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To conduct their review, researchers a n a l y z e d d a t a f r o m t h e S t i r l i n g County Study. Launched in 1952, the Stirling County Study includes 60 years w o r t h o f m e n t a l h e a l t h d a t a obt a i ned from 3,410 adults living in Atlantic Canada. "The Stirling County Study was unique in that it used two diff erent approaches," Gilman says. "First, it enrolled repre- sentative samples of the adults in the county at three diff erent time periods: 1952, 1970 and 1992. Second, it conducted follow-up interviews in 1970 and 1992 of participants enrolled in earlier waves. At each time point in the study, assessments were used to determine participants' experiences with mental health prob- lems — depression and anxiety were a major focus. To determine the vital status of participants, we cross-referenced the Stirling County data with the Canadian [Human] Mortality Database." As part of the investigation into how t he a ssociation cha nged over ti me, r e s e a r c her s e x a m i ne d depr e s s ion and mortality among men and women separately. The team found that depres- sion was associated with an increased risk of death in men during a ll three study periods; however, mortality risk declined in men from the 1950s to the ea rly 2010s. R esea rchers obser ved the opposite eff ect in women. A higher mortality risk was not apparent among women with depression in the 1950s and 1970s. Between 1992 and 2011, how- ever, researchers observed a 50 percent increase in the morta lity risk among women with depression. THE QUEST TO UNDERSTAND WHY The cur rent st udy wa s not desig ned to deter mine rea sons for t he linger- ing a ssociation bet ween depression a nd ea rly deat h, pa r ticu la rly a mong women. Behaviors, such as a lcohol use and smoking, did not seem to play a role in the association, according to Gilman. Instead, resea rchers hy pothesize that women's evolving roles may contribute to the association. "[S]ocieta l roles a re cha ng ing, a nd those cha nges a re putting more pres- sure on women, making it more difficult for women to get help when they a re depr e s s e d ," s ay s s t ud y a ut hor I a n Colma n, PhD, Ca nada Resea rch Cha ir in Menta l Hea lth Epidemiolog y at the Universit y of Ot tawa . " Most notably, the propor tion of women in the work- force ha s increa sed dra matica l ly in recent decades. This is a good thing for women's equa lit y, but if expectations for women a re not cha ng ing outside of the off ice, then that may be putting a pa r ticula rly heav y burden on them, especia lly if they a re str uggling with their menta l hea lth." TAKEAWAYS FOR THE FUTURE The fi ndings of this study highlight the continua l need for public education about depression a nd place g reater emphasis on not only treating depres- sion, but a lso preventi n g recu r rent depressive episodes. For physicia ns, this mea ns ca ring for people in body and mind, according to Rudy Nydegger, Ph D, A BPP, P rofe s sor Emer it u s of Management and Psycholog y at Union Graduate College a nd Union College, a nd Chief, Division of Psycholog y, at Ellis Hospital in Schenectady, New York. "There is a relationship — and ever y- body knows this — bet ween physica l a nd ment a l hea lt h ," says Nydeg ger, who wa s not i nvolved i n t he s t udy. " But it 's ver y ea s y for us to get i nto the of tentimes time-pressure-ba sed approach where we just ta ke ca re of the presenting problem, do the best we ca n a nd [move] on to the nex t patient. ... [I]f we're not looking at some of these p s yc holo g ic a l f a c t or s t h a t m ay b e complementing the medica l condition, we may not be able to treat the medica l condition as effectively." n Eliminating Barriers to Care DE SPITE PROGRE SS IN reducing stigmas associated with mental illness, major depressive disorder (MDD) remains highly undertreated worldwide. A 2016 study published in The British Journal of Psychiatry found that only 20 percent of people who live in high-income coun- tries and have MDD receive treatment. Among those in low- to lower-middle- income countries, treatment rates are even more alarming — a mere 3.7 percent, according to the study. Rudy Nydegger, PhD, ABPP, Professor Emeritus of Management and Psychology at Union Graduate College and Union College, and Chief, Division of Psychology, Ellis Hospital, has observed an increase in referral rates. He attributes these increases to movements in medical training that have raised awareness about depression, the use of depres- sion screening tools in the primary care setting and public education. However, he notes, referrals are only one piece of the puzzle. "Certainly for depression and anxiety disorders ... there's been an increase in people seeking help," Nydegger says. "The problem has been that, very frequently, people who need the help can't get adequate help because they don't have the appropriate type of insurance or the providers available to them are not the best ones for the disorders. So, I'm seeing an increase in referral rates, but I'm also seeing increasing diffi culties that people have in get- ting the kind of care that they need." In addition to addressing stigma, reducing other barriers to mental health care may play an essential role in connecting people to treat- ment and reducing depression's impact on physical health. M D N E W S . 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