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Try out PMC Labs and tell us what you think. Learn More. Stigma associated with mental illness continues to be a ificant barrier to help seeking, leading to negative attitudes about mental health treatment and deterring individuals who need services from seeking care. This study examined the impact of public stigma negative attitudes held by the public and internalized stigma negative attitudes held by stigmatized individuals about themselves on racial differences in treatment seeking attitudes and behaviors among older adults with depression.
Random digit dialing was utilized to identify a representative sample of African American and White adults older adults over the age of 60 with depression symptoms assessed via the Patient Health Questionnaire Telephone based surveys were conducted to assess their treatment seeking attitudes and behaviors, and the factors that impacted these behaviors.
Depressed older adult participants endorsed a high level of public stigma and were not likely to be currently engaged in, nor did they intend to seek mental health treatment. also suggested that African American older adults were more likely to internalize stigma and endorsed less positive attitudes toward seeking mental health treatment than their White counterparts.
Multiple regression analysis indicated that internalized stigma partially mediated the relationship between race and attitudes toward treatment. Stigma associated with having a mental illness has a negative influence on attitudes and intentions toward seeking mental health services among older adults with depression, particularly African American elders.
Interventions to target internalized stigma are needed to help engage this population in psychosocial mental health treatments. Depression is a common psychiatric disorder, affecting nearly Among the elderly, depression is a major public health concern leading to increased disability and morbidity. Depression among elderly persons is widespread and is often undiagnosed and untreated. Bythe s of older adults with depression will nearly double the current s 3. Despite these high prevalence rates, few older adults report seeing a mental health professional for treatment.
In fact, older adults seek professional mental health treatment at a rate lower than any other adult age group 4.
Without appropriate mental health intervention, older adults with depression experience ificant disability and impairment, including impaired quality of life, increased mortality, and poor health outcomes 45. In addition to the above, older adults have the highest rate of completed suicide, which is associated with high rates of depression 5. With the s of older adults rapidly increasing in the United States, untreated mental illness among this population is one of the most ificant challenges facing the mental health service delivery system 6especially considering that the combination of psychotherapy and psychopharmacology is highly effective in treating mental health disorders among older adults 7.
African American older adults suffer more psychological distress than their White counterparts due to their life long exposure to and experiences with racism, discrimination, prejudice, poverty, and violence 8 ; and they tend to have fewer psychological, social, and financial resources for coping with stress than their White counterparts 9. Despite epidemiological research which suggests similar rates of depression among African Americans and Whites 5racial disparities continue to exist in mental health service utilization.
African Americans 10 and African American older adults 11 are ificantly less likely to seek mental health services than their White counterparts. While only one-third of all individuals with a diagnosable mood disorder seek mental health treatment, African Americans seek treatment at a rate half that of their White counterparts 5 These disparities continue even after initial barriers have been overcome.
African Americans attend fewer sessions when they do seek specialty mental health treatment, and are more likely than their White counterparts to terminate treatment prematurely 10 And while older adults, and in particular older African Americans, are more likely to seek mental health treatment in primary care than in specialty mental health settings 1314they remain less likely than their younger counterparts to have their depression detected and treated in these settings 15 - Negative attitudes towards mental health treatment ificantly impact help-seeking behaviors.
Utilizing a nationally representative sample, Diala and colleagues 18 found individuals who endorsed negative attitudes toward treatment were five times less likely to seek mental health services than those with more positive attitudes. Research has reported mixed findings regarding racial differences in attitudes toward seeking mental heath services. Some cross-sectional studies find few or no racial differences in attitudes toward mental health treatment 19 - 21 while others suggest that compared to their White peers, African American adults hold more negative attitudes towards seeking mental health treatment In the existing literature, however, the relationships among race, attitudes and mental health treatment utilization have not been explored in depth among older adults.
Given the mental health service utilization disparities among older adults, we suggest it is critical to explore attitudes about seeking mental health treatment in this population. The stigma associated with having a mental illness may be an important factor Blk f seeking white m older influences treatment-seeking attitudes and behaviors and may, in part, for existing disparities in service utilization among African American older adults.
According to Goffman 23stigma is an identified mark or characteristic, which disqualifies those possessing the mark from full social acceptance in society. This includes the negative perceptions, attitudes, and beliefs held about individuals who bear such a mark.
Stigmatization has been identified as one of the most ificant barriers to mental health treatment and contributes to poor quality care, particularly for African Americans Stigma theory posits that the stigma associated with having a mental illness manifests via public stigma and internalized stigma Public stigma refers to the negative beliefs, attitudes, and conceptions about mental illness held by the general population, which lead to stereotyping, Blk f seeking white m older, and discrimination against individuals with mental health disorders An individual's perceptions about society's attitudes and beliefs about their mental health status often lead to negative attitudes about mental health treatment and thus become a barrier to help-seeking.
Internalized stigma refers to devaluation, shame, secrecy, and social withdrawal, which are triggered by applying the negative stereotypes associated with mental illness to oneself Living in an environment which sanctions the stigmatization of people with mental illness, an individual with a mental health disorder may accept and internalize these stigmatizing attitudes and beliefs endorsed within society According to Cooper, Corrigan and Watson 28an inverse relationship exists between stigma and treatment seeking.
Individuals who perceive society as holding stigmatizing beliefs about mental illness, and individuals who internalize stigma are less likely to seek mental health treatment 29 The relationship between stigma and treatment seeking attitudes and behaviors may be particularly pertinent among older adults. Katon and Livingston 31 identified the stigma of mental illness as the most fundamental reason why older adults chose not to seek mental health services and the Surgeon General's report on mental health 5 highlighted stigma as a powerful obstacle to seeking care among the elderly.
Research suggests that stigma may be a more salient barrier to mental health service utilization for older adults. Utilizing a two stage sampling de, Sirey and colleagues 30 found while younger adults tended to perceive more stigma, stigma about mental illness predicted early treatment discontinuation in elderly mental health patients who suffer from depression.
In their qualitative analysis, Conner and Rosen 32 found that older African Americans with depression often experience multiple, concurrent stigmas and may be less likely to seek help due to bearing more than one stigmatizing characteristic e. Research suggests that African Americans are more likely to experience stigma about mental illness than their White counterparts 33 however this finding has been inconsistent There is still little known about racial differences in stigma experiences among older adults. In order to examine the relationships between stigma associated with having depression, race and treatment seeking attitudes and behaviors among older adults with depression we test the following hypotheses: 1 African American older adults will have more negative attitudes toward seeking treatment than their White counterparts; 2 African American older adults will be less likely to be currently engaged in treatment for depression and less likely to intend to seek treatment for depression than Whites; 3 African American older adults will report higher levels of internalized and public stigma than their White counterparts; 4 Stigma public and internalized will be ificantly associated with more negative treatment seeking attitudes and behaviors among older adults with depression; 5 Stigma will partially mediate the relationship between race and treatment seeking attitudes and behaviors.
This stratified sampling approach increased efficiency and reduced cost.
Upon contact, households were first screened for depression symptoms using the Brief Patient Health Questionnaire-9 Only those reporting mild to moderate depression symptoms a score of 5 or above were eligible. Respondents with bipolar disorder or severe substance abuse were ineligible.
These procedures resulted in a final sample size of participants, which included Whites under age 60, age 60 and olderand African Americans under age 60, and age 60 and older. The findings from the larger sample of adults are presented elsewhere. For the purpose of this paper, we are focusing on the sample of older adults to examine their attitudes about seeking mental health treatment, and the impact of stigma and race on these attitudes.
An extremely labor intensive effort was required to achieve this sample. A total of 63, telephone s were processed, and nearlyactual dialings were conducted. Blk f seeking white m older both high-and low-density strata, Self reported demographic characteristics included: age, gender, race, marital status, education, and employment status.
Cut offs have been established that correspond to minimal scoremild scoremoderate scoremoderately severe scoreand severe score symptom levels and algorithms developed to establish depressive disorder diagnoses. The PHQ-9 has also been found to sensitive to change in depressive symptoms over time This item scale evaluates the extent to which a person believes that other people will devalue or discriminate against individuals with a mental illness.
Higher scores indicate more public stigma. Distinct from other stigma scales, which focus on social attitudes toward the mentally ill or perceptions of these attitudes Link,the ISMI focuses on the individual's subjective experience as someone with a mental illness e. The ISMI demonstrates excellent internal consistency reliability, test-re-test reliability, concurrent and validity Mental Health Treatment was assessed with 3 questions.
Within the past month, months ago, months ago, more than 12 months ago. The ATMHT is comprised of 20 items with a four-point likert scale, and is intended to reflect an individual's attitude toward professional mental health treatment. Despite its utility and vast usage, several conceptual and methodological concerns have been raised regarding the language and cultural appropriateness of the ATSPPHS.
Some identified concerns are the outdated language used and that it only refers to psychiatrists and psychologists as providers of mental health services An additional concern is the lack of attention to culturally relevant items that may impact attitudes toward seeking. To address these concerns, we shortened the original scale, adapted 8 original items by incorporating more inclusive and easier to understand language, and added 12 items that reflect issues that may impact racial minority elder's attitudes about mental health treatment e.
We developed these items based upon comments endorsed within focus groups we conducted with African American older adult primary care patients While the adapted scale refers primarily to psychotherapy, the instructions ask participants to rate their attitudes about seeking mental health treatment from any mental health professional e.
Higher scores indicate more positive attitudes about seeking mental health treatment. Racial differences in demographic variables were examined using either t -tests or Chi Squares. T-tests were utilized to examine racial differences in score variables such as attitudes toward seeking mental health treatment hypothesis 1 and stigma hypothesis 3and chi squares were utilized to examine racial differences in categorical variables relevant to current or engagement in mental health treatment hypothesis 2.Blk f seeking white m older
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