA team members. In this
step, segments of transcripts ranging from a phrase to several paragraphs were assigned codes
based on a priori (i.e., based on questions in the interview guide or main issues found in the
literature) or emergent themes. The principle of constant comparison was used to determine
whether a particular topic is similar or different from a topic raised earlier and to determine when

41

discussion of a particular topic begins and ends. For example, if we identified that the segment of
text that we were working on was similar to the segments that preceded or succeeded it, it was
assigned the same code. If we identified the text segment to be different, then it was assigned a
different code. There were some instances where more than one code was applied to the same
text segment.
After each team member independently coded the transcripts, these codes were discussed,
matched, and then integrated into a single codebook through a consensus process. Disagreements
in assignment or description of codes were resolved through discussion between the team
members. The final list of codes (i.e., the codebook) consisted of a numbered list of themes,
issues, accounts of behaviors, and perceptions or opinions that related to disclosure of depression
among older Latinos.
Based on these codes, the process of axial coding was used to generate a series of
categories, arranged in a treelike structure relating and connecting transcript segments grouped
into separate categories or nodes as described by Strauss and Corbin (1990). These nodes and
trees were then used to create a taxonomy of themes that include a priori and emergent
categories related to the topic of depression disclosure. In other words, the process of constant
comparison (i.e., where we decide how each code is like or different from other codes) enabled
us to organize codes both vertically (i.e., codes describing specific variations of a particular
theme or topic) and horizontally (i.e., codes describing related topics or themes). This taxonomy
was the product of the vertical and horizontal integration of codes in the codebook, which
provides us with a list of themes or topics and helps to illustrate how these themes or topics are
related to one another.

42

Inter-coder reliability and percent agreement. Techniques and procedures used in
other qualitative studies for increasing inter-coder reliability and for assessing percent agreement
were followed (Boyatzis, 1998). To increase the reliability between three coders, the independent
coder method was utilized (Miles & Huberman, 1984). In this technique, three researchers
independently observed the raw information (i.e., transcripts) and identified codes without
interacting or seeing the judgments of the other researcher performing the same task. After
independent coding was completed by the three researchers involved, they convened to discuss
and compare results until agreement was reached.
Percent agreement is a measure of the reliability in assigning codes by different coders.
To assess percent agreement between the researchers, a random sample of 15 pages from the
entire pile of transcripts were distributed to each of the three researchers involved. Each coder
then coded the transcript pages using the codebook. The total number of codes assigned to the 15
pages constituted the denominator, and the total number of the same codes assigned by the
different coders constituted the numerator when calculating percent agreement in coding. The
agreement rate (across the three coders) over all codes was 83%, which was acceptable. Codes
with lesser agreement were then discussed, and the codebook was further clarified. Afterward, all
coding of transcripts from the older adult interviews was performed by the author of this
dissertation.
Analysis of network data. Data that is collected from the network survey generated a
variety of descriptive statistics. As mentioned in the previous section, for each participant the
names provided for the four network questions were compiled to generate a list of all
nonduplicated persons, hence composing each participant’s aggregate support network. Using
this number as the denominator, the individuals’ egocentric network could be described based on

43

numerous characteristics such as the proportions of alters within their respective egocentric
network that: (a) correspond to specific roles (e.g., family member, friend or neighbor, care
attendant, etc); (b) are of same gender; (c) are a source of stigma; and (d) are burdened by the
participant’s depression.
Descriptive statistics regarding the social support relationships within the aggregate
support network were also computed. For example, the proportion of reciprocal emotional
support (ES) relationships within an individual’s aggregate support network would be calculated
by dividing the number of reciprocal ES ties by the number of alters in his/her aggregate support
network. In this way, numerous social support relationships (i.e., emotional support received,
emotional support given, physical assistance received, physical assistance provided, and so forth)
were examined as proportions of the aggregate support network.
Computer software. The SPSS software was utilized for data management and analyses
of the quantitative/network data (IBM, Released 2012). The computer program QSR NVivo was
used to facilitate data management, coding, and analysis of the qualitative data (Fraser, 2000).
Each participant’s socio-demographic data as well as some data generated from the network
survey were organized into an attribute table that was created in NVivo. This attribute table was
then linked to the transcripts and codes.
Analyses of data by aim. In this section, each of the four aims is revisited and the
specific methods are explained.
AIM 1: To quantitatively examine the relationship between the participant demographics
and depression disclosure to the egocentric networks.
The first aim of the study was achieved through the use of the quantitative/network data.
Specifically, bivariate correlations were performed between demographic variables and the

44

network variable of self disclosure. The network variable of self disclosure was operationalized
as the proportion of network that the participant had disclosed to. The participants’ demographic
data had been collected from the PMA diagnostic interview and included the participants’ age,
nativity, preferred language, marital status, living arrangement, and years of education. Other
information, such as the Hamilton Depression Rating Scale (HDRS) score, which ascertains the
severity of depression, and the intervention arm (e.g., PST or EUC), were also explored for
association with the proportion of egocentric network that the participant had self disclosed to.
Coefficients were calculated to determine the statistical significance of the relationships between
the variables.
AIM 2: To quantitatively examine the relationship between the structure (i.e., size and
composition) of the egocentric networks and participants’ depression disclosure to their
network.
The second aim was examined using similar procedures as in the first aim, where all of
the data derived from the network survey. Specifically, for each participant proportions were
calculated for the network variables and these were compared to the proportion of their network
that he/she had self disclosed to. Network variables that were included in this correlation
analysis include the size of the network (i.e., number of nonduplicated alters in the aggregate
social support network) and the proportion of the network that (a) provides emotional support to
participant, (b) provides physical assistance to the participant, (c) provides both emotional
support and physical assistance to the participant, (d) receives emotional support from
participant, (e) receives physical assistance from the participant, (f) reciprocates emotional
support, (g) reciprocates physical assistance, (h) is female, (i) is same gender as participant, (j) is
family or relative, and (k) is a friend or neighbor.

45

As in the previous aim, Pearson product-moment correlation coefficients were calculated
to determine the statistical significance of the relationships between the variables.
AIM 3: To examine the relationship between participants’ perceived stigma, perceived
burden on others, and disclosure of depression to their network.
This aim entailed calculating proportions of each participant’s network that characterized
stigma, burden, and disclosure. In other words, perceived stigma was characterized as the
proportion of the alters in the participant’s network that the participant felt ashamed or
embarrassed to talk to about depression. Perceived burden on others was characterized as the
proportion of the alters in the participant’s network that the participant believes is bothered or
burdened by his/her depression. Self disclosure was operationalized as the proportion of each
participant’s network that he/she had self disclosed to. All data to calculate these proportions
were gathered from the network surveys. Correlation analyses were performed, and correlation
coefficients were calculated to determine the statistical significance of the relationships between
the variables.
From the correlation table, variables that were significantly correlated to the dependent
variable (percent of network disclosed to) were identified. The theoretical and significantly
correlated variables were included in a final multiple regression model for depression disclosure.
With a sample size of 35, results generated from regression analyses serve an exploratory
purpose.
Qualitative data from the interview transcripts were also utilized to contribute in the
understanding of the concepts of depression self disclosure, perceived burden on others, and
perceived stigma. The relationships between these variables as presented in the qualitative
interviews were also examined and documented in the conceptual model of disclosure.

46

AIM 4: To qualitatively examine the disclosure process through which older Latinos
communicate to members of their support network and important others that they have
depression
To achieve Aim 4, the text derived from the last section of the semi-structured interview
guide was analyzed using the qualitative methods described above. Transcript text of examples
of participants’ disclosure was especially relevant to accomplish this aim.

47

CHAPTER 4: RESULTS
Characteristics of the Study Participants
The age of the Latino older adult participants ranged between 60 and 85 years, with an
average age of 71.11 (SD = 7.26). The study sample was comprised primarily of females
(85.7%), and the majority identified Spanish as their preferred language (88.6%). Thirty of the
35 participants were foreign-born: 22 were born in Mexico, 7 were from Central America, and 1
identified as being born in Cuba. At the time of baseline interviews, 40% of the participants
identified as being currently married or in a domestic partnership, while nearly six percent of the
sample identified as being single and never married. The remaining participants were either
widowed (28.6%) or separated/divorced (25.7%). Also at the time of baseline interviews, nearly
two-thirds of the participants were living with family, which includes their spouse (22.9%), adult
children (37.1%), or other relatives (2.9%). Over one-third of the participants reportedly lived
alone. Moreover, the majority of the sample had completed up to eight years of schooling; nearly
17% completed high school or higher. Table 1 provides demographic and selective study
characteristics of the 35 participants in the sample.
The sample’s average depression score based on the Hamilton Depression Rating Scale
(HDRS) was 23.77 (SD = 4.57). Severity levels of at least 26 points were reached by 10 of the 35
participants, indicating severe baseline depression levels amongst these participants. The
remaining 25 participants scored at moderate levels of depression (i.e., 18 - 25 points on the
HDRS). Finally, nearly two-thirds of the 35 participants had been randomized into the Problem
Solving Treatment intervention of the PMA study, while the remaining 34.3% received
Enhanced Usual Care.

48

Table 1: Demographics and other characteristics of the study participants
Variable Mean (SD) n (%)
Age 71.11 (7.26)
Gender
Female 30 (85.7)
Male 5 (14.3)
Nativity
Born in U.S. 5 (14.3)
Born outside of U.S. 30 (85.7)
Preferred language
Spanish 31 (88.6)
English 4 (11.4)
Marital Status
Married or domestic partnership 14 (40.0)
Widow 10 (28.6)
Separated, Divorced 9 (25.7)
Single, Never married 2 (5.7)
Living Arrangement
Lives alone 13 (37.1)
Lives with spouse or other family 22 (62.9)
Education
a

8
th
grade or less 27 (77.1)
Some high school 2 (5.8)
High school or higher 6 (17.2)
Hamilton Depression Rating Scale (Baseline Score) 23.77 (4.57)
Study intervention condition
Problem Solving Treatment (PST) 23 (65.7)
Enhanced Usual Care (EUC) 12 (34.3)
Note.
a
Total percentage might exceed 100% due to rounding.

49

Characteristics of the Network Alters
Persons who were identified as being part of a network are referred to as network alters.
In the network survey, the 35 participants in this study identified a total of 199 individuals (i.e.,
network alters) that either (a) provide them with emotional support and/or physical assistance, or
(b) they provide emotional support and/or physical assistance to. Nearly 73% of these 199
network alters were female; only 54 were male. Approximately 70% were identified as being of
the same gender as the participant whose egocentric network they belong to. With regards to
relation, the majority were family members. Among the 127 alters that were identified as family
or relatives, there were 7 spouses, 45 daughters, 34 sons, 16 siblings, and 10 grandchildren.
Fifteen other relatives were made up of in-laws, cousins, nieces, and so forth. There were 72
alters identified as non-relatives: 42 were friends/neighbors and 13 were home care workers or
attendants. The remaining 17 were healthcare professionals or agency staff persons, persons from
their religious group or organization, and other acquaintances. The participants identified 14 of
the 199 alters as persons whom they are embarrassed or ashamed to talk to about their
depression. Similarly, they identified 74 alters as persons whom they perceive might be burdened
by their depression.
Size and Composition of the Study Participants’ Egocentric Networks
Each of the 199 alters identified during the network survey belongs to one of 35
egocentric support networks, which, in turn, correspond to each of the 35 participants. According
to the survey data, the majority of participants had a medium-sized network that consisted of 4 to
6 alters. Seven of the 35 participants had small aggregate networks (with 1-3 individuals), while
nine participants had large networks of at least seven persons. The average number of alters in a
network was 5.69 (SD = 2.99) across the 35 participants, although the range was quite wide

50

(between 1 and 15 alters). Eighty-eight percent of the participants identified at least one person
who provides him/her with emotional support. Rounding to the nearest whole number, the 35
participants identified an average of three persons that provide them with emotional support
(Mean = 3.31, SD = 2.98), three persons that they provide emotional support to (Mean = 2.86,
SD = 2.97), and two persons that they share a reciprocal relationship of emotional support with
(Mean = 1.97, SD = 2.98). A reciprocal relationship of emotional support was experienced by
60.0% of the participants.
Each participant identified at least one person that provides him/her with physical
assistance, while the majority of the sample (54.3%) could not identify at least one individual
that they provided physical assistance to. The average number of alters providing physical
assistance to participants was 3.09 (SD = 2.96). The average number of alters that the
participants provide physical assistance to was much lower (Mean = 0.77, SD = 1.00). Only
37.1% of participants experienced at least one reciprocal relationship of physical assistance.
Sixty percent of the participants identified at least one person who provides both types of
support (i.e., emotional support and physical assistance). An average number of alters that
provide both types of support was 1.54 (SD = 2.62). A reciprocal relationship of both types of
support was experienced by only 3 of the 35 participants, and this occurred with only four of the
199 alters. See Tables 2 and 3 for details on the composition of the networks.
There was a wide range in the number of persons in the participants’ support networks
that the participants identified as someone that might be burdened by his/her depression (range =
0 - 14). Sixteen participants indicated that no one in their network was burdened by their
(participant’s) depression, while one participant indicated that 14 persons in her network were
burdened by her depression. The mean number of persons burdened by participants’ depression

51

was 2.11 (SD = 3.10) across the sample. Similarly, not all participants identified persons that
they felt embarrassed or ashamed to talk to about their depression; yet some participants
identified up to 5 persons in their egocentric network that they are embarrassed or ashamed to
speak with about their depression. The average number of persons in the participants’ egocentric
networks that the participants identified as being ashamed or embarrassed to talk to about
depression is 0.41 (SD = 3.24) across the sample.
All but one participant identified at least one female in their network. Males were
identified as network alters by nearly three-fourths of the participants. While nearly 89% of the
participants identified at least one family member as part of their aggregate support network,
only 20% identified a spouse. Hence, for the remaining 69% of participants who identified at
least one family member in their network, the family member may have been an adult child, a
sibling, or other relative (e.g., daughter-in-law, son-in-law, etc). Over half of the participants
identified at least one friend or neighbor as a member of their aggregate support network.
All of the participants identified at least one person within their network that was aware
of their depression, and 91.4% identified at least one person that he/she had self disclosed to.
Three participants did not self disclose to anyone in his/her support network. Participants in this
sample self disclosed their depression to an average of three alters in their network (Mean = 3.43,
SD = 2.83). Refer to Tables 2 and 3 for more details on the size and composition of the
participants’ egocentric networks of social support.
During the qualitative interview, some participants expressed that their support networks
were much larger. For example, one participant expressed that she was naming only the first few
persons that came to mind and who were extremely important to her, but that her support
network was much larger than that due to her role in church as a counselor. As the interview was

52

being conducted, it was noted that this participant seemed somewhat frustrated with not being
able to remember everybody’s name in response to each of the types of support provided or
received.
Moreover, several of the participants expressed that they could not provide physical
assistance to anyone due to their health or physical ability. However, they would be willing to
provide this support if they could. Many of the female participants expressed having provided
physical assistance in the form of babysitting grandchildren in years past. It was in this part of
the interview that many of the participants seemed to lament the limitations of their physical
health or functional abilities.

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Table 2: Size of participants’ social support networks according to participant and alter
characteristics
Variable N (%) Mean (SD) Min Max
Size of participants’ network
Small (1-3 ties) 7 (20.0)
Medium (4-6 ties) 19 (54.3)
Large (7+ ties) 9 (25.7)
Across the 35 participants, the number of alters…
in the participants’ egocentric support network 5.69 (2.99) 1 15
who provide participants with emotional support 3.31 (2.98) 0 14
who provide participants with physical assistance 3.09 (2.96) 1 14
who provide participants with both types of support 1.54 (2.62) 0 13
who receive emotional support from participants 2.86 (2.97) 0 14
who receive physical assistance from participants 0.77 (1.00) 0 3
that reciprocate the participants’ emotional support 1.97 (2.98) 0 14
that reciprocate the participants’ physical assistance 0.57 (0.88) 0 3
that are female 4.14 (2.43) 0 11
that are male 1.54 (1.22) 0 5
that are family members 3.63 (2.66) 0 14
that are spouses 0.20 (0.41) 0 1
that are daughters or sons 2.26 (1.87) 0 8
that are siblings 0.46 (1.15) 0 6
that are friends or neighbors 1.20 (1.59) 0 6
that are care attendants 0.37 (0.60) 0 2
that may be burdened by participants’ depression 2.11 (3.10) 0 14
that participant is ashamed to talk about depression 0.40 (1.01) 0 5
that are aware of participant’s depression 4.51 (3.24) 1 15
that participants have self disclosed to 3.43 (2.83) 0 10

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Table 3: Number and percentage of study participants that identified at least one person
that…
Variable n (%)
provides him/her with emotional support 31 (88.6)
provides him/her with physical assistance 35 (100.0)
provides him/her with both types of support 21 (60.0)
he/she provides emotional support to 30 (85.7)
he/she provides physical assistance to 16 (45.7)
he/she shares reciprocal relationship of emotional support with 21 (60.0)
he/she shares reciprocal relationship of physical assistance with 13 (37.1)
is part of his/her support network and…
is female 34 (97.1)
is male 26 (74.3)
is a family member 31 (88.6)
is a spouse 7 (20.0)
is a daughter 22 (62.9)
is a son 22 (62.9)
is a sibling 9 (25.7)
is a friend or neighbor 18 (51.4)
is a care attendant 11 (31.4)
is aware of his/her depression 35 (100.0)
he/she has self disclosed to 32 (91.4)

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Disclosure Patterns by Participant Demographics
The first aim of this study was to examine the relationship between participant
demographics and their self disclosure of depression to their network. Depression disclosure to
the network was operationalized as the proportion of the participant’s network that the
participant had self disclosed to. Bivariate correlation analyses show that only the participant’s
age and education were significantly related to the proportion of the participant’s network that
was disclosed to. In this sample, the proportion of the network that was disclosed to about
depression was significantly (inversely) related to the participant’s age (Pearson’s r = -.431, p =
.01). As age increased among the participants, there was a decrease in the proportion of their
networks that they had disclosed their depression to. The average proportion of network that the
older adult participants disclosed to was 0.581 (SD = 0.34), meaning that on average the
participants disclosed to 58.1% of their corresponding egocentric network.
The proportion of the network that was disclosed to about depression was also
significantly and inversely related to the participant’s number of years of education (Pearson’s r
= -.362, p = .033). Participants with greater number of years of education disclosed to a smaller
proportion of their social support network.
While statistically significant relationships were present between other participant
demographic variables, such as nativity and preferred language (Pearson’s r = .880, p < .001),
education and preferred language (Pearson’s r = -.622, p < .001), and living arrangement and
marital status (Pearson’s r = -.628, p < .001), these variables were not found to be related to the
proportions of networks disclosed to about depression. Participant gender, their baseline HDRS
score, and their participation in the Problem Solving Treatment intervention were not found to be
significantly related to network disclosure or any demographic variable. Refer to Table 4 for the

56

correlation matrix of variables describing the participant demographics and the proportion of
depression disclosure to his/her network.

57

Table 4: Correlation matrix of variables describing participant demographics and depression disclosure to his/her network
1 2 3 4 5 6 7 8 9 10
1. Proportion of participant network that the
participant has disclosed to
1
2. Participant’s age -.431** 1
3. Gender (Female) .318 -.119 1
4. Nativity (Foreign-born) .042 .064 .067 1
5. Preferred language (Spanish) .159 .219 .110 .880** 1
6. Marital status (Married, domestic partnership) -.237 .158 -.333 .000 .110 1
7. Living arrangement (lives alone) .179 .021 .145 .145 .090 -.628** 1
8. Education (years) -.362* -.064 -.313 -.548 -.622** .046 -.064 1
9. HDRS score .016 .170 -.202 -.034 .121 .287 -.145 -.055 1
10. PST intervention -.073 -.173 -.123 -.049 -.070 .098 .057 -.137 .150 1
Note. HDRS = Hamilton depression rating scale; PST = problem solving treatment.
* = p < .05. ** = p < .01.

58

Disclosure Patterns by Participants’ Network Characteristics
The second aim was to examine the relationship between network characteristics and
participants’ depression disclosure to their network. In this study, network characteristics
included size, demographic composition, and types of social support relationships within the
network. Bivariate correlation analyses showed that disclosure to the network was significantly
related to providing emotional support. Specifically, as the proportion of the network that the
participant provided emotional support to increased, so did the proportion of alters within the
network that were disclosed to about depression (Pearson’s r = .343, p = .044). On average
participants provided emotional support to 46.4% (SD = 0.30) of their network and disclosed to
58.1% (SD = 0.34) of their network.
Other types of social support relationships (e.g., receiving emotional support, providing
physical assistance, and so forth) were not found to be significantly related to depression
disclosure to the social network. Network size and demographics of the network were also not
found to be related to participants’ depression disclosure to their network. However, statistically
significant relationships were observed between other variables, including proportion of network
that is female and proportion of network that receives emotional support from participant
(Pearson’s r = .469, p = .009) and the proportion of network that is female and proportion of
network that is family (Pearson’s r = -.378, p = .025). From this data we find that networks that
had high proportions of females had higher proportion of alters that received emotional support
from the participant. Similarly, as proportion of females increased within the networks, so did
the proportion of family members. Refer to Table 5 for the correlation matrix of variables
describing the size, demographic composition, social support relationships, and the proportion of
depression disclosure to the network.

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Table 5: Correlation matrix of variables describing the size, composition, relationships, and disclosure within the network
Proportion of alters in the support
network that …
1 2 3 4 5 6 7 8 9 10 11 12 13
1. participant disclosed to 1
2. provides ES to participant .114 1
3. provides PA to participant -.094 -.088 1
4. provides ES and PA to participant -.215 .563** .581** 1
5. receives ES from participant .343* -.219 .037 -.240 1
6. receives PA from participant -.051 -.303 -.108 -.241 -.026 1
7. reciprocates ES .037 .631** .115 .469** -.169 -.229 1
8. reciprocates PA -.031 -.209 .318 .194 -.047 -.083 -.011 1
9. is female .253 .094 .125 .144 .433** .068 -.042 -.072 1
10. is same gender as participant .098 .265 .043 .136 -.104 -.350* .175 .056 .248 1
11. is family -.202 -.111 -.028 -.046 -.079 -.081 -.181 -.049 -.378* -.165 1
12. is friend or neighbor .141 -.094 -.064 -.221 .244 .297 -.171 .099 .293 .014 -.733** 1
13. Network size .127 .026 .157 .012 .287 -.391* .103 .213 -.011 .100 .070 -.041 1
Note. ES = emotional support; PA = physical assistance.
* = p < .05. ** = p < .01.

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Depression Disclosure, Perceived Stigma, and Perceived Burden to Others
The third aim of this study was to examine the relationship between perceived stigma,
self-perceived burden, and the disclosure of depression to members of their support network.
Bivariate correlation analyses of the proportions of alters within the networks (that the
participant was embarrassed or ashamed to talk with about depression, that were potentially
burdened, and that were disclosed to) show that self perceived burden –but not perceived
stigma– was significantly related to participant disclosure of his/her depression. Specifically in
this analysis, the proportion of the network that participants perceive might be burdened by
his/her depression is significantly related to the proportion of the network that the participants
disclosed to (Pearson’s r = .338, p = .047). On average, participants identified 31.6% (SD = 0.38)
of alters in their networks that might be burdened or bothered by the participant’s depression.
Although the relationship between the proportion of the network that the participant was
ashamed to talk with about depression and the proportion of the network disclosed to was not
found to be statistically significant, the direction of the correlation was in the expected (negative)
direction (Pearson’s r = -.257, p = .136). On average, participants were ashamed or embarrassed
to talk with 6.4% (SD = 0.17) of their network about his/her depression.
A moderate, positive correlation was found between the proportion of the network that
might be burdened or bothered by the participants’ depression and the proportion of the network
that receives emotional support from the participant (Pearson’s r = .433, p = .009). Furthermore,
a weak correlation was observed between the proportion of the network that might be burdened
by the participant’s depression and the proportion of the network that the participant felt
ashamed or embarrassed to talk to about depression. However, this correlation was not
statistically significant at the .05 level (Pearson’s r = .290, p = 0.091). See Table 6.

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Table 6: Correlation matrix of variables describing emotional support, stigma, burden, and depression disclosure within the
egocentric networks
Proportion of alters in the support network that … 1 2 3 4 5 6
1. participant disclosed to 1
2. provides emotional support to participant .114 1
3. receives emotional support from participant .343* -.219 1
4. participant reciprocates emotional support to .037 .631** -.169 1
5. might be burdened by participant’s depression .338* -.112 .433** -.084 1
6. participant is ashamed or embarrassed to talk to about depression -.257 -.003 .017 .128 .290 1
Note. * = p < .05. ** = p < .01.

62

To examine the relative contribution of the independent variables representing stigma and
burden to the variance of the dependent variable representing disclosure, a hierarchical
regression was conducted. Tests for multicollinearity indicated that a very low level of
multicollinearity was present (VIF = 1.365 for proportion of network that is burdened by
depression; VIF = 1.109 for proportion of network that may be source of stigma; and VIF =
1.251 for proportion of network that participant provides emotional support to), and thus suggest
that the estimated b coefficients are well established in the following regression models.
Intercorrelations between the variables were reported in Table 6 and results of the hierarchical
regression predicting the proportion of network disclosed to are reported in Table 7. The variable
proportion of the network that might be burdened by the participant’s depression was entered in
the first stage. The results of stage one (Model I) show the effect of the Burden variable to be
statistically significant on the dependent variable (F
(1, 33)
= 4.27, p = .047), and indicate that the
variance accounted for (R
2
) with the first predictor equaled 0.114 (adjusted R
2
= 0.088). In other
words, the proportion of the network burdened by depression explained 8.8% of the variance in
the proportion of the network that was disclosed to. In the second stage, the variable proportion
of the network that participant is ashamed or embarrassed to talk with about depression was
added. Model II was also found to be significant overall (F
(2, 32)
= 5.39, p = .01). The first two
independent variables combined accounted for a total of 20.5% (Adj. R
2
) of the variance in the
data. This represents an increase of approximately 12% that was significant ( ∆F
(1, 32)
= 5.89, p =
.021) from the previous model which included only the first independent variable (i.e.,
proportion of network that was burdened by depression). In the third stage, the variable
proportion of the alters in the network that the participant provides ES to was entered into the
regression equation, which resulted in statistical significance for Model III overall (F
(3,31)
= 4.05,

63

p = .015). The three variables combined accounted for a total of 21.2% of the variance in the
proportion of the network that participants disclosed to. However, the 0.7% increase in variance
was not found to be statistically significant ( ∆F
(1,31)
= 1.28, p = .266) from the explanatory power
of the previous model, Model II. Based on the change in adjusted R
2
, the variable representing
Stigma contributed the most to the model. The equation for the final model is:
Y
PropNetworkDisclosedTo
= 0.421 + 0.334X
PropNetworkBurdened
- 0.741X
PropNetworkStigmaSource
+
0.218X
PropNetworkReceivesES

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Table 7: Summary of hierarchical regression analysis for variables predicting the proportion of
network that the participant has disclosed to about his/her depression
Model I Model II Model III
Variables B SE B β B SE B β B SE B β
Constant .482 .073 .499 .068 .421 .097
Proportion of
network
burdened by
participant’s
depression
.313 .152 .338* .417 .148 .451*** .334 .165 .361*
Proportion of
network that
participant is
ashamed or
embarrassed
to talk with
about
depression
-.788 .325 -.388** -.741 .326 -.365**
Proportion of
network that
the participant
provides
emotional
support to
.218 .193 .193
F 4.27** 5.39** 4.05**
R
2
.114 .205 .212
Adjusted R
2
.088 .205 .212
∆F 4.27** 5.89** 1.28
∆R
2
.114 .138 .030
∆Adj.R
2
.088 .117 .007
Note. * = p < .10. ** = p < .05. *** = p < .01.

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An analysis of the relationship between the variables of depression disclosure, perceived
stigma, perceived burden, and emotional support among the participants in this study was also
conducted utilizing the qualitative data. These findings helped inform some of the disclosure
patterns observed in the quantitative analysis. Specifically, qualitative data revealed that
perceived stigma and perceived burden were predictors of disclosure and they were also
important consequences. Especially with regard to self-perceived burden, numerous participants
expressed that they feared overburdening their loved ones due to their depression. They did not
want to worry the individuals in their support network, but they also found their depression to be
important information that their loved ones needed to know. Hence, depression disclosure to the
support network was common despite it being a perceived burden to others. Furthermore, in the
qualitative interviews it was noted that self-perceived burden might influence how often or for
how long the older adult will bring up the topic of depression in the future. In other words,
perceived burden may not necessarily predict disclosure, but it may predict the extent of ongoing
conversations regarding depression between the older adult and that particular network alter. In
the following example, the theme of self-perceived burden emerged as the participant talked
about how she felt with regard to ongoing discussion about her depression with her daughter,
whom she has already disclosed to.
Es una mortificación también porque ella es corajuda y eso tiene su modo, pero sí me
comprende. Pero yo también no les quiero decir nada. Me preguntan cómo estoy. Yo les
digo, “Yo estoy bien. Me siento bien.” Pero yo lo que no quiero es estarlas mortificando
con lo mismo, con lo mismo, que estoy deprimida, que estoy deprimida. Yo trato de
sacarlo yo sola, así, de hacerme fuerte yo sola para no mortificarlas porque yo sé que
lloro con decirles todo lo que yo siento. Las mortifico a ellas porque yo sé que ellas se

66

sienten mal y no pueden hacer nada tampoco. Aunque quieran ellas apoyarme, no se
puede. A veces no se puede que le den todo a uno.
[It’s a worry also because she is very moody, and that has its ways, but she understands
me. However, I also don’t want to say anything. They ask me how I’m doing. I tell them,
“I’m fine”. But I don’t want to be burdening them with the same, with the same, that I am
depressed, that I am depressed. I try to get it out by myself first, and that way make
myself stronger so I don’t worry them, because I know I’d cry by telling them everything
that I feel. I’d worry them because I know they’d feel bad and there’s nothing they can do
either. Even though they want to support me, it can’t be done. Sometimes one can’t be
given everything.]
Moreover, participants may express feeling stigmatized in general, but not necessarily by
members of their network. For example, in the network survey, perceived stigma was
operationalized as feeling ashamed or embarrassed speaking with others about depression. These
feelings of shame or embarrassment were not very commonly attributed to relationships with the
network alters. However, during the interview, depression-related stigma was mentioned as a
barrier to disclosure in general. In the following example, a male participant illustrates why
depression is a private matter that should not be revealed.
Sí, es, es muy privada. Porque la mayoría de personas, como dice el dicho, “Cómo te veo,
te trato”. Si una persona, a usted la ve mal vestida, mal arreglada, sin peinarse y con
cabizbaja,… va a valer menos que si usted va bien decorada, con la mirada en alto,
viéndole a los ojos, con la sonrisa. Uno trata diferente. Y, y eso es como natural. Nadie
quiere estar cerca de alguien que, que esta negativo, porque es como agarrar una
enfermedad que se va a pegar. Y eso, es muy normal en la mayoría de personas.

67

[Yes it is; it’s very private. Because the majority of persons, like the saying goes, “How I
see you is how I’ll treat you”. If a person sees you badly dressed, badly groomed, hair
uncombed, crestfallen,… you’ll be worth less than if you were well-accessorized, head
up, making eye-contact, with a smile. We treat differently. It’s like, natural. Nobody
wants to be near someone who is negative, because it is like catching a contagious illness.
And that is very normal among the majority of people.]
Emotional support was found to be an important factor related to the disclosure of
depression. When inquiring about the reasons for differential disclosure between members in the
network, the participants oftentimes brought up the issue of emotional support and caring. In
general, those individuals who provide the recipient with support deserve to know about the
participant’s true experiences with their health and well-being. Moreover, if the participant
provided or reciprocated support, it solidified the relationship as a stronger bond, and disclosure
seemed more likely to occur.
A Conceptual Model of Depression Disclosure among Older Latinos
The fourth aim of the study was to examine the disclosure process through which older
Latinos communicate to members of their support network and important others that they have
depression. The analyses of the qualitative data identified eight general themes that reveal a
heuristic model of the disclosure process among Latino older adults. These themes are illustrated
in Figure 1. The eight themes were placed into three categories, illustrating separate, but
interrelating phases of disclosure: determinants of disclosure, the disclosure event, and
consequences of disclosure. Each of the three categories and their corresponding themes are
described below.

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The disclosure event. In this study, the disclosure event is defined as the moment when
the participant’s depression disclosure takes place or is avoided. Three main themes emerged
from the disclosure event: (a) the dynamics of disclosure that are attributed to the person with
depression (e.g., usually the discloser); (b) the dynamics of disclosure those that are attributed to
the recipient of the disclosure information (e.g., sometimes called the target); and (c) the
outcome of the disclosure.
The participants’ dynamics surrounding the disclosure event. For participants, the
dynamics of the disclosure were characterized by three main interrelated factors (a) intention, (b)
method, and (c) level of clarity. In this study, intention is the active effort made by the
participant to disclose or conceal the depression. The method of disclosure is the means or
mechanism by which the disclosure took place, and could also be characterized as active or
passive. For example, an intentional disclosure could take place by active methods of
conversation or through signals or gestures (e.g., deliberately showing others their
antidepressants). The level of clarity of the information being emitted also characterized the
dynamics of the disclosures. For example, in some cases, the language or signals utilized (by the
older adult with depression) were clear, straightforward, and direct. In other cases, participants
were roundabout, vague, and elusive.
The following intentional disclosure dynamics occurred through an active method of
conversation in the context of talking about the medical visit. When asked who had let her adult
children know about her depression, this participant answered the following, “Pues yo, porque
les dije que el doctor me había mandado a ese centro… Porque dice el doctor que tengo
depresión, y que necesito tener una distracción, y que eso me va a ayudar.” [Well, I did, because
I told them that the doctor had sent me to that center. Because the doctor says I have depression

69

and that I need a distraction, and that going to the center will help me.] Another participant
described her disclosure dynamics as the following, “Yo ya les dije, ‘Fíjate que me
diagnosticaron de depresión’. Entonces ya todos saben.” [I already told them, ‘Look, I was
diagnosed with depression’. So they all know.]
The next example illustrates intentional disclosure dynamics that were clear and direct,
but took place years after the participant had been diagnosed, “Les platiqué ya que había pasado
buen tiempo. Les digo, ‘Yo no quería mortificarlos, pero cuando ustedes me veían que me
encerraba era porque estaba tomando pastillas.’ Porque [en ese tiempo] yo nunca les dije que yo
tomaba [anti-]depresivos.” [I told them after a long time had passed. I tell them, I didn’t want to
worry you, but when you would see that I would lock myself up it was because I was taking
pills. Because [at that time] I never told them that I took anti-depressives.]
Unintentional disclosures tended to be more passive in nature, and did not always
represent forms of self disclosure. However, it is important to note that dynamics of unintentional
disclosure started off as passive, but often led to active dynamics of self disclosure. Dynamics of
unintentional self disclosure occurred when the participants were forced to disclose due to a
present situation (e.g., others were present during a crisis, others came across the antidepressant
medications, others confronted them about their depressive symptoms, etc.). In the case of an
older adult who lives alone, her friend and her sister first found out about her depression when
they came across her medications. “They were asking if I had a pain pill. And I said, ‘Wait a
minute’. So I started taking out my medicines. And she says, ‘Paxil? Isn't that for depression?’”
The participant then described the conversation that she had with her friend and sister about
being prescribed medications for depression. Although it was not the intention, she self disclosed
about her depression upon having her pill container drop out of her purse. Similar situations

70

occurred with the home care workers, as they often helped the older adult arrange his/her
medications in pill boxes and so forth. One participant stated, “Bueno, ya ni sé si le he dicho,
pero como ella ve las medicinas, pues así se da cuenta.” [Well, I don’t even know if I have told
her, but since she sees my medicines, well, she finds out.]
Dynamics of unintentional disclosure also occurred when older adults talked about their
depression within hearing range of others, when participants identified each other at the Adult
Day Healthcare Centers as belonging to the PMA study, and by method of being outed by
someone else. One participant explained that her home care worker found out by overhearing her
in-home Problem Solving Treatment session with the PMA interventionist. “Ella miraba cuando
venía. Ella oía las pláticas.” [She would see when she would come. She would hear our talks.]
In the context of describing his long journey toward access to appropriate treatment for
his depression, one participant described his wife’s efforts in trying to help. In her attempts to
help, she disclosed his depression symptoms to other people.
No quería que nadie me hablara, no quería comer, no quería nada. Solo quería morirme.
… Es que lógicamente mi esposa que es la que convive conmigo sí se da cuenta que yo
no quiero hablar, no quiero contestar el teléfono y todo eso… Ella, eh, debe haber
hablado con alguien o consejo de alguien, de mis mismos hijos…de eso no me di cuenta.
Uno por estar encerrado ahí, y viene alguien aquí, hablan esas cosas y uno no sabe. De
repente aparece… “te voy a llevar al psicólogo” y eso.
[I didn’t want anyone to talk to me, I didn’t want to eat, I didn’t want anything. I only
wanted to die. It’s logical that my wife who lives with me would find out that I don’t
want to talk, I don’t want to answer the phone, and all that. She must have spoken with
someone or someone’s advice, perhaps my own kids…of that I didn’t find out. Due to

71

being locked up in there, someone comes over, they talk about these things, and one
doesn’t even know. All of a sudden, “I’m going to take you to the psychologist” and all
that.]
Another participant self disclosed to only one daughter, and the daughter in turn disclosed
about the participant’s depression to the rest of the family. “Sí, ella les dijo a los demás porque a
veces se sienten que aaay… que a veces no estoy de humor. Y ya entonces ella les dice, ‘Tienen
que tener paciencia con mi mama porque tiene esto, y tiene esto otro’.” [Yes, she told the rest
because sometimes they feel that… that sometimes I’m not in a good mood. So she tells them,
‘You have to have patience with my mom because this and that’.] While the two are examples of
unintentional disclosure dynamics, they do not exemplify self disclosure.
The recipients’ dynamics surrounding the disclosure event. In a few interviews,
discrepancies were noted between the data that was reported in the network survey and the open-
ended sections of the interview. Luckily, the semi-structured nature of the interview allowed the
interviewer to probe further and explore these discrepancies with the participant to gain a better
understanding of the participant’s disclosure experiences. It was quickly detected that —in some
cases— how the information was received and understood by the recipient was different from the
intentions or expectations of the participant who had disclosed. The following example describes
a participant’s opinions for why her son may not have recently acknowledged or remembered
about her depression.
Mire, yo le voy a decir una cosa. Mi hijo es muy despistado. Y como le digo, si yo le
comenté eso,…pues ya hace tiempo de eso. … Fue una cosa que el doctor lo comento.
Yo no sé si sería,… o nomas fue un comentario. Pero mire, tal vez él no se acuerde que
yo le comente del sicólogo y todo. Y sí le comenté por la sencilla razón de que me habían

72

platicado que si podían hablar con la familia. Yo le dije a la muchacha que probamente sí.
… Yo digo, sí le comenté, pero es muy despistado.
[Look, let me tell you something. My son is very absent-minded. And like I tell you, I
commented to him, … Well it’s been a long time since that happened. It was something
that the doctor commented. I don’t know if it was...or just a commentary. But look,
perhaps he doesn’t remember that I told him about the psychologist and everything. And
if I told him it was for the simple reason that they had asked if they could speak with a
family member. I told the lady that probably yes. I say, I did tell him, but he is very
absent-minded.]
In other cases, the intentional disclosures were not very direct, but perhaps clear enough
for the recipient to understand. In the following example, the participant explained that she does
not use the word depression, but instead conveys her depression through her tone of voice. “Por
la forma en que hablo. No precisamente de la depresión. Preguntan, ‘Te sientes mal, ¿verdad? Te
sientes decaída, te sientes triste.’ Eso es para ellos, esos son síntomas de depresión.” [By the
manner that I speak. Not necessarily saying depression. They ask, “You feel ill, right? You feel
down, you feel sad.” Those are the symptoms they recognize as depression.]
The outcome of the disclosure event. The outcome of the disclosure refers to whether or
not the disclosure was achieved, or if it was a limited or incomplete self disclosure. True self
disclosure was achieved when the participant actively communicated his/her depression matter
with a recipient who understood the information as intended. A limited or incomplete disclosure
occurred when the older adult deliberately disclosed some —but not entirely— about his/her
depression. This is exemplified by a participant who has vaguely told somebody in her network
that she is not well, but does not get into specifics about it being due to depression. “Bueno, yo le

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he dicho a él que a veces me siento mal, pero bien, bien, no.” [Well, I have told him that I
sometimes feel ill, but well, well, no.] A limited or incomplete disclosure also occurred in events
when the participant self disclosed about his/her depression illness, but later realized that the
disclosure information had been only partially —or not at all— understood by the recipient. This
might have been the situation with the “absent-minded” son in our previous example. No
disclosure occurred in situations when there was no attempt made or when there was active
concealment of the depression.
Determinants of the disclosure. The disclosure process entailed the evaluation of
numerous factors (e.g., facilitators and barriers) that served as determinants of disclosure. Some
determinants to disclosure were identified in response to the interview questions, while others
emerged from the interviews. Three general themes include intrapersonal determinants,
interpersonal determinants, and institutional determinants of disclosure.
Intrapersonal determinants of disclosure. Intrapersonal characteristics exist within the
individual, and in this section this refers to the participant. Intrapersonal determinants of
disclosure that emerged from the qualitative data include gender, knowledge of depression,
illness severity, individual needs, and personality traits. With regard to gender, men’s networks
were relatively smaller compared to the females’ networks, and their depression disclosure
seemed to be limited to few family members and even fewer friends. Although not necessarily
referring to depression disclosure to network alters, the following quote illustrates a male
participants’ quandary with gender-related identity and disclosure for the purpose of seeking
treatment as his mental health needs increased. “¿Dónde queda el machismo? Porque según
nosotros somos … Digo, y más por dónde venimos, de México. En México, puro machista y
todo. Pero yo aquí doble las manos. Sí, porque yo me sentía ya muy mal.” [And where do we

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leave the machismo? I mean, mostly due to where we’re from, from Mexico. In Mexico, mostly
machista and all. But here, I had to bend my arms. Yes, because I was feeling very ill.]
Knowledge of depression and illness severity were two important factors that influenced
the disclosure of depression. Disclosure was unlikely to occur when participants were unaware of
their own depression (e.g., depression not recognized as illness), or when the symptoms were not
as severe. When asked what facilitated her disclosure, one participant mentioned that she
disclosed about her depression with her family once she learned what depression was, “Por las
sesiones que empecé a tener en AltaMed. Porque antes yo no sabía que era la depresión.”
[…because of the sessions that I started having at AltaMed. Because before, I didn’t know what
depression was.] In another example, a participant expressed the difference in disclosure between
two periods in her life when she had depression. “Yo tenía depresión pero no ganas de decirle a
nadie porque pues era una cosa que yo la tomaba como pasajera. Y esto que paso ahora; la
depresión es demasiado fuerte. Entonces sí, todos lo supieron, y ya.” [I had depression, but didn’t
want to tell anybody because I took it like something that would pass. Then this happened now;
the depression is very strong. Then yes, everybody knew about it. That’s it.]
The individual’s needs, such as a need for services or the need for catharsis, were also
important to the depression disclosure among some older adults. For example, the need to
desahogar was a common determinant of disclosure identified by participants. In Spanish,
desahogo is a compound word, stemming from ahogo, which means drowning or suffocation. A
desahogo is a figurative un-drowning, which is oftentimes spoken about with regard to venting
ones pent-up emotions or secrets. For many participants in the study, desahogo was necessary.
One participant expressed the following,

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Pues es como, como toda la gente cuando tiene un pesar, una tristeza, una alegría..., uno
necesita platicarle a otra persona para salir… para que le salga a uno aquello que tiene.
Si uno tiene rencor, uno necesita platicarlo con otra persona. Pa’ desahogarse, para
decirle lo que siente. Y si uno lo platica se desahoga uno. Como que queda uno agusto”.
[Well it’s like all people when one has a regret, a sadness, a joy,… one needs to tell
another person. To vent, to say how you feel. And if one talks about it, one vents. Then
you feel at ease.]
Another participant simply expressed that she couldn’t take it anymore. She had to talk
with someone. “¡Porque yo no aguantaba! Yo salí. ¡Yo sí tenía que hablar con alguien, alguien!”
[Because I couldn’t take it; I couldn’t endure! I came out. I had to talk with somebody,
somebody!]
Personality traits, such as being an innately quiet and private person, also influenced self
disclosure. For example, collateral information was collected from a family member that was
present during the qualitative interview of a very quiet participant. She commented, “Es bien
calladito. Siempre es bien reservado. A él hay que sacarle las palabras con cucharas.” [He is
very quiet; has always been very reserved. You need to take out his words with a spoon.] It was
then discovered that he had not self disclosed to any of his network alters. They were all aware
of his depression through other methods.
Importantly, the personality trait or concept of altruism emerged from this data, where it
was clear that the desire to help others motivated the depression disclosure of some participants.
In the following example, the participant explains that she shares with friends about her
experiences with depression so that they can increase their awareness on how to help themselves
if they need it. “Ah, pues pa’ con tiempo ellos, ellas tengan conocimiento de cómo ayudarse ellas

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mismas… Bueno, para ayudar…” [Oh, well, so that with time, they can have the awareness
about how to help themselves… Well, to help…] However, later in the interview, she states that
she helps herself by helping others.
Interpersonal determinants of disclosure. Interpersonal interactions exist between
individuals, and in this section refer to interactions between the participant and any other
individual he/she may have mentioned in the interview process (i.e., within or outside of the
network) in the context of disclosure. Interpersonal determinants of disclosure that emerged from
the interviews include social support, confianza (trust), reciprocity, perceived public stigma, and
perceived burden on others. Personal characteristics of the recipient were also important when
selecting whom to disclose to. Of all interpersonal determinants, social support seemed to be the
most important. The following passage illustrates how a participant decided to tell one daughter
and not the others about her depression.
Porque ella siempre ha estado mas pegada a mí. Ella es la que, si me dificulta algo, luego,
luego yo le hablo a ella. Mis pagos y todo ella me los hace. Por eso tengo más
comunicación con ella y mas ella sabe de mi situación, más ella sabe de todo. Ella está
más al tanto de mi de todo.
[Because she has always been closest to me. She is the one that if something comes up, I
call her right away. My bills and everything, she does for me. That is why I have more
communication with her, and more so, she knows my situation. She knows everything.
She is more aware of everything about me.]
Another participant describes support and confianza (trust) in one of her sons as being the
reasons why she disclosed to him and not the others.

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No les tengo mucha confianza para contarle todo, mis enfermedades, mis problemas
económicos, y todo eso. A él le puedo contar todo, porque no me da la solución, porque
no me la puede dar, pero cuando menos me apoya. Dice, “No te preocupes mamá. Ya, ya
vendrán tiempos mejores. Ya veremos haber como nos ayudamos.” Todo eso me levanta
el ánimo. Yeah, con él.
[I don’t have the trust in them to tell them everything, my illness, my economic problems,
and all that. However, I can tell him everything, because he does not give me the
solution, because he can’t give it to me, but at least he supports me. He says, “Don’t
worry mama. There will be better times. We’ll see how we can help each other.” All of
that lifts my spirits. Yeah, with him.]
Participants in this study described family dynamics that were positive and some that
were negative, often describing the relationship between presence or absence of social support
(e.g., emotional support) and perceived burden on others. These concepts and how they influence
depression disclosure are highlighted in the following example:
Okay, because first of all, I had awareness they were all concerned about me. I mean, you
just feel, you know. Cuz... I changed, but they changed too. They were sad. They were
concerned. They were always constantly trying to make me happy and trying to take me
out, and I mean, more than normal. And I know that my girls are always busy, and then
they were still trying to take me out. It's like, I mean, that’s not normal. Understand? So I
mean, the first thing I did once I came to the reality of what was happening to me, I
apologized for the grief I was giving them, subconciousness. You know? I did not do it
on purpose. And let them -to a certain degree- hear the good news, "But you know, mom
is getting help! And I am going to do all I can to move on." And that gave them hope too.

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I mean, we're family. You got to know what’s going on. I mean, I don’t like to hide
anything, and because... it’s no good. Sooner or later they are going to find out, and then
there is hard feelings. How come you told him, and not me? You know. They all have the
same value, so you got to,… they all have the same privileges of knowing.
In this following example, a lack of social support inhibits the disclosure. “No, no hay razones
pero como veo que,… Como yo entiendo y yo comprendo que no les interesa, pues por eso no.
Falta de aprecio a las cosas que me pasan.” [No, there are no specific reasons, but how I see
it…how I understand and recognize that they don’t care, well that’s why I don’t. They don’t
care, and that’s why I don’t… There’s lack of understanding/appreciation of the things that
happen to me.]
Reciprocity emerged as a determinant of disclosure among some individuals. In the
following example, a participant decided to disclose her depression to her friend at the Adult Day
Healthcare Center only after the friend initiates disclosure to her. “Si pues es que me empezaron
a decir que sufrían de depresión y ya me dijeron que tenían ansiedad. Y yo le dije, ‘Bueno, pues
sabe, el doctor dice que también yo tengo depresión’". [Yes, well they started to tell me that they
suffered from depression, and then they told me that they had anxiety. I told them, ‘Well, guess
what, the doctor says that I have depression too’.] Another participant had a similar experience,
and expressed that she shared about her depression diagnosis with another individual because
they shared the same pains. “Porque ella también tiene depresión. Porque las dos padecemos
pues de depresión. Pero compartíamos las mismas penas, por ser los mismos problemas, pues los
compartía yo con ella.” [Because she also has depression. Because the both of us have
depression. We would share the same sorrows, for being the same problems, well I would share
that with her.]

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Institutional determinants of disclosure. As described in a previous section, being
identified as an AltaMed patient who receives services from the psychologist or as a participant
of the PMA research study led to unintentional disclosures for some participants. However,
institutional factors were also found to influence intentional disclosures. For example, belonging
to an Adult Day Healthcare Center for the most part meant that the participant was in a situation
that increased his/her opportunities for socialization and other types of interactions with peers.
The socialization was structured into the setting and the activities endorsed by the organization,
such as group exercises, field trips, round lunch tables for communal meals, and so forth. As
illustrated in the last quote from the previous section, a participant shared with an ADHC peer
about her depression because they shared the same illness, the same problems, and the same
sorrows. The organizational setting increased the opportunity for these types of peer interactions
to occur. Participation in the PMA study also increased opportunities for disclosure through the
knowledge and skill transfer, as well as through increased opportunities to identify peers that
they share depression in common with.
Consequences of the disclosure. Although this study did not specifically ask the
participants to share about the consequences of their depression disclosure, positive and negative
consequences of disclosure emerged from the data at the interpersonal and intrapersonal levels.
Some interview segments highlighted the influence that the consequences of a present disclosure
had on decisions regarding new or future disclosure events. These are discussed below.
Interpersonal consequences of disclosure. Confianza and support from others were the
most commonly mentioned positive consequences of disclosure at the interpersonal level. As
shown in the quote below, more confianza —which means trust in Spanish— was followed by
additional emotional support from a friend. The participant stated,

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Cómo que debido a eso, me ha agarrado más confianza. ... Pues se hizo más cerca de mí y
me dice, “Bueno pues, no se quede en casa. Llámeme cuando se sienta muy depressed.
Vámonos a dar la vuelta. Vamos a comer a la calle. Vamos a tomar un café, o vamos a oír
música.” Es lo que ella me dice. [As a result of that she entrusted more in me. Well, she
got closer to me, and she tells me, “Well, don’t stay at home. Call me when you feel very
depressed. We’ll go take a spin. We’ll go out to eat. We’ll go drink coffee or just listen to
music.” That’s what she tells me.]
However, not all participants’ disclosures were met with positive consequences or the
same level of support. For example, the majority of the participants expressed a concern about
burdening their support network with their depression. Many participants expressed that the
depression disclosure resulted in preocupación or worry to their loved ones and they did not
wish to cause them such worry. While this is not a pleasant or comfortable situation to be in for
neither the participant nor the recipient of the disclosure, burden —in the form of worry— still
implies some affection or caring toward the participant. Yet other participants experienced a
complete lack of interest or support from the recipient in response to his/her disclosure.
Furthermore, for some participants, disclosure opened up the doors to future
conversations about depression with those same recipients. However and for a variety of reasons,
not all of these participants wished to continue dialoguing about their depression. One participant
stated, “Sí, bueno, yo les he dicho. Pero ahora ellos saben. Pero yo ya no lo saco. Yo ya no
comento”. [Yes, well, I have told them. So now they know. But I don’t take it out anymore. I
don’t comment about it.] She later explained that there is no point in dwelling in conversation
about the depression. There are other things to talk about than illness.

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Intrapersonal consequences of disclosure. Support from others is important in the lives
of older adults, and this was no exception in this sample. While in itself it was an interpersonal
consequence of disclosure, emotional support also moderated the effect of the disclosure at the
intrapersonal level in some cases. For example, when a participant disclosed to someone who
demonstrated concern for her and who helped her, then she felt good. On the other hand, when
she disclosed to someone who did not show any interest in helping her or who did not care, then
she felt frustrated.
Si yo le digo a una persona que me ayuda y me pone atención, yo me siento bien. … Sin
embargo, si tú les enseñas este papel, y te dicen... o no te le hacen caso, entonces se
queda uno bien frustrado.
[If I tell a person who help me and they give me their attention, I feel good. However, if
you show them this paper (referring to PMA diploma) and they say…or they don’t pay
attention, they you feel very frustrated.]
Desahogo was a common intrapersonal determinant of disclosure. Importantly, it also
emerged from the data as an important intrapersonal consequence when participants described
feeling desahogo as a result of sharing with others about their depression.
The loop. These consequences of disclosure have an impact on future disclosures. A
positive consequence at either of two levels (i.e., interpersonal or intrapersonal) encourages
future disclosures. A negative or unpleasant consequence of a disclosure was likely to result in
less disclosure in the future, but that was only with respect to the specific individual and not
necessarily in general. As one participant described, she has a lot of family, but she knows who
she can count on. In her quote, she demonstrates how the disinterested reaction from a disclosure
recipient helped her decide not to make future comments to that person regarding her health.

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Tengo mucha familia, pero uno sabe que aunque tenga mucha familia uno sabe con quién
cuenta y con quien no cuenta. … Si tú estás platicándole a alguien aunque sea de tu
familia -muy de tu familia- lo que sientes y no sientes que te está poniendo atención, que
no está tomando en cuenta lo que le estás diciendo, tú no sientes las ganas de volverle
hacer ningún comentario acerca de tu salud.
[I have a lot of family, but one knows that despite having a large family one knows whom
to count on and whom not to count on. … If you’re telling someone about what you are
feeling and you feel that they are not giving you their attention or that they are not taking
you seriously, you no longer feel the desire to make any more comments to them
regarding your health.]
The same applies to intrapersonal consequences. If a disclosure did not result in the expected
catharsis or other positive consequence, then it seemed less likely to repeat.

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Figure 1: Conceptual model of depression disclosure process among Latino older adults

Determinants of disclosure

Intrapersonal determinants
Gender (machismo)
Knowledge & understanding
of depression
Illness severity
Needs (desahogo, etc)
Personality traits
(private, altruistic)

Interpersonal determinants
Personal characteristics of
recipient
Social support
Confianza
Reciprocity
Perceived public stigma
Perceived burden on others

Institutional determinants
AltaMed characteristics
PMA study

Outcome

Disclosure
No disclosure
Limited
disclosure

Dynamics

Recipient of
disclosure
How
information is
received &
understood
Person with
depression
Intention
Method
Level of clarity

Intrapersonal consequences
Desahogo (catharsis, relief)

Interpersonal consequences
Burden on others
Confianza (trust)
Emotional support

Disclosure Event Consequences of disclosure

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CHAPTER FIVE: DISCUSSION
To the knowledge of the author, this is the first study to examine the experience of
depression disclosure among a sample of minority older adults, specifically Latinos. This
research has a number of implications for improving the cultural relevance in social work
practice when addressing the disclosure needs of Latino older adults. There were four aims in
this study, and the results were presented by aim. Hence, this discussion follows a similar format.
After the findings for each of the four aims are reviewed and discussed, implications for social
work practice and research are presented. Limitations of the study and suggestions for future
research are also discussed.
Review of Findings
Participant demographics and disclosure to the network. The first aim of the study
was to quantitatively examine the relationship between the participant demographics and
depression disclosure to the egocentric networks. Bivariate correlation analyses showed that the
participant’s age and education were significantly related to the proportion of the participant’s
network that they had self disclosed to. With regard to the finding between disclosure and age,
this study found that as participants’ age increased, there was a decrease in the proportion of
their networks that they disclosed to. This finding is consistent with other studies on general self-
disclosure (Goodstein & Reinecker, 1974; Jourard, 1961), on disclosure of HIV status (Emlet,
2006), and also older adults’ disclosure of depression symptoms to healthcare providers
(O'Connor, et al., 2001; Probst, et al., 2007). As age increases, disclosure tends to decrease. This
trend may be due to a couple of reasons. Firstly, these patterns may reflect a combination of
generational and cultural differences with regard to disclosure in general, and especially
regarding disclosure of stigmatized illnesses such as depression tends to be. Values common

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among older adults and less acculturated immigrants regarding the importance of a favorable
family reputation might be playing a role in their disclosure of depression, especially to persons
outside of the family circle. As such, evidence from the HIV literature suggests that acculturation
has an impact on disclosure (Mason, Marks, Simoni, Ruiz, & Richardson, 1995; Simoni et al.,
1995). Interestingly, upon further review of the data from this study, it was noted that the two
youngest participants were U.S.-born, preferred to speak English over Spanish —thus implying a
higher level of acculturation— and tended to disclose to peers (e.g., spouse and friends) in
addition to some of their adult children. This further supports the notion that disclosure may
reflect generational and cultural differences with younger, more acculturated adults being more
likely to disclose in general.
Secondly, less disclosure with increasing age might also be related to the notion that
symptoms of depression are often confused with or misinterpreted as a normal part of aging.
While all participants in the present study had met criteria for major depression and were also
made aware of their depression status, their family members may not have been as informed as
to the signs and symptoms of depression. Therefore, the family members’ (or networks’)
perceptions of what constitutes depression and a normal part of aging might have played a part in
the (decreased) amount of opportunities presented for the older adult to disclose. As will be more
thoroughly discussed as part of Aim 4, this study found that participant self disclosure sometimes
followed the recipients’ reactions to nonverbal cues of disclosure. Hence, under those
circumstances, if the older adults’ nonverbal cues (e.g., expression of their depression symptoms)
were misattributed to a normal part of aging, then subsequent self disclosure of depression might
not occur. This finding highlights the importance of depression knowledge among family and

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friends in the disclosure patterns among older adults, and implies a potential need for depression
education that targets older adults’ families and networks.
Moreover, results from this sample found a statistically significant (negative) association
between older adults’ years of education and the proportion of the network disclosed to. This
trend has not yet been observed among older adults with mental illness. In a study of disclosure
of schizophrenia diagnosis among adults in the U.S., education was not found to be a significant
predictor of overall openness score (Pandya, et al., 2011). However, the finding in this study
might be explained by the notion that adults with higher education may feel that there are greater
costs (e.g., adverse consequences) to disclosing a mental illness in comparison to adults with less
education. In other words, for individuals with higher levels of education, there may be more at
stake. This is especially relevant if depression is viewed as a stigmatizing illness (Hayward &
Bright, 1997; Link, et al., 1987). Another potential explanation for the observed negative
association between participants’ years of education and the proportion of network disclosed to
may entail the issue of social desirability. Previous studies have demonstrated an inverse
relationship between education and social desirability, indicating that individuals with less
education tend to over-report or provide socially desirable responses in research (Klassen,
Hornstra, & Anderson, 1975; Ross & Mirowsky, 1983). Hence, when discussing the topic of
disclosure, participants with less years of education might have be more likely to over-report
disclosure (e.g., provide information they think we want to hear) for purposes of pleasing the
research staff. The relationship between depression disclosure and education, as these relate to
stigma and social desirability, require further exploration in other samples containing immigrant
Latinos with major depression.

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Network structure and disclosure to the network. The second aim of this study was to
examine the relationship between the structure (i.e., size and composition) of the egocentric
networks and participants’ depression disclosure to their network. In this analysis, various
aspects of the aggregate social support network such as the size, the composition (e.g.,
proportion that are female, proportion that are family, and so forth), and the relationships of
social support (e.g., emotional support provided, emotional support received, and so forth) were
examined in comparison to the proportion of self disclosure within that same network. Of all
variables examined, only one variable (i.e., the proportion of the network receiving ES from
participant) was significantly related to the proportion of disclosure within the network. This
finding from quantitative data was at least partially explained by a common theme that emerged
from the qualitative data, which is that of altruism. During the interviews, some participants
expressed altruistic motivations for disclosing their depression. In other words, they decided to
disclose their depression specifically to other individuals that were struggling with the same
issues of depression, with the intent of helping them. As such, the participant disclosed to others
whom he/she provided emotional support to.
While it may seem counterintuitive for someone with major depression to still manage to
feel altruistic —when withdrawal from social relations is a symptom of depression— the
altruistic motivations to disclose in this study may be related to issues of depression severity and
cultural variations in the expression of depression. With regard to depression severity, the
participants expressing altruistic motivations for disclosing may have no longer been as
depressed as when they took the diagnostic assessments. It may also be an issue of cultural
expression of depression, where social withdrawal may not be as strongly associated with

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depression in Latino cultures as it is in mainstream American non-Hispanic white cultures
(Kleinman & Good, 1985).
A direct (positive) association between receipt of emotional support from others and the
disclosure of a stigmatized illness has been observed in other studies of disclosure among ethnic
samples (Simoni, et al., 2000; Zea, et al., 2005), and it was an expected finding in this sample.
However, results from this present sample (albeit, through the analysis of proportions of
networks disclosed to) did not really support this finding. While there was a positive association
observed between the proportion of the network that provides the participant with emotional
support and the proportion of the network that the participant disclosed to, the association was
weak and not statistically significant. This may largely be due to the manner in which the
variables were operationalized. In other words, by examining the proportion of the network that
provides emotional support, in lieu of examining individuals in the network who provide
emotional support, precision is lost. Hence, further exploration using different statistical methods
may be required.
Perceived stigma, perceived burden, and disclosure to the network. The third aim of
this study was to examine the relationship between participants’ perceived stigma, perceived
burden on others, and disclosure of depression to their network. To accomplish this aim,
bivariate correlation analyses of the proportions of alters within the networks (that the participant
was embarrassed or ashamed to talk with about depression, that were potentially burdened, and
that were disclosed to) were conducted. Findings show that in this sample, self perceived burden
–but not perceived stigma– was significantly related to participant disclosure of his/her
depression. Specifically in this analysis, the proportion of the network that participants perceive
might be burdened by his/her depression was significantly related to the proportion of the

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network that the participants disclosed to. The positive association between these variables
seemed contradictory at first; however, it is contradictory only when burden is conceptualized as
a predictor of disclosure. Findings from the qualitative analysis point causality in the other
direction. Mainly, the qualitative data revealed that perceived burden was not only a predictor of
disclosure, but it was also an important consequence. Numerous participants expressed that they
feared overburdening their loved ones due to their depression. Consistent with observations in
other research (Cahill, et al., 2009), the older adults in this study did not want to worry the
individuals in their support network. However, the participants in this study also found their
depression to be important information that their loved ones needed to know. Hence, depression
disclosure to the support network was common despite it also being a perceived burden on
others.
Results regarding the relationship between disclosure and stigma occurred in the
expected direction, however was not statistically significant. The greater the proportion of the
network that the participant was embarrassed or ashamed to talk with about depression, the
smaller the proportion of the network alters disclosed to.
Process of disclosure among Latino older adults. The final aim of this study was to
examine the disclosure process through which older Latinos communicate to members of their
support network and important others that they have depression. The analysis of the qualitative
data revealed eight themes that were grouped into three separate, but interrelated, phases of
disclosure: determinants of disclosure, the disclosure event, and the consequences of disclosure.
The disclosure event is defined as the moment when the disclosure takes place or is avoided.
Three main interrelated themes emerged that are characteristic of this phase: the dynamics of
disclosure that are attributed to the person with depression (i.e., intention, method, and level of

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clarity), the dynamics of disclosure that are attributed to the recipient or target of the disclosure
(i.e., how the information was understood or received), and the outcome of the disclosure (e.g.,
whether or not the disclosure actually occurred, and if it was complete). Together, the dynamics
between the discloser and the recipient determined the actual disclosure outcome. During the
interviews, participants provided some examples of consequences that were experienced after the
disclosure event. Consequences occurred at the intrapersonal as well as the interpersonal levels.
The influence of these consequences, along with various other emergent factors (i.e.,
determinants of disclosure), characterized the decision-making phase of a new disclosure.
Determinants of disclosure emerged at the intrapersonal, interpersonal, and institutional levels.
As portrayed in the conceptual model in Figure 1, the consequences of disclosure also influenced
new disclosure events through a more direct feedback loop.
Essentially, these phases and the factors that characterize them are similar to those
identified in the research literature on processes of disclosure. For example, the three phases in
the model presented in this study are characteristic of the global process of disclosure decision-
making episode described by Greene and her colleagues (Greene, 2009; Greene, Derlega, Yep, &
Petronio, 2003), where the decision to disclose enables a series of disclosure message strategies
that result in disclosure outcomes. Those outcomes, in turn, influence future decisions to
disclose. In a similar fashion, Chaudoir and Fisher’s (2010) model of disclosure processes goes
beyond disclosure decision-making, and also characterizes the disclosure event and
consequences or outcomes. Furthermore, this qualitative analysis revealed emergent themes
which were found to be similar to important dimensions of disclosure described in early studies
(Cozby, 1973; Goodstein & Reinecker, 1974). Specifically, these dimensions of disclosure
address characteristics of the target/recipient and the characteristics of discloser. This study,

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however, is unique as it focuses on specific disclosure content (i.e., depression disclosure), and
examines the potential uniqueness of the sample according to the social and cultural context of
only one ethnic group (i.e., Latinos) and during one stage in life (i.e., their older adulthood).
Culture has been described as the lens by which individuals interpret the world and
experiences, and, as such, culture influences how individuals understand and respond to illness
(Angel & Thoits, 1987; Kleinman, Eisenberg, & Good, 1978; Lopez & Guarnaccia, 2000).
Through the use of individual’s stories and narratives regarding their understanding of the cause,
course, and consequence of illness, Cultural Explanatory Models (Kleinman, et al., 1978;
Kleinman, Eisenberg, & Good, 2006) provide a framework to understand how individuals make
meaning from their experience with illness and develop ways of coping with their illness and
managing their care.
In this study it was found that the terms used by participants to describe to others what
they were feeling (e.g., to describe their depression) influenced their ability to verbally
communicate with others (i.e., disclose) about the depression. For example, some participants
used diagnostic terminology such as I have depression while others verbally described their
depression through symptoms, such as feeling triste (sad), mal (bad or ill), or decaida (down).
Nervios (nerves), a common term used amongst Latinos to describe depression, was also used.
Among the Latino older adults in this sample, these seemed to be very common ways of verbally
disclosing to others that they had depression. Largely, this terminology seems to be consistent
with the manner in which Latinos describe depression, and therefore how they would verbally
disclose to others about their depression (Cabassa, et al., 2007; Guarnaccia, et al., 2003; Lackey,
2008; Pincay & Guarnaccia, 2007). In this sense, it would be expected that the recipient of the
disclosure would understand that what the participant is feeling is indeed depression. However,

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misinterpretation might arise in identifying the depression as an actual illness that can be treated
vs. being a set of emotions (e.g., yet not an illness) that might arise from interpersonal problems
or that arise as a normal part of aging. Moreover, study results showed that the clarity of
disclosures also varied through the use of nonverbal cues (e.g., visual or other types of
expressions). Hence, as in the previous example, if the recipient is not aware that these verbal
and nonverbal cues and expressions are related to depression illness, the disclosure may not be
understood as a diagnosis of depression. In general, disclosures that were less clear were at risk
of being misinterpreted by the recipient and instead attributed as being a normal part of getting
old. This is a common phenomenon that contributes to undetected depression among older adults
(Charney et al., 2003).
With regard to reasons for disclosure, many participants identified desahogo (catharsis)
as an anticipated consequence for disclosing their depression to others, and thus identified
desahogo as their motivation to disclose. Desahogo was also identified as a consequence of past
disclosures. This might indicate a culturally shared understanding that disclosure is good because
it provides desahogo. Through desahogo, there was a therapeutic value of disclosing to others.
This particular meaning tied to disclosure is consistent with what has been found among Latinos
in clinical interviews and online cancer support groups (Changrani et al., 2008; Vázquez-
Montilla, Reyes-Blanes, Hyun, & Brovelli, 2000).
Implications for Social Work Practice
The current study has important implications for social work practice. Firstly, this study
draws attention to important reasons for depression disclosure, which have clinical relevance for
Latinos older adults. At the intrapersonal level, disclosure seemed to have a substantial amount
of therapeutic value in the form of desahogo (undrowning or catharsis). As an experienced and

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anticipated consequence of disclosure, desahogo served as an important motivation to disclose.
This is relevant in the practice of social work, as disclosure provides a viable intervention for
improving their psychological wellbeing. Moreover, being able to desahogar (undrown or talk)
also allows for opportunity for the disclosure recipient to provide suggestions on what to do to
get better, thus increasing opportunities for additional social support and potential linkage to
resources. Social workers can assist older Latinos with depression by providing guidance on how
to select a disclosure target and how to minimize risks of adverse consequences, while
optimizing the potential benefits of disclosure. Contrary to popular belief, perceived stigma was
not the most important determinant of depression disclosure in this sample. While it was a
concern for some of the participants, it was not an important barrier to disclosure. Knowing
about determinants of disclosure at the intrapersonal, interpersonal, and institutional levels
allows for social workers to develop more tailored interventions for assisting older Latinos to
evaluate their decision to disclose.
Secondly, this study highlights the relevance of perceived burden on depression
disclosure among Latino older adults with depression. Older Latinos worry a lot about burdening
others, especially overburdening their support network. While this fear of burdening their loved
ones was not a barrier to disclosing about their depression, it was a barrier of continued
conversation about their depression. Through individual coaching or through family
interventions, social work professionals can assist older adults and their families with developing
communication skills and advocating with regard to their needs relating to ongoing depression
illness.
Overall, this study also highlights the complexity of the process of self disclosure that
often entails a combination of verbal and nonverbal cues which may be culturally bound not only

94

by the Latino culture but also by the culture of older adulthood. Moreover, the dynamics of
disclosure involve not only the clarity of the discloser, but also how well the information is
received and understood by the recipient of the disclosure. In this study, we found that older
adults used terms such as nervios, feeling triste (sad), mal (ill), or decaida (down) in
combination with tone of voice and nonverbal expressions to disclose to their loved ones that
they have depression. While these may represent culturally congruent ways of expressing to
others about their depression, there are still opportunities for misinterpretation if the recipient of
the disclosure is not clear on what has been communicated to them. Hence, social work can
intervene through development of appropriate education to family and friends regarding the
disclosure patterns among older Latinos with depression. In general, this information from the
emic perspective informs the development of culturally-sensitive strategies to support older
Latinos who face the dilemma of disclosure.
Limitations and Suggestions for Further Study
There are several limitations of the study that need to be considered. Firstly, the study
cannot be generalized to all older adults who experience symptoms of depression as this study
only included older adults who had been identified by PMA research staff as experiencing
moderate to severe levels of Major Depression per the Structured Clinical Interview of the DSM-
IV (SCID) and the Hamilton Depression Rating Scale (HDRS). Moreover, all the participants
were already accessing services at an Adult Day Healthcare Center of the AltaMed, Corp. in Los
Angeles, California. Therefore, if the participant had not already received a depression diagnosis
prior to the study, the depression symptomatology was further assessed and addressed by the
Adult Day Healthcare Center upon entering the PMA study. Hence, this sample represents a

95

segment of the older adult population that already has some level of access to services and
possibly some experience with mental health services.
Secondly, because the participants of this sample had already been exposed and
socialized to at least one segment of the healthcare system in the United States (i.e., ADHC), the
ability to capture the participants’ “idioms of distress” (i.e., disclosure using traditional terms
that they might use to describe what they understood to be experiencing as depression) was
compromised. As such, their explanatory models of depression, which contain explanations for
any or all of the five issues (i.e., etiology, symptom onset, pathophysiology, course, and
treatment) not only reflect knowledge and values of their native Latino culture, but they may also
reflect the culture of the American healthcare sector in general and of the Adult Day Health Care
settings in particular (Kleinman, 1978). In a similar fashion, their explanatory models of
depression might also be influenced by their participation in a depression treatment study (i.e.,
the PMA) where they received information about the causes, symptoms, and treatment of
depression.
A third potential limitation is that of response bias when conducting face-to-face
interviews. On one hand, participants may have been reluctant to disclose to the research staff
what they did or did not disclose to others. This might be especially relevant among participants
that were reluctant to disclose to others. If they were reluctant to disclose to others, why should
they disclose to the research staff (not only about whether or not they were depressed, but also
about whether or not they disclosed to others)? In these situations, we may expect underreporting
of disclosure to their networks. On the other hand, there might be overreporting of disclosure due
to the potential impact of social desirability, where participants provide information in a manner
that would be viewed favorably by the research staff (Ross & Mirowsky, 1983). In this sense,

96

some participants might have over-reported about their disclosure in efforts to seem open and
willing to help (e.g., by being willing to talk openly) during the qualitative interviews. To
mitigate against this potential limitation, conscious effort was taken on behalf of research staff to
appear neutral and unbiased when interviewing the participants.
A fourth limitation to this study has to do with the manner in which stigma and burden
were conceptualized and measured in the quantitative analyses. For example, the concept of
stigma has multiple dimensions, which can be examined through the use of multi-item scales.
However the network survey in this study only queried about one dimension, which is that of
embarrassment or shame. Hence, there might have been participants that might have answered
differently to the question on stigma if they had been asked about its other dimensions (such as
experienced prejudice or discrimination and so forth). Similarly, the concept of burden was
initially described as being a carga, peso, or molestia (i.e., load, weight, or bother) and soon had
to incorporate the dimension of preocupación (i.e., worry) as many of the Spanish-speaking
participants identified worry as an important dimension to burden that they experienced in the
context of disclosure. While this presented a limitation in the quantitative analysis, obtaining
such clarifications and understanding of disclosure in relation to concepts of stigma and burden
was an important part of the aims of the study that were also accomplished through the use of
qualitative inquiry.
Moreover, any conclusions drawn from solely the quantitative network data must be
interpreted with caution. Concepts such as disclosure, burden, and stigma in the networks, as
well as the numerous types of network compositions (e.g., emotional support received, emotional
support provided, and so forth) were operationalized by calculating the proportion of alters
within each participant’s network who represented each of those characteristics. Hence, the

97

relationships between the participants’ disclosure and each of the independent variables become
less sensitive to the specific characteristics of the individual network members. Further
exploration with the use of multi-level statistical analyses is required to obtain a more specific
and perhaps more accurate representation of the relationships between disclosure and network
characteristics. On a similar note, a sample size of 35 is considered small for substantive
statistical analyses. Considering that the quantitative portion of the study had a supportive but
secondary role in this exploratory study, this study had an appropriate sample size for gaining a
deeper understanding of depression disclosure through qualitative methods.
Despite its limitations, this study provides the groundwork for further exploration into
depression disclosure among Latino older adults. This study uncovered an interesting
relationship between self disclosure and perceived burden, as well as between disclosure and
stigma, that needs to be disentangled further in the context of social support. Using larger sample
size and more precise statistical methodologies (e.g., generalized linear mixed models) or
longitudinal methodologies, future studies can more accurately study the relationship and
directionality between disclosure and these important variables. Further, future studies should
incorporate additional measures of disclosure, stigma, burden, social support, and acculturation.
Considering that disclosure provided desahogo in this sample and altruism was found to
be an important determinant for self disclosure, future studies should examine the effects of
depression disclosure on depression symptoms and participants’ involvement in peer support.
The utilization of services should also be examined to examine effects of disclosure on access to
care.
Conclusion

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Depending on the severity of symptoms, depression disclosure might be a choice. In
other instances (e.g., when there is a need for accommodations or treatment-related assistance),
disclosure may be a necessity. Knowledge of Latino older adults’ perspectives and experiences
with depression disclosure informs the development of culturally-sensitive strategies to support
older Latinos who face the dilemma of disclosure. Findings from the current study provide a
good foundation for understanding the process of depression disclosure among Latino older
adults. This study advances research in depression disclosure by focusing on the experience of
one ethnic group (i.e., Latinos) in their older adulthood, therefore increasing the cultural
competence of strategies and interventions for depression disclosure among this particular group.
In general, we recommend that approaches to depression disclosure respect the role of the
person with the mental illness as the discloser. While there is a need for culturally-sensitive
strategies for depression disclosure, it is also important to recognize that “the planning and
patterns of disclosure ultimately belong to the person with the lived experience of mental illness
and nobody else” (Korsbek, 2013, p. 283). Informing and involving family, non-kin, and others
into the depression care for Latino older adults with depression is important, but only if it is
desired by the older Latino with depression.

99

REFERENCES
Afifi, T., & Steuber, K. (2009). The revelation risk model (RRM): Factors that predict the
revelation of secrets and the strategies used to reveal them. Communication Monographs,
76(2), 144-176. doi: 10.1080/03637750902828412
Aisenberg, E. (2008). Evidence-based practice in mental health care to ethnic minority
communities: has its practice fallen short of its evidence? Social Work, 53(4), 297-306.
doi: 10.1093/sw/53.4.297
Akincigil, A., Olfson, M., Siegel, M., Zurlo, K. A., Walkup, J. T., & Crystal, S. (2012). Racial
and ethnic disparities in depression care in community-dwelling elderly in the United
States. American Journal of Public Health, 102(2), 319-328. doi:
10.2105/ajph.2011.300349
Alegria, M., Canino, G., Rios, R., Vera, M., Calderon, J., Rusch, D., & Ortega, A. N. (2002).
Inequalities in use of specialty mental health services among Latinos, African Americans,
and non-Latino whites. Psychiatric Services, 53(12), 1547-1555. doi:
10.1176/appi.ps.53.12.1547
Alegria, M., Chatterji, P., Wells, K., Cao, Z., Chen, C. N., Takeuchi, D., . . . Meng, X. L. (2008).
Disparity in depression treatment among racial and ethnic minority populations in the
United States. Psychiatric Services, 59(11), 1264-1272. doi: 10.1176/appi.ps.59.11.1264
Americans with Disabilities Act, L:No. 101-336; 42 USC 12211, 1990.
Angel, R., & Thoits, P. (1987). The impact of culture on the cognitive structure of illness.
Culture, medicine and psychiatry, 11(4), 465-494. doi: 10.1007/BF00048494

100

Angermeyer, M., & Matschinger, H. (1994). Lay beliefs about schizophrenic disorder: the results
of a population survey in Germany. Acta psychiatrica Scandinavica, 89(s382), 39-45.
doi: 10.1111/j.1600-0447.1994.tb05864.x
Anglin, D., Link, B., & Phelan, J. (2006). Racial differences in stigmatizing attitudes toward
people with mental illness. Psychiatric Services, 57(6), 857-862. doi:
10.1176/appi.ps.57.6.857
Aranda, M. P., Lee, P.-J., & Wilson, S. (2001). Correlates of depression in older Latinos. Home
Health Care Services Quarterly, 20(1), 1-20. doi: 10.1300/J027v20n01_01
Auerbach, E. S., & Richardson, P. (2005). The long-term work experiences of persons with
severe and persistent mental illness. Psychiatric Rehabilitation Journal, 28(3), 267-273.
doi: 10.2975/28.2005.267.273
Banks, B., Novak, J., Mank, D., & Grossi, T. (2007). Disclosure of a psychiatric disability in
supported employment: an exploratory study. International Journal of Psychosocial
Rehabilitation, 11, 69-84.
Baron, R. (2002). People at work: The past and future career patterns of people with serious
mental illnesses. Tinley Park, IL: Recovery Press.
Barrera Jr, M. (1981). Social support in the adjustment of pregnant adolescents: Assessment
issues. In B. Gottlieb (Ed.), Social Networks and Social Support (pp. 69-96). Beverly
Hills, CA: Sage.
Bartels, S. J., Dums, A. R., Oxman, T. E., Schneider, L. S., Arean, P. A., Alexopoulos, G. S., &
Jeste, D. V. (2002). Evidence-based practices in geriatric mental health care. Psychiatric
Services, 53(11), 1419-1431. doi:10.1176/appi.ps.53.11.1419

101

Blumer, H. (1954). What is Wrong with Social Theory? American Sociological Review, 19(1), 3-
10. doi:10.2307/2088165
Bos, A. E. R., Kanner, D., Muris, P., Janssen, B., & Mayer, B. (2009). Mental illness stigma and
disclosure: Consequences of coming out of the closet. Issues in Mental Health Nursing,
30(8), 509-513. doi:10.1080/01612840802601382
Bowen, G. (2006). Grounded theory and sensitizing concepts. International Journal of
Qualitative Methods, 5(3), 12.
Boyatzis, R. (1998). Transforming qualitative information: Thematic analysis and code
development. Thousand Oaks, CA: Sage.
Brohan, E., Henderson, C., Wheat, K., Malcolm, E., Clement, S., Barley, E. A., . . . Thornicroft,
G. (2012). Systematic review of beliefs, behaviours and influencing factors associated
with disclosure of a mental health problem in the workplace. BMC Psychiatry, 12(1), 11.
doi: 10.1186/1471-244X-12-11
Bronfenbrenner, U. (1979). The ecology of human development: Experiments by design and
nature: Cambridge, MA: Harvard University Press.
Bushnell, J., McLeod, D., Dowell, A., Salmond, C., Ramage, S., Collings, S., . . . McBain, L.
(2005). Do patients want to disclose psychological problems to GPs? Family Practice,
22(6), 631-637. doi: 10.1093/fampra/cmi080
Cabassa, L. J., Hansen, M. C., Palinkas, L. A., & Ell, K. (2008). Azucar y nervios: Explanatory
models and treatment experiences of Hispanics with diabetes and depression. Social
Science & Medicine, 66(12), 2413-2424. doi: 10.1016/j.socscimed.2008.01.054

102

Cabassa, L. J., Lester, R., & Zayas, L. H. (2007). "It's like being in a labyrinth:" Hispanic
immigrants' perceptions of depression and attitudes toward treatments. Journal of
Immigrant and Minority Health, 9(1), 1-16. doi: 10.1007/s10903-006-9010-1
Cahill, E., Lewis, L. M., Barg, F. K., & Bogner, H. R. (2009). “You Don't Want to Burden
Them”. Journal of Family Nursing, 15(3), 295-317. doi: 10.1177/1074840709337247
Cape, J., & McCulloch, Y. (1999). Patients reasons for not presenting emotional problems in
general practice consultations. British Journal of General Practice, 49(448), 875-879.
Changrani, J., Lieberman, M., Golant, M., Rios, P., Damman, J., & Gany, F. (2008). Online
cancer support groups: experiences with underserved immigrant Latinas. Primary
Psychiatry, 15(10), 55-62.
Chapman, D. P., & Perry, G. S. (2008). Depression as a major component of public health for
older adults. Preventing Chronic Disease, 5(1), A22.
Charney, D. S., Reynolds, C. F., Lewis, L., Lebowitz, B. D., Sunderland, T., Alexopoulos, G. S.,
. . . Arean, P. A. (2003). Depression and Bipolar Support Alliance consensus statement
on the unmet needs in diagnosis and treatment of mood disorders in late life. Archives of
General Psychiatry, 60(7), 664-672. doi:10.1001/archpsyc.60.7.664
Chaudoir, S. R., & Fisher, J. D. (2010). The disclosure processes model: understanding
disclosure decision making and postdisclosure outcomes among people living with a
concealable stigmatized identity. Psychological Bulletin, 136(2), 236-256. doi:
10.1037/a0018193
Chen, F. P., Lai, G., & Yang, L. H. (2013). Mental illness disclosure in Chinese immigrant
communities. Journal of Counseling Psychology, 60(3), 379-391. doi: 10.1037/a0032620

103

Chen, J., & Rizzo, J. (2010). Racial and Ethnic Disparities in Use of Psychotherapy: Evidence
From U.S. National Survey Data. Psychiatr Serv, 61(4), 364-372. doi:
10.1176/appi.ps.61.4.364
Cole, M. G. (1997). The prognosis of depression in old age. The American Journal of Geriatric
Psychiatry, 5(1), 4-14. doi: 10.1097/00019442-199700510-00002
Conner, K. O., Copeland, V. C., Grote, N. K., Koeske, G., Rosen, D., Reynolds III, C. F., &
Brown, C. (2010). Mental health treatment seeking among older adults with depression:
the impact of stigma and race. The American Journal of Geriatric Psychiatry, 18(6), 531-
543. doi: 10.1097/JGP.0b013e3181cc0366
Cook, B., McGuire, T., & Miranda, J. (2007). Measuring trends in mental health care disparities,
2000–2004. Psychiatric Services, 58(12), 1533-1540. doi: 10.1176/appi.ps.58.12.1533
Corrigan, P., Edwards, A., Green, A., Diwan, S., & Penn, D. (2001). Prejudice, social distance,
and familiarity with mental illness. Schizophrenia Bulletin, 27(2), 219-225. doi:
10.1093/oxfordjournals.schbul.a006868
Corrigan, P., Kosyluk, K., & Rüsch, N. (2013). Reducing self-stigma by coming out proud.
American Journal of Public Health, 103(5), 794-800. doi: 10.2105/AJPH.2012.301037
Corrigan, P., Larson, J., Hautamaki, J., Matthews, A., Kuwabara, S., Rafacz, J., . . .
O’Shaughnessy, J. (2009). What lessons do coming out as gay men or lesbians have for
people stigmatized by mental illness? Community Mental Health Journal, 45(5), 366-
374. doi:10.1007/s10597-009-9187-6
Corrigan, P., Larson, J., & Ruesch, N. (2009). Self ‐stigma and the “why try” effect: Impact on
life goals and evidence ‐based practices. World Psychiatry, 8(2), 75-81.
Corrigan, P., & Lundin, R. (2001). Don't call me nuts. Tinley Park, IL: Recovery Press.

104

Corrigan, P., Markowitz, F., & Watson, A. (2004). Structural levels of mental illness stigma and
discrimination. Schizophrenia Bulletin, 30(3), 481-491. doi:
10.1093/oxfordjournals.schbul.a007096
Corrigan, P., & Matthews, A. K. (2003). Stigma and disclosure: Implications for coming out of
the closet. Journal of Mental Health, 12(3), 235-248. doi:
10.1080/0963823031000118221
Corrigan, P., Morris, S., Larson, J., Rafacz, J., Wassel, A., Michaels, P., . . . Rüsch, N. (2010).
Self-stigma and coming out about one's mental illness. Journal of Community
Psychology, 38(3), 259-275. doi: 10.1002/jcop.20363
Corrigan, P., & Penn, D. (1999). Lessons from social psychology on discrediting psychiatric
stigma. American Psychologist, 54(9), 765. doi:10.1037//0003-066X.54.9.765
Corrigan, P., & Phelan, S. (2004). Social Support and Recovery in People with Serious Mental
Illnesses. Community Mental Health Journal, 40(6), 513-523. doi: 10.1007/s10597-004-
6125-5
Corrigan, P., & Rao, D. (2012). On the self-stigma of mental illness: Stages, disclosure, and
strategies for change. Canadian Journal of Psychiatry, 57(8), 464-469.
Corrigan, P., River, L., Lundin, R., Penn, D., Uphoff-Wasowski, K., Campion, J., . . . Goldstein,
H. (2001). Three strategies for changing attributions about severe mental illness.
Schizophrenia Bulletin, 27(2), 187-195. doi: 10.1093/oxfordjournals.schbul.a006865
Corrigan, P., Slopen, N., Gracia, G., Phelan, S., Keogh, C., & Keck, L. (2005). Some recovery
processes in mutual-help groups for persons with mental illness; II: Qualitative Analysis
of Participant Interviews. Community Mental Health Journal, 41(6), 721-735.
doi:10.1007/s10597-005-6429-0

105

Corrigan, P., Sokol, K., & Rüsch, N. (2013). The impact of self-stigma and mutual help
programs on the quality of life of people with serious mental illnesses. Community
Mental Health Journal, 49(1), 1-6. doi: 10.1007/s10597-011-9445-2
Corrigan, P., Swantek, S., Watson, A., & Kleinlein, P. (2003). When do older adults seek
primary care services for depression? The Journal of Nervous and Mental Disease,
191(9), 619-622. doi:10.1097/01.nmd.0000087190.09305.b6
Corrigan, P., & Watson, A. (2002a). The Paradox of Self-Stigma and Mental Illness. Clinical
Psychology: Science and Practice, 9(1), 35-53. doi: 10.1093/clipsy.9.1.35
Corrigan, P., & Watson, A. (2002b). Understanding the impact of stigma on people with mental
illness. Habitat World, 1(1), 16-20.
Corrigan, P., Watson, A., & Barr, L. (2006). The self–stigma of mental illness: Implications for
self–esteem and self–efficacy. Journal of Social and Clinical Psychology, 25(8), 875-
884. doi: 10.1521/jscp.2006.25.8.875
Cozby, P. C. (1973). Self disclosure: A literature review. Psychological Bulletin, 79(2), 73-91.
doi: 10.1037/h0033950
Creswell, J. W., & Clark, V. L. P. (2007). Designing and conducting mixed methods research (2
ed.). Los Angeles: Sage.
Dalgin, R. S., & Gilbride, D. (2003). Perspectives of people with psychiatric disabilities on
employment disclosure. Psychiatric Rehabilitation Journal, 26(3), 306-310.
doi:10.2975/26.2003.306.310
Derlega, V. J., Winstead, B. A., Greene, K., Serovich, J., & Elwood, W. N. (2004). Reasons for
HIV disclosure/nondisclosure in close relationships: Testing a model of HIV–disclosure

106

decision making. Journal of Social and Clinical Psychology, 23(6), 747-767.
doi:10.1521/jscp.23.6.747.54804
Dew, K., Morgan, S., Dowell, A., McLeod, D., Bushnell, J., & Collings, S. (2007). ‘It puts things
out of your control’: Fear of consequences as a barrier to patient disclosure of mental
health issues to general practitioners. Sociology of Health & Illness, 29(7), 1059-1074.
doi: 10.1111/j.1467-9566.2007.01022.x
Ellison, M. L., Russinova, Z., MacDonald-Wilson, K. L., & Lyass, A. (2003). Patterns and
correlates of workplace disclosure among professionals and managers with psychiatric
conditions. Journal of Vocational Rehabilitation, 18(1), 3-13.
Emlet, C. A. (2006). A comparison of HIV stigma and disclosure patterns between older and
younger adults living with HIV/AIDS. AIDS Patient Care & STDs, 20(5), 350-358. doi:
10.1089/apc.2006.20.350
Ennis, S. R., Rios-Vargas, M., & Albert, N. G. (2011). The Hispanic population: 2010 (2010
Census Briefs). Washington, DC: U.S. Census Bureau.
Fabian, E. S., Waterworth, A., & Ripke, B. (1993). Reasonable accommodations for workers
with serious mental illness: Type, frequency, and associated outcomes. Psychosocial
Rehabilitation Journal, 17(2), 163-172. doi:10.1037/h0095591
Fekete, E. M. (2009). Men's serostatus disclosure to parents: associations among social support,
ethnicity, and disease status in men living with HIV. Brain, behavior, and immunity,
23(5), 693-699. doi: 10.1016/j.bbi.2009.01.007
Fisher, D. B. (1995). Disclosure, discrimination and the ADA. The Journal of the California
Alliance for the Mentally Ill, 6(4), 55-56.

107

Foster, T. (2003). Suicide note themes and suicide prevention. International Journal of
Psychiatry in Medicine, 33(4), 323-331.
Fraser, D. (2000). QSR NVivo NUD*IST Vivo Reference Guide. Melbourne: QSR International.
Freidl, M., Lang, T., & Scherer, M. (2003). How psychiatric patients perceive the public's
stereotype of mental illness. Social Psychiatry and Psychiatric Epidemiology, 38(5), 269-
275. doi: 10.1007/s00127-003-0626-3
Fuentes, D., & Aranda, M. P. (2012). Depression interventions among racial and ethnic minority
older adults: a systematic review across 20 years. The American Journal of Geriatric
Psychiatry, 20(11), 915-931. doi: 10.1097/JGP.0b013e31825d091a
Gallo, J. J., & Lebowitz, B. D. (1999). The epidemiology of common late-life mental disorders
in the community: themes for the new century. Psychiatric Services, 50(9), 1158-1166.
Garcia, J. A., & Crocker, J. (2008). Reasons for disclosing depression matter: The consequences
of having egosystem and ecosystem goals. Social Science & Medicine, 67(3), 453-
462. doi: 10.1016/j.socscimed.2008.03.016
Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for
qualitative research. New York: Aldine de Gruyter.
Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ:
Prentice-Hall.
Golding, J. M., & Baezconde-Garbanati, L. A. (1990). Ethnicity, culture, and social resources.
American Journal of Community Psychology, 18(3), 465-486. doi: 10.1007/bf00938118
González, H. M., Tarraf, W., Whitfield, K. E., & Vega, W. A. (2010). The epidemiology of
major depression and ethnicity in the United States. Journal of Psychiatric Research,
44(15), 1043-1051. doi: 10.1016/j.jpsychires.2010.03.017

108

Goodstein, L. D., & Reinecker, V. M. (1974). Factors affecting self-disclosure: a review of the
literature. Progress in experimental personality research,7, 49-77.
Granger, B. (2000). The role of psychiatric rehabilitation practitioners in assisting people in
understanding how to best assert their ADA rights and arrange job accommodations.
Psychiatric Rehabilitation Journal, 23(3), 215-223. doi: 10.1037/h0095165
Granger, B., Baron, R., & Robinson, S. (1997). Findings from a national survey of job coaches
and job developers about job accommodations arranged between employers and people
with psychiatric disabilities. Journal of Vocational Rehabilitation, 9(3), 235-251.
Greene, K. (2009). An integrated model of health disclosure decision-making Uncertainty,
information management, and disclosure decisions: Theories and applications. (pp. 226-
253): Routledge/Taylor & Francis Group, New York, NY.
Greene, K., Derlega, V. J., Yep, G. A., & Petronio, S. (2003). Privacy and disclosure of HIV in
interpersonal relationships: A sourcebook for researchers and practitioners: Routledge.
Guarnaccia, P. J., Lewis-Fernandez, R., & Marano, M. R. (2003). Toward a Puerto Rican
Popular Nosology: Nervios and Ataque de Nervios. Culture, Medicine and Psychiatry,
27(3), 339-366. doi: 10.1023/a:1025303315932
Gum, A. M., King-Kallimanis, B., & Kohn, R. (2009). Prevalence of mood, anxiety, and
substance-abuse disorders for older Americans in the national comorbidity survey-
replication. The American journal of geriatric psychiatry, 17(9), 769-781. doi:
10.1097/JGP.0b013e3181ad4f5a
Hayward, P., & Bright, J. A. (1997). Stigma and mental illness: a review and critique. Journal of
Mental Health, 6(4), 345-354.

109

Hellemans, S., De Mol, J., Buysse, A., Eisler, I., Demyttenaere, K., & Lemmens, G. M. D.
(2011). Therapeutic processes in multi-family groups for major depression: Results of an
interpretative phenomenological study. Journal of affective disorders, 134(1–3), 226-234.
doi: 10.1016/j.jad.2011.05.050
Herman, N. J. (1993). Return to sender: Reintegrative stigma-management strategies of ex-
psychiatric patients. Journal of Contemporary Ethnography, 22(3), 295-330. doi:
10.1177/089124193022003002
Horne, G., & Payne, S. (2004). Removing the boundaries: palliative care for patients with heart
failure. Palliative Medicine, 18(4), 291-296. doi: 10.1191/0269216304pm893oa
Hsiung, P. C., Pan, A. W., Liu, S. K., Chen, S. C., Peng, S. Y., & Chung, L. (2010). Mastery and
stigma in predicting the subjective quality of life of patients with schizophrenia in
Taiwan. The Journal of Nervous and Mental Disease, 198(7), 494-500.
doi:10.1097/NMD.0b013e3181e4d310
IBM. (Released 2012). IBM SPSS Statistics for Windows, Version 21.0. . Armonk, NY: IBM
Corp. .
Jahn, D. R., Van Orden, K. A., & Cukrowicz, K. C. (2013). Perceived burdensomeness in older
adults and perceptions of burden on spouses and children. Clinical Gerontologist, 36(5),
451-459. doi: 10.1080/07317115.2013.816817
Jimenez, D. E., Alegría, M., Chen, C., Chan, D., & Laderman, M. (2010). Prevalence of
psychiatric illnesses in older ethnic minority adults. Journal of the American Geriatrics
Society, 58(2), 256-264. doi: 10.1111/j.1532-5415.2009.02685.x

110

Jimenez, D. E., Bartels, S. J., Cardenas, V., & Alegría, M. (2013). Stigmatizing attitudes toward
mental illness among racial/ethnic older adults in primary care. International Journal of
Geriatric Psychiatry, 28(10), 1061-2068. doi:10.1002/gps.3928
Jones, A. (2011). Disclosure of mental illness in the workplace: A literature review. American
Journal of Psychiatric Rehabilitation, 14(3), 212-229. doi:
http://dx.doi.org/10.1080/15487768.2011.598101
Jones, E., Farina, A., Hastorf, A., Markus, H., Miller, D., & Scott, R. (1984). Social stigma: The
psychology of marked relationships. New York, NY: Freeman.
Jourard, S. M. (1959). Healthy personality and self-disclosure. Mental Hygiene, 43, 499-507.
Jourard, S. M. (1961). Age trends in self-disclosure. Merrill-Palmer Quarterly of Behavior and
Development, 191-197.
Jourard, S. M. (1971). Self-disclosure: An experimental analysis of the transparent self. Oxford,
England: Wiley.
Jourard, S. M., & Lasakow, P. (1958). Some factors in self-disclosure. The Journal of Abnormal
and Social Psychology, 56(1), 91-98. doi: 10.1037/h0043357
Joyce, T., McMillan, M., & Hazelton, M. (2009). The workplace and nurses with a mental
illness. International Journal of Mental Health Nursing, 18(6), 391-397.
doi:10.1111/j.1447-0349.2009.00629.x
Kadushin, G. (2000). Family secrets: Disclosure of HIV status among gay men with HIV/AIDS
to the family of origin. Social Work in Health Care, 30(3), 1-17.
doi:10.1300/J010v30n03_01
Keefe, S. E., Padilla, A. M., & Carlos, M. L. (1979). The Mexican-American extended family as
an emotional support system. Human Organization, 38(2), 144-152.

111

Kirsh, B. (2000). Work, workers, and workplaces: A qualitative analysis of narratives of mental
health consumers. Journal of Rehabilitation, 66(4), 24-30.
Klassen, D., Hornstra, R. K., & Anderson, P. B. (1975). Influence of social desirability on
symptom and mood reporting in a community survey. Journal of Consulting and Clinical
Psychology, 43(4), 448-452. doi: 10.1037/h0076863
Kleinman, A. (1978). Concepts and a model for the comparison of medical systems as cultural
systems. Social Science & Medicine. Medical Economics, 12, 85-93. doi:10.1016/0160-
7987(78)90014-5
Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, Illness, and Care. Annals of Internal
Medicine, 88(2), 251-258. doi: 10.1059/0003-4819-88-2-251
Kleinman, A., Eisenberg, L., & Good, B. (2006). Culture, illness, and care: Clinical lessons from
anthropologic and cross-cultural research. Foreign Policy in Focus, 4(1), 140-149.
Kleinman, A., & Good, B. (1985). Culture and depression: Studies in the anthropology and
cross-cultural psychiatry of affect and disorder. Berkeley, CA: University of California
Press.
Kohn, R., Saxena, S., Levav, I., & Saraceno, B. (2004). The treatment gap in mental health care.
Bulletin of the World Health Organization, 82(11), 858-866.
Korsbek, L. (2013). Disclosure: What is the point and for whom? Journal of Mental Health,
22(3), 283-290. doi: doi:10.3109/09638237.2013.799264
Koser, D. A., Matsuyama, M., & Kopelman, R. E. (1999). Comparison of a physical and a
mental disability in employee selection: An experimental examination of direct and
moderated effects. North American Journal of Psychology, 1, 213-222.

112

Lackey, G. F. (2008). “Feeling blue” in Spanish: A qualitative inquiry of depression among
Mexican immigrants. Social Science & Medicine, 67(2), 228-237. doi:
10.1016/j.socscimed.2008.03.026
Lane, J. D., & Wegner, D. M. (1995). The cognitive consequences of secrecy. Journal of
Personality and Social Psychology, 69(2), 237-253. doi:10.1037/0022-3514.69.2.237
Levinson, C. M., & Druss, B. G. (2000). The evolution of mental health parity in American
politics. Administration and Policy in Mental Health and Mental Health Services
Research, 28(2), 139-146.
Limandri, B. J. (1989). Disclosure of stigmatizing conditions: the discloser's perspective.
Archives of Psychiatric Nursing, 3(2), 69-78.
Link, B., Cullen, F., Struening, E., Shrout, P., & Dohrenwend, B. (1989). A modified labeling
theory approach to mental disorders: An empirical assessment. American Sociological
Review, 54(3), 400-423. doi:10.2307/2095613
Link, B., Cullen, F. T., Frank, J., & Wozniak, J. F. (1987). The social rejection of former mental
patients: Understanding why labels matter. American Journal of Sociology, 92(6), 1461-
1500. doi:10.1086/228672
Link, B., Mirotznik, J., & Cullen, F. (1991). The effectiveness of stigma coping orientations: Can
negative consequences of mental illness labeling be avoided? Journal of Health and
Social Behavior, 32(3), 302-320. doi:10.2307/2136810
Link, B., & Phelan, J. (2001). Conceptualizing stigma. Annual Review of Sociology, 27(1), 363-
385. doi: 10.1146/annurev.soc.27.1.363

113

Link, B., Struening, E., Neese-todd, S., Asmussen, S., & Phelan, J. (2002). On describing and
seeking to change the experience of stigma. Psychiatric Rehabilitation Skills, 6(2), 201-
231. doi: 10.1080/10973430208408433
Link, B. G., Struening, E., Neese-Todd, S., Asmussen, S., & Phelan, J. (2001). Stigma as a
barrier to recovery: The consequences of stigma for the self-esteem of people with
Mental Illnesses. Psychiatric services, 52(12), 1621-1626. doi:
10.1176/appi.ps.52.12.1621
López, S. R. (2002). Mental health care for Latinos: A research agenda to improve the
accessibility and quality of mental health care for Latinos. Psychiatric Services, 53(12),
1569-1573. doi:10.1176/appi.ps.53.12.1569
Lopez, S. R., & Guarnaccia, P. J. (2000). Cultural psychopathology: uncovering the social world
of mental illness. Annual review of psychology, 51, 571-598. doi:
10.1146/annurev.psych.51.1.571
Major, B., & O'Brien, L. T. (2005). The social psychology of stigma. Annual Review
Psychology, 56, 393-421. doi:10.1146/annurev.psych.56.091103.070137
Marín, G., & Marín, B. V. (1991). Research with Hispanic populations, from
http://srmo.sagepub.com/view/research-with-hispanic-populations/sage.xml
Mason, H. R., Marks, G., Simoni, J. M., Ruiz, M. S., & Richardson, J. L. (1995). Culturally
sanctioned secrets? Latino men's nondisclosure of HIV infection to family, friends, and
lovers. Health Psychology, 14(1), 6-12. doi:10.1037//0278-6133.14.1.6
McKenna, M. T., Michaud, C. M., Murray, C. J. L., & Marks, J. S. (2005). Assessing the burden
of disease in the United States using disability-adjusted life years. American Journal of
Preventive Medicine, 28(5), 415-423. doi: 10.1016/j.amepre.2005.02.009

114

Michalak, E. E., Yatham, L. N., Maxwell, V., Hale, S., & Lam, R. W. (2007). The impact of
bipolar disorder upon work functioning: A qualitative analysis. Bipolar Disorders,
9(1 ‐2), 126-143. doi: 10.1111/j.1399-5618.2007.00436.x
Miles, M. B., & Huberman, A. M. (1984). Qualitative data analysis: A sourcebook of new
methods. Beverly Hills, CA: Sage.
Miranda, J., Nakamura, R., & Bernal, G. (2003). Including ethnic minorities in mental health
intervention research: a practical approach to a long-standing problem. Culture, Medicine
and Psychiatry, 27(4), 467-486. doi:10.1023/B:MEDI.0000005484.26741.79
Moussavi, S., Chatterji, S., Verdes, E., Tandon, A., Patel, V., & Ustun, B. (2007). Depression,
chronic diseases, and decrements in health: Results from the World Health Surveys. The
Lancet, 370(9590), 851-858. doi: 10.1016/s0140-6736(07)61415-9
Mueller, T. I., Kohn, R., Levaenthal, N., Leon, A. C., Solomon, D., Coryell, W., . . . Keller, M.
B. (2004). The course of depression in elderly patients. The American journal of geriatric
psychiatry, 12(1), 22. doi:10.1176/appi.ajgp.12.1.22
Mulvaney-Day, N. E., Alegría, M., & Sribney, W. (2007). Social cohesion, social support, and
health among Latinos in the United States. Social Science & Medicine, 64(2), 477-
495. doi: 10.1016/j.socscimed.2006.08.030
National Research Council. (2006). Hispanics and the Future of America. Washington, DC: The
National Academies Press.
Nelson, J. C., Delucchi, K., & Schneider, L. S. (2008). Efficacy of second generation
antidepressants in late-life depression: a meta-analysis of the evidence. The American
Journal of Geriatric Psychiatry, 16(7), 558-567. doi: 10.1097/JGP.0b013e3181693288

115

O'Connor, D. W., Rosewarne, R., & Bruce, A. (2001). Depression in Primary Care 1: Elderly
patients' disclosure of depressive symptoms to their doctors. International
Psychogeriatrics, 13(03), 359-365. doi: doi:10.1017/S1041610201007748
Okuyama, T., Endo, C., Seto, T., Kato, M., Seki, N., Akechi, T., . . . Hosaka, T. (2008). Cancer
patients' reluctance to disclose their emotional distress to their physicians: a study of
Japanese patients with lung cancer. Psycho-Oncology, 17(5), 460-465. doi:
10.1002/pon.1255
Omarzu, J. (2000). A disclosure decision model: Determining how and when individuals will
self-disclose. Personality and Social Psychology Review, 4(2), 174-185. doi:
10.1207/s15327957pspr0402_05
Pachankis, J. (2007). The psychological implications of concealing a stigma: A cognitive-
affective-behavioral model. Psychological Bulletin, 133(2), 328-345. doi:10.1037/0033-
2909.133.2.328
Pandya, A., Bresee, C., Duckworth, K., Gay, K., & Fitzpatrick, M. (2011). Perceived impact of
the disclosure of a schizophrenia diagnosis. Community Mental Health Journal, 47(6),
613-621. doi: http://dx.doi.org/10.1007/s10597-010-9341-1
Perry, B. L. (2011). The labeling paradox: Stigma, the sick role, and social networks in mental
illness. Journal of health and social behavior, 52(4), 460-477.
doi:10.1177/0022146511408913
Peterson, D., Currey, N., & Collings, S. (2011). "You don't look like one of them": Disclosure of
mental illness in the workplace as an ongoing dilemma. Psychiatric Rehabilitation
Journal, 35(2), 145-147. doi: http://dx.doi.org/10.2975/35.2.2011.145.147

116

Pincay, I. E., & Guarnaccia, P. J. (2007). “It’s like going through an earthquake”:
Anthropological perspectives on depression among Latino immigrants. Journal of
immigrant and minority health, 9(1), 17-28. doi: 10.1007/s10903-006-9011-0
Prior, L., Wood, F., Lewis, G., & Pill, R. (2003). Stigma revisited, disclosure of emotional
problems in primary care consultations in Wales. Social Science & Medicine, 56(10),
2191-2200. doi: http://dx.doi.org/10.1016/S0277-9536(02)00235-6
Probst, J. C., Laditka, S. B., Moore, C. G., Harun, N., & Powell, M. P. (2007). Race and
ethnicity differences in reporting of depressive symptoms. Administration and policy in
mental health, 34(6), 519-529. doi: 10.1007/s10488-007-0136-9
Pyne, J. M., Patterson, T. L., Kaplan, R. M., Gillin, J. C., Koch, W. L., & Grant, I. (1997).
Assessment of the quality of life of patients with major depression. Psychiatric Services,
48(2), 224-230.
Ralph, R. O. (2002). The dynamics of disclosure: Its impact on recovery and rehabilitation.
Psychiatric Rehabilitation Journal, 26(2), 165-172. doi:10.2975/26.2002.165.172
Rao, D., Feinglass, J., & Corrigan, P. (2007). Racial and ethnic disparities in mental illness
stigma. The Journal of nervous and mental disease, 195(12), 1020-1023. doi:
10.1097/NMD.0b013e31815c046e
Rappaport, J. (2000). Community narratives: Tales of terror and joy. American Journal of
Community Psychology, 28(1), 1-24.
Rice, E., Comulada, S., Green, S., Arnold, E., & Rotheram-Borus, M. (2009). Differential
disclosure across social network ties among women living with HIV. AIDS and Behavior,
13(6), 1253-1261. doi: 10.1007/s10461-009-9554-x

117

Rollins, A. L. (2002). Predictors of interpersonal relationships in the workplace for people with
severe mental illness (Unpublished doctoral dissertation). Indianapolis: Indiana
University-Purdue University.
Rollins, A. L., Mueser, K. T., Bond, G. R., & Becker, D. R. (2002). Social relationships at work:
Does the employment model make a difference? Psychiatric Rehabilitation Journal,
26(1), 51-61. doi:10.2975/26.2002.51.61
Ross, C. E., & Mirowsky, J. (1983). The worst place and the best face. Social Forces, 62(2),
529-536. doi:10.2307/2578321
Rüsch, N., Angermeyer, M. C., & Corrigan, P. W. (2005). Mental illness stigma: Concepts,
consequences, and initiatives to reduce stigma. European Psychiatry, 20(8), 529-539.
doi: 10.1016/j.eurpsy.2005.04.004
Rüsch, N., Corrigan, P., Wassel, A., Michaels, P., Olschewski, M., Wilkniss, S., & Batia, K.
(2009). Ingroup perception and responses to stigma among persons with mental illness.
Acta Psychiatrica Scandinavica, 120(4), 320-328. doi: 10.1111/j.1600-
0447.2009.01403.x
Rüsch, N., Lieb, K., Bohus, M., & Corrigan, P. (2006). Brief reports: Self-stigma, empowerment,
and perceived legitimacy of discrimination among women with mental illness.
Psychiatric Services, 57(3), 399-402. doi:10.1176/appi.ps.57.3.399
Sabogal, F., Marín, G., Otero-Sabogal, R., Marín, B. V., & Perez-Stable, E. J. (1987). Hispanic
Familism and Acculturation: What Changes and What Doesn't? Hispanic Journal of
Behavioral Sciences, 9(4), 397-412. doi: 10.1177/07399863870094003

118

SAMHSA. (2000). Proceedings of the National Congress for Hispanic Mental Health: Creating
a Vision for the 21st Century. . Rockville, Maryland: Substance Abuse and Mental Health
Services Administration.
Sankar, P. (2005). To Tell or Not to Tell: Primary Care Patients' Disclosure Deliberations.
Archives of internal medicine (1960), 165(20), 2378-2383. doi:
10.1001/archinte.165.20.2378
Sclar, D. A., Robison, L. M., & Skaer, T. L. (2008). Ethnicity/race and the diagnosis of
depression and use of antidepressants by adults in the United States. International
clinical psychopharmacology, 23(2), 106-109. doi: 10.1097/YIC.0b013e3282f2b3dd
Scogin, F. (2005). Evidence-based psychotherapies for depression in older adults. Clinical
Psychology: Science and Practice, 12(3), 222-237. doi: 10.1093/clipsy/bpi033
Simoni, J., Mason, H., Marks, G., Ruiz, M., Reed, D., & Richardson, J. (1995). Women's self-
disclosure of HIV infection: Rates, reasons, and reactions. Journal of consulting and
clinical psychology, 63(3), 474-478. doi: http://dx.doi.org/10.1037/0022-006X.63.3.474
Simoni, J. M., Demas, P., Mason, H. R., Drossman, J. A., & Davis, M. L. (2000). HIV disclosure
among women of African descent: Associations with coping, social support, and
psychological adaptation. AIDS and Behavior, 4(2), 147-158. doi:
10.1023/A:1009508406855
Smith, R., Rossetto, K., & Peterson, B. L. (2008). A meta-analysis of disclosure of one's HIV-
positive status, stigma and social support. AIDS Care, 20(10), 1266-1275. doi:
10.1080/09540120801926977
Solway, E., Estes, C. L., Goldberg, S., & Berry, J. (2010). Access barriers to mental health
services for older adults from diverse populations: Perspectives of leaders in mental

119

health and aging. Journal of Aging & Social Policy, 22(4), 360-378. doi:
10.1080/08959420.2010.507650
Steffens, D. C., Fisher, G. G., Langa, K. M., Potter, G. G., & Plassman, B. L. (2009). Prevalence
of depression among older Americans: The Aging, Demographics and Memory Study.
International Psychogeriatrics, 21(5), 879-888. doi: 10.1017/S1041610209990044
Stek, M. L., Exel, E. v., Tilburg, W. V., Westendorp, R. G. J., & Beekman, A. T. F. (2002). The
prognosis of depression in old age: Outcome six to eight years after clinical treatment.
Aging & mental health, 6(3), 282-285. doi: 10.1080/13607860220142413
Strauss, A. L., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures
and techniques. Newbury Park, CA: Sage Publications.
Thornicroft, G., Brohan, E., Rose, D., Sartorius, N., & Leese, M. (2009). Global pattern of
experienced and anticipated discrimination against people with schizophrenia: A cross-
sectional survey. The Lancet, 373(9661), 408-415. doi:10.1016/S0140-6736(08)61817-6
U.S. Census Bureau. (2008). Projections of the population by age and sex for the United States:
2010 to 2050 (NP2008-T12). Washington, D.C.: U.S. Census Bureau.
U.S. Census Bureau. (2011). Age and sex composition in Age and sex composition in the United
States: 2011. Table 1. Current Population Survey, Annual Social and Economic
Supplement. Washington, D.C.: U.S. Census Bureau.
U.S. Census Bureau. (2012). Statistical Abstract of the United States: 2012. Washington, D.C.:
U.S. Census Bureau.
U.S. Department of Health and Human Services. (2001). Mental Health: Culture, race, and
ethnicity: A supplement to Mental Health: A report of the Surgeon General. Rockville,

120

MD: U.S. Department of Health and Human Services, Public Health Service, Office of
the Surgeon General.
United States Code. (1990). Americans with Disabilities Act of 1990 CHAPTER 126 - EQUAL
OPPORTUNITY FOR INDIVIDUALS WITH DISABILITIES. Washington, DC: The
Public Health and Welfare.
Unützer, J., Patrick, D. L., Diehr, P., Simon, G., Grembowski, D., & Katon, W. (2000). Quality
adjusted life years in older adults with depressive symptoms and chronic medical
disorders. International Psychogeriatrics, 12(01), 15-33. doi:
10.1017/S1041610200006177
Valle, M., & Levy, J. (2009). Weighing the consequences. Health Education & Behavior, 36(1),
155-166. doi: 10.1177/1090198108316595
Vázquez-Montilla, E., Reyes-Blanes, M. E., Hyun, E., & Brovelli, E. (2000). Practices for
culturally responsive interviews and research with Hispanic families. Multicultural
Perspectives, 2(3), 3-7. doi: 10.1207/S15327892MCP0203_02
Vincent, G. K., & Velkoff, V. A. (2010). The next four decades - The older population in the
United States: 2010 to 2050. In U. S. C. Bureau (Ed.). Washington, D.C.: U.S. Census
Bureau.
Wagner, J. A., Perkins, D. W., Piette, J. D., Lipton, B., & Aikens, J. E. (2009). Racial differences
in the discussion and treatment of depressive symptoms accompanying type 2 diabetes.
Diabetes Research and Clinical Practice, 86(2), 111-116. doi:
10.1016/j.diabres.2009.08.004
Wahl, O. F. (1999). Mental health consumers' experience of stigma. Schizophrenia Bulletin,
25(3), 467-478. doi:10.1093/oxfordjournals.schbul.a033394

121

Wang, P. S., Lane, M., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2005). Twelve-
month use of mental health services in the United States: Results from the National
Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 629-240.
doi:10.1001/archpsyc.62.6.629
Wegner, D. M., & Lane, J. D. (1995). From secret to psychopathology. In J. W. Pennebaker
(Ed.), Emotion, disclosure, & health. Washington: American Psychological Association.
Whaley, A. L. (1997). Ethnic and racial differences in perceptions of dangerousness of persons
with mental illness. Psychiatric Services, 48(10), 1328-1330.
Wheat, K., Brohan, E., Henderson, C., & Thornicroft, G. (2010). Mental illness and the
workplace: conceal or reveal? Journal of the Royal Society of Mecidine, 103(3), 83-86.
WHO Department of Mental Health and Substance Abuse. (2011). Mental Health Atlas. Geneva,
Switzerland: World Health Organization.
Willms, D. G., Best, A. J., Taylor, D. W., Gilbert, J. R., Wilson, D. M. C., Lindsay, E. A., &
Singer, J. (1990). A Systematic Approach for Using Qualitative Methods in Primary
Prevention Research. Medical Anthropology Quarterly, 4(4), 391-409. doi:
10.1525/maq.1990.4.4.02a00020
Wilson, K., Mottram, P., & Vassilas, C. (2008). Psychotherapeutic treatments for older
depressed people. Cochrane Database of Systematic Reviews, CD004853. doi:
10.1002/14651858.CD004853.pub2
Wohl, A., Galvan, F., Myers, H., Garland, W., George, S., Witt, M., . . . Lee, M. (2011). Do
social support, stress, disclosure and stigma influence retention in HIV care for Latino
and African American men who have sex with men and women? AIDS and Behavior,
15(6), 1098-1110. doi: 10.1007/s10461-010-9833-6

122

Zea, M. C., Reisen, C. A., Poppen, P. J., Bianchi, F. T., & Echeverry, J. J. (2007). Predictors of
disclosure of human immunovirus-positive serostatus among Latino gay men. Cultural
Diversity and Ethnic Minority Psychology, 13(4), 304. doi:10.1037/1099-9809.13.4.304
Zea, M. C., Reisen, C. A., Poppen, P. J., & Echeverry, J. J. (2005). Disclosure of HIV status and
psychological well-being among Latino gay and bisexual men. AIDS and Behavior, 9(1),
15-26. doi:10.1007/s10461-005-1678-z

123

Footnotes
1
Problem Solving Treatment is used to refer to the intervention provided by the PMA
interventionists, and is different from Problem Solving Therapy. Problem Solving Treatment,
because it is delivered by non-licensed professionals, is not considered psychotherapy in this
study.

124

Appendix A: Interview Guide (English)

Programa Mano Amiga©
Primary Participant Qualitative Interview - English (05.17.12)

A. RA ID _______ B. Interview Type: 1=over phone 2=face to face C. Location ID:______ D. Study ID _________ E. Language: 1= Eng 2=Span 3=Bil
F. Interview Date /___/___/___ (mm/dd/yy) G. Interview Time #1: from ___________ to ___________ H. Interview Time #2: from ___________ to
___________

PHONE SCRIPT
Hello Mrs./Mr. [name]. My name is [name], and I am calling from the Programa Mano Amiga
study. Some time ago you gave us permission to interview you as part of a research study
conducted at AltaMed, the agency where you receive services (or used to receive services). [IF
NEEDED, HELP THE SUBJECT REMEMBER THEIR PARTICIPATION BY STATING
WHO THEY SAW AS THEIR PST INTERVENTIONIST AND ABOUT WHEN THEY SAW
THEM FOR PST SESSION]. This is the last interview we will ask you to complete. May I
schedule the interview with you now? [CONTINUE WITH SCHEDULING OF THE IN-
DEPTH INTERVIEW].
DATE___________ TIME___________ COMMENTS____________________________
SECTION A: Introduction and
Thank you for agreeing to speak with me. I would like to ask you a few questions regarding your
experience with the study or program, Programa Mano Amiga. There is no right or wrong
answer to any of my questions. What is important is that you share your personal experiences
with this study (program).
You participated in several interviews with our personnel as part of your participation in the
program. [PROVIDE PROMPTS/REMINDERS OF WHEN, WITH WHOM, ON WHAT].
SECTION B: Knowledge about depression
In our study (program) we try to teach the participants about depression and how it affects older
people. Tell me what you remember learning about depression as a result of participating in our
study (program).
PROBES:
 Tell me what you know about depression.
 How would you know if someone you cared about is depressed?
 What signs would you look for?
 If someone that you cared about were depressed, what would you tell them to do?

SECTION C: Study Interviews (PST AND EUC SUBJECTS)
Now I would like to ask you about your experiences with the interviews that you participated in
as part of our study (program). Each person in our study had completed several interviews,
either at the AltaMed sites, or in their home. During each interview we asked lots of questions.
You participated in a few of these interviews. [PROVIDE PROMPTS/REMINDERS OF
WHEN, WITH WHOM, ON WHAT].

125

Can you tell me about your experience with these interviews/questions? (IF PST SUBJECT:
These are separate from the weekly sessions with [NAME OF INTERVENTIONIST])
PROBES:
 Tell me what you remember about these interviews/questions.
 How easy or difficult was it to answer the questions during these interviews/questions?
 What did you find interesting about the answers you gave in the interviews/questions?

Some participants had no hesitation about being interviewed, while others had some concerns or
reservations. Can you tell me why you decided to be interviewed?
PROBES:
 What were some reasons that made you decide to meet with us and do these interviews?
 What were some of your concerns or reservations?
Most participants in the study did not want to complete the interviews at their homes but rather at
the AltaMed location. Would you have any idea of why participants preferred being interviewed
at the AltaMed site rather than at home?
PROBE:
 What were your reasons for being interviewed at home or at AltaMed for these
interviews?

SECTION D: Experiences with PST sessions / Components (FOR PST SUBJECTS ONLY)
Now, I would like to ask you about your experiences with the counseling sessions that you
received in our program. These questions have to do with the counseling sessions you received
from [NAME OF INTERVENTIONIST].
PST sessions--Overall Impressions
If someone asked you what the sessions were about, what would you tell them?
PROBES:
 How would you describe the sessions?
 What was the purpose of the sessions?
 What was discussed during the sessions?

If someone asked you if you liked these sessions or not, what would you tell them?
PROBES:
 Can you give me some examples of why you liked these sessions?
 Can you give me some examples of why you did not like these sessions?
 What were the reasons that helped you decide to continue (or discontinue) with the
counseling sessions?

PST in-session handouts
I would like to show you the papers that were used during the sessions. Tell me what you
remember about these papers. SHOW THE HANDOUTS AND ELICIT RESPONSES. MAKE
SURE THAT THE SUBJECT DOES NOT FEEL UNCOMFORTABLE WITH PROBLEMS
REMEMBERING ALL OF THE DETAILS.

126

PROBES:
 What do you remember about these papers and what they were for? Please explain.
 Did you share these papers with anyone else? Please explain.
 Are you using any of the papers now, or following the advice that they give?

PST Sessions-Skill acquisition
Sometimes people learn new ways to manage their problems differently when they attend these
types of sessions, while others do not. Can you tell me what was the case with you?
[DOCUMENT EXAMPLES OF PROBLEM-SOLVING KNOWLEDGE AND STRATEGIES.]
PROBES:
 Can you tell me what new tips or strategies, if any, you learned from the
counseling sessions about how to solve your problems? Please explain.
 If there is anything that you do differently now to solve your problems, what
would that be? Please give examples. (USE THE FOLLOWING PROMPTS:)
i. Do you try to think positive?
ii. Do you try to figure out what part of the problem you want to face first?
iii. Do you try to think about different solutions to your problem?
iv. Do you look at the advantages and disadvantages of these solutions?
v. Do you pick one solution and plan how you are doing to try it out?
vi. Do you evaluate if your plan worked, or not?
vii. Do you try to increase pleasant activities in your life that you once stopped
doing (or did less)?

Did these new tips and strategies help you get better (or not)?
PROBES:
 In what ways did these tips and strategies help you decrease your depression?
Please explain.
 In what ways did these tips and strategies help you care for other illnesses (such
as diabetes, heart disease, arthritis, chronic pain, etc.)? Please explain.
 In what ways did the sessions help you get the services you needed from AltaMed
or other places?
PHQ-9
Each week, your interventionist asked you about your symptoms of depression.
(READ OUT LOUD THE FIRST AND SECOND ITEMS OF THE PHQ-9 SCALE).
PROBES:
 What did you think about (or what did you find interesting about) your answers to
these questions?
 Were you concerned about having depression?

Homework assignments (i.e., implementing their action plan and doing pleasurable activity)
When you were given assignments (i.e., implementing action plan and doing pleasurable
activity) to work on your problems during the week, did you actually attempt to do the
assignments?

127

If you were to give yourself a score on how much effort you gave to doing the assignments, what
score would you give yourself? SHOW RESPONSE BELOW

0 1 2 3 4 5 6 7 8 9 10
Did not do any homework. Did the homework all the time

Termination
When you and (NAME OF INTERVENTIONIST) said goodbye during the last counseling
session, how did you react?
PROBE:
 Did anything stand out about the last session, in comparison to the previous
sessions?
 What would you do if you got depressed again?

Final remarks about the sessions
Of everything we talked about so far is there anything about the sessions that you would change?
Or, what would you leave the same?

If you had to do this over again, would you participate, or not? (PROBE WHETHER YES OR
NO). On a scale of 0 to 10 on average what is the chance that you would participate in this
program again? SHOW SCALE
 Please explain

0 1 2 3 4 5 6 7 8 9 10
Would not participate again for any reason. Would not think twice about participating again for any reason.
If you knew someone close to you who had depression, would you recommend this program to
her/him? Please explain.
SECTION E: Family / Caregivers Open
Part of our study included speaking with family members of the participants in the study. We
found that some family members did not know that the participant was in the study. Do you
have any idea why participants may have not wanted to, or thought of, telling family members
about their participation in the study? (INTERVIEWER SHOULD FOCUS DISCUSSION
ON THE PARTICIPATION OF THE STUDY, RATHER THAN GENERAL DISCUSSION OF
DEPRESSION DISCLOSURE).
PROBES:
 Did you speak to family, friends, AltaMed staff, or anyone else about the possibility
of participating in the study even before you got involved?
 Whom did you speak with to ask if you should participate or not?
 What were some of the reasons you spoke to someone, or decided not to speak to
someone about participating in the study in the first place?

128

SECTION F: Sociocultural and Contextual Issues Open

Gender.
We found that not very many men expressed that they may have been depressed. Women on the
other hand appeared to be more open about discussing that they might be depressed.

Do you have any thoughts of why this may have been so? Why do men and women differ in
terms of sharing that they may be depressed?
PROBES:
 male vs. female issues
 machismo and self-reliance vs. dependence on others
 preferences for male vs. female interventionists/interviewers
 the way the person perceives this type of counseling (PST)
 stigma (e.g., embarrassment, shame, etc)
 presenting stressors

Do you have any suggestions of what we can do in the future to increase participation by Latino
males into depression treatment programs?

Language/Culture:
Sometimes older Latinos do not find it easy to obtain services when they need them. This may
be partly because they cannot find someone that speaks their language or understands their
cultural values.

(Language)
In your case, how easy or difficult was it to communicate with [Name of Interventionist or
Interviewer] during the sessions/interviews?
PROBES:
 Do you believe that you and [Name of Interventionist or Interviewer] spoke the same
language? In other words, that you could communicate with her/him enough that you felt
understood, or that she/he could understand you?
 Does it matter that the sessions and interviews are in Spanish or English? In what ways
does it matter to you (or not)?

(Culture)
Aside from being able to speak to with the counselor/interviewer who speaks your same
language, I would like to know if other things mattered, or not. For example, sometimes people
communicate well (or better) with others when they come from the same cultural background.
For others, this may not be the case. How is it for you?
PROBES
 Does it matter that the counselor/interviewer was Latino/Hispanic? In what ways does it
matter to you (or not)?
 Do you believe that she/he understood your values, or not? Please explain.
 Was there anything about the sessions that went against your cultural values? If yes,
please explain.

129

PROBE FOR CULTURAL EXPLANATORY MODELS OF LANGUAGE OR ETHNIC
MATCHING, IF NOT STATED.
Do you have any suggestions of what we can do in the future to increase participation by
older adults of Latino descent into depression treatment programs?

Experiences with the research site, AltaMed.
 Did anyone at AltaMed ever comment on these sessions, or any assistance that our study
gave you?
 Do you think that AltaMed should provide these services in the future?
 Do you think that the staff at AltaMed can provide these counseling sessions?
 Of the social workers, nurses, or other staff, who would you say are the best qualified to
provide these sessions?
 Are you still currently attending AltaMed for day care services? If not, why not?
PROBE:
 Do you have anywhere to go for day care as a result of the closing of
ADHCs. Please describe.

Experiences with the downturn of the economy.

Some people in our study have shared with us about how the bad economy has affected them.
Others have not. How has it been for you?
PROBES
 Has the bad economy affected you (in any way)? If so, please explain.
 How about others in your family? Your friends?

What changes have happened (if any) due to the country’s economic situation?
PROBE FOR POTENTIAL CONSEQUENCES:
 Have you had to move from your own home to live somewhere else (or had to move in
with family)
 Has someone had to move in for economic reasons (or family had to move in with me)
 Have you had to cut down on spending (food, clothes, medications, social activities, etc.)
 Have you had to take on work for pay (child care, etc.)
 Has someone in family lost a job and has been unable to find another
 Has someone in the house lost a job and had to take a lower-paying one
 Have you had to sell something important to use up savings
 Have been unable to pay bills that were able to pay before
 Have you lost your usual source of income
 Other: (SPECIFY).

130

SECTION G: Network Survey Open
Now, I would like to know more about the people who are important to you. I will read
descriptions of the different ways in which they can be important to you. Please give me the first
names or initials of the people that provide specific types of support, or that you provide support
to. These people could be friends, family members, neighbors, doctors, nurses, social workers,
ministers, or others that you know.
[NOTE: IF THEY MENTION TWO PEOPLE BY THE SAME NAME, DISTINGUISH WHOM
EXACTLY SHE/HE IS REFERRING TO WHEN PROVIDING ATTRIBUTE INFORMATION IN
THE TABLE].

CODES FOR RELATIONSHIPS:
01 Spouse/Partner
02 Daughter (includes Step-Daughter)
03 Daughter–in–Law
04 Son (includes Step-Son)
05 Son–in–Law
06 Grandchildren /Great Grandchildren
07 Parent
08 Brother/Sister
09 Other Relative
10 Friend or Neighbor (INCLUDES COMPADRES IF THEY ARE NOT RELATED)
11 Home Chore Worker/Attendant
12 Other Non-Relative
13 Professional/Agency Staff Person--Specify: social worker, doctor, nurse
14 Person from a Religious Group or Organization—Specify: minister, pastor
15 Self (for Social Network Analysis)

131

PRIVATE FEELINGS (RELATED TO MOS #4: SOMEONE TO CONFIDE IN OR TALK
ABOUT YOURSELF OR YOUR PROBLEMS)
1. If you wanted to talk to someone about things that were very personal and private, who would
you talk to? Please, give me the first names or initials of up to 12 people that you would talk to
about things that are very personal and private. (PROBE: Is there anyone else?)
Check this box if none or zero persons were mentioned.
1 5 9
2 6 10
3 7 11
4 8 12
2. Who are the persons that come to you to talk about things that are very personal and private to
them? Please, give me the first names or initials of up to 12 people that call you to talk about
things that are very personal and private to them. (PROBE: Is there anyone else?)
Check this box if none or zero persons were mentioned.
1 5 9
2 6 10
3 7 11
4 8 12

PHYSICAL ASSISTANCE (RELATED TO MOS #3: SOMEONE TO TAKE YOU TO THE
DOCTOR IF YOU NEEDED IT; AND MOS #7: SOMEONE TO HELP YOU WITH DAILY
CHORES IF YOU WERE SICK)
3. Who are the people that you could call on to give you some of their time and energy to help to
take care of things that you needed to do? This includes things like driving you someplace, or
helping you do some work around the house, or going to the store for you? Please give me the
first names or initials of up to 12 people that you could count on to give you their time and
energy. You can name persons that you have mentioned before, and you can also name new
persons. (PROBE: Is there anyone else?)
Check this box if none or zero persons were mentioned.
1 5 9
2 6 10
3 7 11
4 8 12

4. Who are the people that call on you for your time and energy to help them take care of things
that they need to do? This includes things like babysitting, helping them with some work around
the house, etc? Please give me the first names or initials of up to 12 people that you provide
physical assistance to. You can name persons that you have mentioned before, and you can also
name new persons. (PROBE: Is there anyone else?)
Check this box if none or zero persons were mentioned.
1 5 9
2 6 10
3 7 11
4 8 12

132

Personal Characteristics of Network Members
Now I would like to get some information about all the people you have named in answer to the previous questions. I will read
through the list of persons, and I will ask you questions about each person. For example, I will ask about their relationship to you,
whether you know him/her from the same Altamed center (ADHC/PACE), whether they know about your depression, etc.

[INSTRUCTIONS: REFER TO RELATIONSHIP CODES LISTED PREVIOUSLY. SPECIFY THE EXACT RELATIONSHIP (E.G.,
SPOUSE, DAUGHTER, PARENT, HOMEMAKER, ETC). FOR PROFESSIONAL PEOPLE SPECIFY THE EXACT PROFESSION, (E.G.,
NURSE SOCIAL WORKER, MINISTER, COUNSELOR, DOCTOR, ETC). DETERMINE IF THEY MEANT FRIENDS, ATTENDANTS,
AND PROVIDERS AT THE ALTAMED ADHC/PACE CENTER (E.G., ARE THEY FROM THE SAME ADHC/PACE CENTER?) IF THE
PARTICIPANT ANSWERS ‘NOBODY’ FOR F, THEN PROBE TO INQUIRE HOW THE ALTER FOUND OUT ABOUT THE
PARTICIPANT’S DEPRESSION.]

A. NAME B.
Gender
Code
C.
Relatio
n Code
D. Does
[name] belong
to same ADHC
/ PACE?
E. Does [name] know
that you have depression?
[IF NO, SKIP TO G]
F. Who told [name] that you
have (or had) depression?
G. Do you think that
your depression is a
bother or creates burden
for [name]?
H. Do you feel that talking
about your depression with
[name] is shameful or
embarrassing?

1

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

2

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

3

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

4

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

5

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

6

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

7

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

133

A. NAME B.
Gender
Code
C.
Relatio
n Code
D. Does
[name] belong
to same ADHC
/ PACE?
E. Does [name] know
that you have depression?
[IF NO, SKIP TO G]
F. Who told [name] that you
have (or had) depression?
G. Do you think that
your depression is a
bother or creates burden
for [name]?
H. Do you feel that talking
about your depression with
[name] is shameful or
embarrassing?

8

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

9

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

10

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

11

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

12

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

13

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

134

Disclosure of Depression
1. Aside from the persons mentioned to me today, is there anyone else who knows about
your depression? [FOLLOW SAME INSTRUCTIONS AS FOR “PERSONAL
CHARACTERISTICS OF NETWORK MEMBERS” SECTION, AND ADD ANY
ADDITIONAL ALTERS TO THE LIST].

2. What guided or influenced your decision to disclose (or not disclose) about your
depression to people who are important to you? [i.e., your support network including
family, caregivers, friends, and providers] Probes: Did your decision to disclose (or not
disclose) have anything to do with:
 not wanting to worry, bother, inconvenience, or burden others? If so, please
explain.
 feeling embarrassment or shame, or fear of alienation or discrimination by others?
If so, please explain.
 the support provided to you? If so, please explain.
 the support that you provide to them? If so, please explain.
 Any other reason?

3. Please describe how your depression was disclosed or communicated to family
members/caregivers and others who are important to you? Probes:
 Direct or indirect communication? (e.g., found out from you directly, or from
others?) Describe.
 What words were used, if any? (e.g., verbal or non-verbal/body language)
 What was the context of the conversation or situation? (e.g., spontaneous vs.
planned discussion, etc)
 How did the process of disclosure differ by type of person/relation, if at all?

NOTES & COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

SECTION H: Closing Open
Before we end, is there anything you would like to add to what to have said so far? Do you have
any questions?
If we needed to speak to you in the near future to clarify any of your responses, where can we
call you? [FILL OUT ATTACHED SUBJECT CONTACT FORM].
I have enjoyed talking with you and I appreciate the time you have given me. Your responses
will assist us in enhancing geriatric depression treatment in older Latinos

135

Appendix B: Interview Guide (Spanish)

Programa Mano Amiga©
Primary Participant Qualitative Interview - Spanish (05.17.12)

A. RA ID _______ B. Interview Type: 1=over phone 2=face to face C. Location ID:_______ D. Study ID ________ E. Language: 1= Eng 2=Span 3=Bil
F. Interview Date /___/___/___ (mm/dd/yy) G. Interview Time #1: from _________ to ________ H. Interview Time #2: from _______ to _________

PHONE SCRIPT
Buenos días/tardes Sr(a). [name]. Mi nombre es [name], y le estoy llamando de parte del
Programa Mano Amiga. Hace un tiempo usted nos dio permiso para entrevistarla/o para este
estudio que conducimos en AltaMed, la agencia donde Ud. recibió (o recibía) servicios. [IF
NEEDED, HELP THE SUBJECT REMEMBER THEIR PARTICIPATION BY STATING
WHO THEY SAW AS THEIR PST INTERVENTIONIST AND ABOUT WHEN THEY SAW
THEM FOR PST SESSION]. Esta será la última entrevista que le haremos. ¿Cual día y a qué
hora sería más conveniente para usted para completar esta entrevista? Como sea más conveniente
para usted, podemos hacer la entrevista en su casa o en el centro de AltaMed. [CONTINUE
WITH SCHEDULING OF THE IN-DEPTH INTERVIEW].

DATE____________ TIME__________ LOCATION__________ COMMENTS ____________

SECTION A: Introduction

Gracias por haber accedido a hablar conmigo. Me gustaría hacerle algunas preguntas acerca de
su experiencia con el estudio (o programa), Programa Mano Amiga. No hay respuestas correctas
o incorrectas a ninguna de mis preguntas. Lo importante es que usted comparta sus experiencias
personales con este estudio (del programa).
Usted participó en varias entrevistas con nuestro personal como parte de su participación en el
programa.
[PROVIDE PROMPTS/REMINDERS OF WHEN, WITH WHOM, ON WHAT].

SECTION B: Knowledge about depression
En nuestro estudio (programa) tratamos de enseñar a los participantes acerca de la depresión y
cómo afecta a las personas mayores. Dígame lo que Ud. recuerda de lo que le enseñaron sobre la
depresión como resultado de su participación en nuestro estudio (el programa).
PROBES:
 Dígame lo que sabe usted acerca de la depresión.
 ¿Cómo supiera si alguien cerca de Ud. está deprimido/a?
 ¿Qué signos o señas buscaría?
 Si alguien importante a usted estuviera deprimido/a, ¿qué le diría Ud. que hiciera?

SECTION C: Study Interviews (PST AND EUC SUBJECTS)
Ahora me gustaría preguntarle acerca de sus experiencias con las entrevistas que usted completo
como parte de nuestro estudio (el programa). Cada persona en el estudio había terminado varias
entrevistas, ya sea en los sitios de AltaMed, o en su casa. Durante cada entrevista les hicimos
muchas preguntas. Usted participó en algunas de estas entrevistas. [PROVIDE
PROMPTS/REMINDERS OF WHEN, WITH WHOM, ON WHAT].

136

¿Me podría hablar sobre sus experiencias con estas entrevistas o cuestionarios?
(IF PST SUBJECT: Estas entrevistas fueron diferentes a las sesiones semanales con [NAME OF
INTERVENTIONIST])
PROBES:
 Dígame lo que usted recuerda de estas entrevistas/preguntas.
 ¿Qué tan fácil o difícil era para usted responder a las preguntas durante las entrevistas?
 ¿Qué le pareció interesante de las respuestas que usted dio durante las entrevistas?

Algunos participantes no tuvieron ninguna duda acerca de ser entrevistados, mientras que otros
tenían algunas preocupaciones o reservas. ¿Puede usted decirme por qué decidió ser
entrevistado?
PROBES:
 ¿Cuáles fueron algunas de las razones que le hicieron decidir hacer estas entrevistas?
 ¿Cuáles fueron algunas de sus preocupaciones o reservas?

La mayoría de los participantes en el estudio no querían completar las entrevistas en sus hogares,
sino más bien en el centro de AltaMed. ¿Tiene usted alguna idea de por qué algunos
participantes prefirieron ser entrevistados en el centro de AltaMed en lugar de en casa?
PROBE:
 ¿Cuáles fueron sus razones para ser entrevistado en su casa o en AltaMed para estas
entrevistas?

SECTION D: Experiences with PST sessions/Components (FOR PST SUBJECTS ONLY)
Ahora, me gustaría preguntarle acerca de sus experiencias con las sesiones de
asesoramiento/consejería que ha recibido en nuestro programa. Estas preguntas tienen que ver
con las sesiones de asesoramiento/ consejería que ha recibido de [NAME OF
INTERVENTIONIST].

PST sessions--Overall Impressions
Si alguien le preguntara de qué se trataban las sesiones, ¿usted qué les diría?
PROBES:
 ¿Cómo describiría las sesiones?
 ¿Cuál fue el propósito de las sesiones?
 ¿Qué se discutió durante las sesiones?

Si alguien le preguntara a usted si le gustaron estas sesiones, ¿usted qué les diría?
PROBES:
 ¿Puede darme algunos ejemplos de por qué le gustaron estas sesiones?
 ¿Puede darme algunos ejemplos de por qué no le gustaron estas sesiones?
 ¿Cuáles fueron las razones que le ayudaron a decidir a continuar (o interrumpir) con las
sesiones de consejería?

PST in-session handouts
Me gustaría mostrarle los documentos que fueron utilizados durante las sesiones. Dígame lo que
usted recuerda de estos documentos. [SHOW THE HANDOUTS AND ELICIT RESPONSES.

137

MAKE SURE THAT THE SUBJECT DOES NOT FEEL UNCOMFORTABLE WITH
PROBLEMS REMEMBERING ALL OF THE DETAILS.]
PROBES:
 ¿Qué recuerda acerca de estos documentos y para qué eran? Por favor, explique.
 ¿Compartió estos documentos con otras personas? Por favor, explique.
 ¿Está utilizando cualquiera de los documentos ahora, o está siguiendo los consejos que le
dan?

PST Sessions-Skill acquisition
A veces las personas aprenden nuevas formas de manejar sus problemas cuando asisten a este
tipo de sesiones, mientras que otros no lo hacen (i.e., no aprenden nuevas formas de manejar
problemas). ¿Me puede decir cuál era el caso con usted? [DOCUMENT EXAMPLES OF
PROBLEM-SOLVING KNOWLEDGE AND STRATEGIES.]
PROBES:
 ¿Me puede hablar sobre las nuevas estrategias que usted aprendió de las sesiones de
asesoramiento acerca de cómo resolver sus problemas? Por favor, explique.
 ¿Hay algo que usted hace diferente ahora para resolver sus problemas? Por favor, de
ejemplos. (USE THE FOLLOWING PROMPTS:)
o ¿Trata de pensar en positivo?
o ¿Trata de averiguar qué parte del problema quiere enfrentar primero?
o ¿Trata de pensar en diferentes soluciones para su problema?
o ¿Se fija en las ventajas y desventajas de estas soluciones?
o ¿Elige una solución y hace plan de cómo lo va a probar?
o ¿Evalúa si el plan funcionó, o no?
o ¿Trata de aumentar las actividades agradables que una vez dejó de hacer o hizo
menos?

¿Estos nuevos consejos y estrategias le ayudaron en alguna manera a sentirse mejor (o no)?
PROBES:
 ¿De qué manera le ayudaron estos consejos y estrategias a disminuir la depresión?
Por favor, explique.
 ¿De qué manera le ayudaron estos consejos y estrategias a cuidar de otras
enfermedades (como diabetes, enfermedad cardiaca, artritis, dolor crónico, etc)? Por
favor, explique.
 ¿De qué manera le ayudaron las sesiones a obtener los servicios que usted necesita de
AltaMed o de otros lugares? Por favor, explique.

PHQ-9
Cada semana, la consejera (el consejero) le preguntó acerca de sus síntomas de depresión.
(READ OUT LOUD THE FIRST AND SECOND ITEMS OF THE PHQ-9 SCALE).
PROBES:
 ¿Usted qué piensa acerca de sus respuestas a estas preguntas, o que le parece
interesante de sus respuestas?
 ¿Le preocupa tener depresión?

138

Homework assignments (i.e., implementing their action plan and doing pleasurable activity)
Cuando se le dio tareas (es decir, la aplicación de su plan de acción y hacer su actividad
placentera) para trabajar en sus problemas durante la semana, ¿usted realmente intento a hacer
las tareas?

Si tuviera que darse un puntaje en la cantidad de esfuerzo que le dio a hacer las tareas, ¿qué
puntuación se diera a sí mismo? (SHOW RESPONSE BELOW)

0 1 2 3 4 5 6 7 8 9 10
No hizo ninguna tarea. Hizo la tarea todo el tiempo.

Termination
Cuando usted y (NAME OF INTERVENTIONIST) se despidieron durante la última sesión de
consejería, ¿cómo reaccionó usted?
PROBE:
 ¿Hubo algo que se destaca de la última sesión, en comparación con las sesiones
anteriores?
 ¿Qué hará usted si se deprime de nuevo?

Final remarks about the sessions
De todo lo que hemos hablado hoy, ¿Hay algo con respecto a las sesiones que usted cambiaría?
O, ¿que dejaría igual?

Si tuviera que hacerlo de nuevo, ¿usted participaría o no? (PROBE WHETHER YES OR NO).
En una escala de 0 a 10 en promedio, ¿cuál es la probabilidad de que usted participaría en este
programa de nuevo?
(SHOW SCALE)
 Por favor, explique.

0 1 2 3 4 5 6 7 8 9 10
Yo no participaría de nuevo por cualquier razón. Absolutamente sí participaría de nuevo en el programa.
Si usted supiera que alguien cercano a usted tiene depresión, ¿le recomendaría este programa a él
/ ella? Por favor, explique.

139

SECTION E: Family / Caregivers Open
Parte de este estudio incluyó a hablar con los familiares de los participantes del estudio. Hemos
encontrado que algunos miembros de la familia no sabían que el participante estaba en el estudio.
¿Tiene usted alguna idea de por qué algunos de los participantes no quisieron o no pensaron en
informar a sus familiares acerca de su participación en el estudio? (INTERVIEWER
SHOULD FOCUS DISCUSSION ON THE PARTICIPATION OF THE STUDY, RATHER
THAN GENERAL DISCUSSION OF DEPRESSION DISCLOSURE).
PROBES:
 ¿Usted ha hablado con familiares, amigos, personal de AltaMed, o cualquier otra
persona acerca de la posibilidad de participar en el estudio incluso antes de que se
involucrara? ¿Por qué, o por qué no?
 ¿Con quién habló usted para preguntar si debe participar o no?
 ¿Cuáles fueron algunas de las razones que explican por qué usted decidió hablar (o no
hablar) con otras personas acerca de la posibilidad de participar en el estudio?

SECTION F: Sociocultural and Contextual Issues Open
Gender.
Hemos encontrado que no muchos hombres expresaron la posibilidad de estar deprimidos. Las
mujeres por otra parte parecen ser más abiertas al hablar sobre la depresión.

¿Tiene usted alguna idea de por qué los hombres no hablan sobre la depresión o la posibilidad de
estar deprimidos? ¿Por qué piensa usted que los hombres y las mujeres son diferentes en la
manera de expresar que tal vez estén deprimidos?
PROBES: Usted piensa que tiene algo que ver con….
 temas masculinos frente a femeninos
 el machismo y la autonomía frente a la dependencia de otros
 preferencias para los interventores hombres en vez de mujeres
 puntos de vistas sobre este tipo de consejería (PST)
 el estigma (por ejemplo, la vergüenza, pena, etc.)
 factores de estrés

¿Tiene alguna sugerencia de lo que podemos hacer en el futuro para aumentar la participación de
los hombres latinos en los programas de tratamiento de la depresión?

Language/Culture:
A veces a los latinos mayores les resulta algo difícil a obtener los servicios cuando los necesitan.
Esto puede deberse, en parte, porque no pueden encontrar a alguien que hable su idioma o que
entienda sus valores culturales. [IF PST, FOCUS ON INTERVENTIONIST. IF EUC, FOCUS
ON INTERVIEWER]

(Language/Idioma)
En su caso, qué tan fácil o difícil era comunicarse con [Name of Interventionist / Interviewer]
durante las sesiones (o entrevistas if EUC)? PROBES:
 ¿Cree que usted y [Name of Interventionist / Interviewer] hablaban en mismo idioma? En
otras palabras, ¿que podía usted comunicarse con él/ella suficientemente para sentirse
comprendido, o que él/ella podría entender?

140

 ¿Es importante que las sesiones fueran en español o inglés? ¿De qué manera le importa (o
no)?

(Culture/Cultura)
Además de poder hablar con el consejero en su mismo idioma, me gustaría saber si otras cosas
eran importantes. Por ejemplo, a veces la gente se comunica bien con los demás cuando son de
su misma tradición cultural. Para otros, eso no es tan importante. ¿Cómo es para usted?
PROBES:
 ¿Es importante que el consejero/a fuera latino/hispano? ¿De qué manera es importante (o
no)?
 Cree usted que él/ella entendió sus valores (culturales), o no? Por favor, explique.
 ¿Hubo algo en las sesiones que iban en contra de sus valores culturales? Por favor,
explique.

PROBE FOR CULTURAL EXPLANATORY MODELS OF LANGUAGE OR ETHNIC
MATCHING, IF NOT STATED.
¿Tiene alguna sugerencia de lo que podemos hacer en el futuro para aumentar la
participación de los adultos mayores de origen latino en los programas de tratamiento de
la depresión?

Experiences with the research site, AltaMed.
 ¿Usted ha oído comentarios de parte de las personas de AltaMed acerca de estas sesiones,
o cualquier tipo de asistencia que nuestro estudio le dio?
 ¿Cree usted que debe AltaMed proveer estos servicios en el futuro?
 ¿Cree usted que el personal de AltaMed puede proporcionar estas sesiones de consejería?
(PST)
 De los trabajadores sociales, enfermeras u otro personal, ¿quién diría usted que son los
más indicados para ofrecer estas sesiones?
 ¿Sigue asistiendo a AltaMed para servicios diurnos (cuidado de día donde le daban
almuerzo y terapias)? Si no, ¿por qué no?
PROBE:
 ¿Tiene usted a donde ir para el cuidado de día como resultado del cierre de los
centros de AltaMed? Por favor, describa.

Experiences with the downturn of the economy.
Algunas personas de nuestro estudio han compartido con nosotros acerca de cómo la mala
situación económica les ha afectado. En cambio, a otros participantes no les ha afectado tanto
los cambios de la economía. ¿Cómo ha sido para usted?

PROBES:
• ¿Cómo le ha afectado la mala economía? Por favor explique.
• ¿Qué hay de otros en su familia? Tus amigos?
•¿Qué cambios han ocurrido debido a la situación económica del país? ¿Le ha ocurrido lo
siguiente?
POSIBLES CONSECUENCIAS:

141

 Usted tuvo que mudarse/cambiar de casa propia para vivir en otra parte (o tuvo que
mudarse con su familia)
 Alguien tuvo que mudarse por razones económicas (o la familia tuvo que vivir con ellos)
 Usted ha tenido que reducir el gasto (comida, ropa, medicamentos, actividades sociales,
etc)
 Usted ha tenido que asumir el trabajo para pagar (cuidado de niños, etc)
 Alguien en la familia ha perdido su trabajo y no ha podido encontrar otro
 Alguien en la casa ha perdido su trabajo y tuvo que tomar otro trabajo por menos dinero
 Usted ha tenido que vender algo importante para utilizar los ahorros
 Usted no ha podido pagar las facturas (bills) que fueron capaces de pagar antes
 Usted ha perdido su fuente habitual de ingresos (loss of usual source of income)
 Otras consecuencias: (especificar).

SECTION G: Network Survey Open
Ahora me gustaría saber más sobre las personas quienes son importantes para usted. Le voy a
leer descripciones de las diferentes formas en que ellos pueden ser importantes. Por favor, deme
el nombre o iniciales de las personas que le proveen diferentes tipos de apoyo. Estas personas
pueden ser amigos, familiares, vecinos, doctores, enfermeras, trabajadores sociales, pastores, u
otras personas que conozca.
[NOTE: IF THEY MENTION TWO PEOPLE BY THE SAME NAME, DISTINGUISH WHOM
EXACTLY SHE/HE IS REFERRING TO WHEN PROVIDING ATTRIBUTE INFORMATION IN
THE TABLE].

CODES FOR RELATIONSHIPS:
01 Spouse/Partner
02 Daughter (includes Step-Daughter)
03 Daughter–in–Law
04 Son (includes Step-Son)
05 Son–in–Law
06 Grandchildren /Great Grandchildren
07 Parent
08 Brother/Sister
09 Other Relative
10 Friend or Neighbor (INCLUDES COMPADRES IF THEY ARE NOT RELATED)
11 Home Chore Worker/Attendant
12 Other Non-Relative
13 Professional/Agency Staff Person--Specify: social worker, doctor, nurse
14 Person from a Religious Group or Organization—Specify: minister, pastor
15 Self (for Social Network Analysis)

142

PRIVATE FEELINGS (RELATED TO MOS #4: SOMEONE TO CONFIDE IN OR TALK
ABOUT YOURSELF OR YOUR PROBLEMS)
1. Si usted quisiera platicar con alguien acerca de cosas que son muy personales y privadas,
¿con quién platicaría? Por favor, dígame los nombres o iniciales de las personas con quién
platicaría acerca de las cosas que son muy personales y privadas. (PROBE: Hay alguien más?)
Check this box if none or zero persons were mentioned.
1 5 9
2 6 10
3 7 11
4 8 12

2. ¿Quiénes son las personas que acuden a usted para hablar de cosas que son muy personales y
privadas para ellos? Por favor, dígame los nombres o las iniciales de hasta 12 personas que
llaman a usted para hablar de cosas que son muy personales y privadas para ellos. (PROBE: Hay
alguien más?)
Check this box if none or zero persons were mentioned.
1 5 9
2 6 10
3 7 11
4 8 12

PHYSICAL ASSISTANCE (RELATED TO MOS #3: SOMEONE TO TAKE YOU TO THE
DOCTOR IF YOU NEEDED IT; AND MOS #7: SOMEONE TO HELP YOU WITH DAILY
CHORES IF YOU WERE SICK)
3. ¿Quiénes son las personas en las cuales podría contar con su apoyo, su tiempo o su energía en
caso de que las necesitara para hacer sus cosas? Ejemplos: como llevarla(o) a un lugar donde
necesita ir, ayudar para hacer un trabajo alrededor de la casa, ir a la tienda para usted y cosas así?
Por favor, dígame los nombres o las iniciales de la gente con quien le ayudaría de esas maneras.
Recuerde, puede mencionar algunas de las mismas personas que ha mencionado antes y también
puede nombrar nuevas personas. (PROBE: Hay alguien más?)
Check this box if none or zero persons were mentioned.
1 5 9
2 6 10
3 7 11
4 8 12

4. Quiénes son las personas que acuden a usted para su tiempo y energía para cosas que ellos
tienen que hacer? Esto incluye cosas como cuidado de niños, ayudándoles con quehaceres, etc?
Por favor, deme los nombres o las iniciales de hasta 12 personas que usted les proporciona
asistencia física. Usted puede nombrar a personas que usted ha mencionado antes, y también se
puede nombrar a nuevas personas. (PROBE: Hay alguien más?)
Check this box if none or zero persons were mentioned.
1 5 9
2 6 10
3 7 11
4 8 12

143

Personal Characteristics of Network Members
Ahora me gustaría obtener información acerca de todas las personas que usted ha nombrado en las preguntas previas. Yo le voy a
leer la lista de personas, y le voy a hacer preguntas acerca de cada persona. Por ejemplo, le preguntare cual es su relación, si los
conoce porque pertenecen al mismo centro de AltaMed (ADHC/PACE), si acaso saben de su depresión, etc.

[INSTRUCTIONS: REFER TO RELATIONSHIP CODES LISTED PREVIOUSLY. SPECIFY THE EXACT RELATIONSHIP (E.G., SPOUSE, DAUGHTER, PARENT,
HOMEMAKER, ETC). FOR PROFESSIONAL PEOPLE SPECIFY THE EXACT PROFESSION, (E.G., NURSE SOCIAL WORKER, MINISTER, COUNSELOR,
DOCTOR, ETC). DETERMINE IF THEY MEANT FRIENDS, ATTENDANTS, AND PROVIDERS AT THE ALTAMED ADHC/PACE CENTER (E.G., ARE THEY
FROM THE SAME ADHC/PACE CENTER?) IF THE PARTICIPANT ANSWERS ‘NOBODY’ FOR F, THEN PROBE TO INQUIRE HOW THE ALTER FOUND OUT
ABOUT THE PARTICIPANT’S DEPRESSION.]
A. NAME B.
Gender
Code
C.
Relation
Code
D. ¿[Name]
pertenece al
mismo ADHC/
PACE que
Ud?
E. ¿[Name] sabe que
usted sufre de la
depresión? [IF NO,
SKIP TO G]
F. ¿Quién le dijo a [name] que
usted tiene (o tenía) depresión?
G. ¿Usted cree que la
depresión de Ud. es una
carga, un peso, o una
molestia para [name]?
H. ¿Usted cree que hablar
con [name] acerca de su
depresión es algo
vergonzoso o penoso?

1

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

2

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

3

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

4

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

5

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

6

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

7

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

8

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

144

A. NAME B.
Gender
Code
C.
Relation
Code
D. ¿[Name]
pertenece al
mismo ADHC/
PACE que
Ud?
E. ¿[Name] sabe que
usted sufre de la
depresión? [IF NO,
SKIP TO G]
F. ¿Quién le dijo a [name] que
usted tiene (o tenía) depresión?
G. ¿Usted cree que la
depresión de Ud. es una
carga, un peso, o una
molestia para [name]?
H. ¿Usted cree que hablar
con [name] acerca de su
depresión es algo
vergonzoso o penoso?

9

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

10

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

11

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

12

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

13

□F 1
□M 0

□Yes 1 □No 2

□Yes 1 □No 2 □DK 3
□ Subject 1 □ Another person 2
□ Nobody 5 [probe how found
out]
□ Don’t Know 3 □ N/A 4

□Yes 1 □No 2 □DK 3

□Yes 1 □No 2 □DK 3

145

Disclosure of Depression

1. Aparte de las personas mencionadas anteriormente, ¿hay alguien más que sabe acerca de su
depresión? [FOLLOW SAME INSTRUCTIONS AS FOR “PERSONAL CHARACTERISTICS
OF NETWORK MEMBERS” SECTION, AND ADD ANY ADDITIONAL ALTERS TO THE
LIST].

2. Que ha guiado o influido en su decisión de divulgar/revelar (o no divulgar/revelar) sobre la
depresión a las personas que son importantes para usted? [es decir, su red de apoyo incluyendo a
la familia, cuidadores, amigos y proveedores]
Probes: ¿Su decisión de divulgar/revelar (o no divulgar/revelar) tiene algo que ver con:
 No querer preocupar, molestar, o traer inconvenientes o cargas para otros? Si es
así, por favor explique.
 Sentir vergüenza, pena, o miedo a la alienación o discriminación por parte de los
demás? Si es así, por favor explique.
 El apoyo proporcionado a usted? Si es así, por favor explique.
 El apoyo que usted proporciona a ellos? Si es así, por favor explique.
 Cualquier otra razón?

3. Por favor describa cómo su depresión fue divulgada/revelada o comunicada a los familiares o
cuidadores y otras personas que son importantes para usted.
Probes:
 ¿Fue comunicación directa o indirecta? (por ejemplo, se enteró por usted
directamente, o por parte de los demás?) Por favor, describa.
 ¿Qué palabras utilizo? (fue el lenguaje verbal o por algún tipo de señas?)
 ¿Cuál fue el contexto de la conversación o situación? (por ejemplo, fue la
discusión o platica espontánea vs planificada, etc.)
 ¿Cómo fue diferente el proceso de divulgación según el tipo de persona/relación?

NOTES & COMMENTS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

SECTION H: Closing Open
Antes de finalizar, ¿hay algo que quisiera agregar a lo que hemos dicho hasta ahora? ¿Tiene
alguna pregunta?

Si necesitamos hablar con usted en un futuro próximo para aclarar cualquiera de sus respuestas,
¿dónde podemos llamar? [FILL OUT ATTACHED SUBJECT CONTACT FORM].

He disfrutado hablar con usted y le agradezco el tiempo que me ha dado. Sus respuestas nos
ayudarán a mejorar el tratamiento de depresión en los latinos de la tercera edad.

Abstract (if available)

Abstract Self disclosure has been defined as the process of making the self known to others, and usually entails the act of verbally revealing personal information about oneself. Although disclosure of a mental illness can have deleterious effects, such as the stigmatization that results in discrimination, benefits have also been documented. Disclosure has been found to improve self‐esteem, to decrease distress related to secrecy and self‐stigmatization, and may increase quality of life. Moreover, disclosure to family and friends has been found to influence care and increase retention among individuals with other stigmatized identities. This is of special relevance for Latino older adults, as in the U.S. the treatment gap is largest among traditionally underserved groups such as older adults and racial/ethnic minorities. However, mental illness disclosure among Latino older adults has not yet been examined. The goal of this study was to develop a conceptual model of depression disclosure that is based on the experiences of older Latinos. Data were collected from 35 Latino older adults who were receiving care at community Adult Day Healthcare Centers (ADHCs) and who were also participating in an NIMH‐funded randomized control depression intervention study titled ""Enhanced Geriatric Depression Treatment in Adult Day Health Care"" (i.e., Programa Mano Amiga, PMA). This cross‐sectional exploratory study utilized a mixed method approach, where network questions were embedded within the predominant qualitative methodology. Correlation analyses show that the participant’s age and education were significantly related to the proportion of the participant’s network that was disclosed to. Older participants and higher‐educated participants disclosed to a smaller proportion of their social support network. Moreover, disclosure to the network was significantly related to providing emotional support. As the proportion of the network that the participant provided emotional support to increased, so did the proportion of alters within the network that were disclosed to about depression. Correlation analyses also demonstrated that self perceived burden—but not perceived stigma—was significantly related to participant disclosure of his/her depression. Specifically, the proportion of the network that participants perceive might be burdened by his/her depression was significantly related to the proportion of the network that the participants disclosed to. The analyses of the qualitative data revealed a heuristic model of the depression disclosure process that identified eight general themes contained in three separate but interrelated phases of disclosure: (a) determinants of disclosure, (b) the disclosure event, and (c) consequences of disclosure. With regard to culture, the terms used by participants to describe to others what they were feeling (e.g., to describe their depression) influenced their ability to verbally communicate with others (i.e., disclose) about the depression. Overall, this study highlights the complexity of the process of self disclosure that often entails a combination of verbal and nonverbal cues which may be culturally bound not only by the Latino culture but also by the culture of older adulthood. These results drawn from the emic perspective of Latino older adults can inform the development of culturally‐sensitive strategies to support older Latinos who face the dilemma of disclosure.

Linked assets

University of Southern California Dissertations and Theses

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Asset Metadata

Creator Fuentes, Dahlia (author)

Core Title A study of depression disclosure among Latino older adults in Los Angeles

School School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 01/23/2016

Defense Date 03/24/2014

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Depression,disclosure,Latinos,mental illness,minorities,OAI-PMH Harvest,older adults,self‐perceived burden,stigma

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Palinkas, Lawrence A. (committee chair), Aranda, María P. (committee member), Baezconde-Garbanati, Lourdes (committee member)

Creator Email dfuentes@usc.edu,dfuentes999@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-447847

Unique identifier UC11286956

Identifier etd-FuentesDah-2732.pdf (filename),usctheses-c3-447847 (legacy record id)

Legacy Identifier etd-FuentesDah-2732.pdf

Dmrecord 447847

Document Type Dissertation

Format application/pdf (imt)

Rights Fuentes, Dahlia

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA