The key finding from this study is that, contrary to frequent speculation in the gerontological literature, older Americans do not have negative help-seeking attitudes or negative beliefs about the efficacy of treatment for mental health problems. This finding is true in an absolute sense; more than 80% of adults 55 and older had positive attitudes, and more than 70% had positive treatment beliefs. Our results also show that older adults’ attitudes are positive relative to younger adults’.
Data from the NCS-R revealed increasingly positive help-seeking attitudes across the lifespan until 55 to 64 years of age, and then a slight decrease among the young-old (65–74) and old-old (75+) age groups. Importantly, adults 55 to 74 years of age exhibited significantly more positive attitudes than those 18 to 24 years of age, and the help-seeking attitudes of our old-old (75+) age group did not differ from the youngest age group. The first of the baby boom generation, represented by adults 55 to 64 years old in this survey, exhibited the most positive help-seeking attitudes. After controlling for other variables, they were nearly three times more likely than the young reference group to endorse positive attitudes toward seeking professional help for emotional concerns. It may not be a coincidence that this same age group showed the largest increase in outpatient psychotherapy use from 1987 to 1997 in the National Medical Expenditure Survey (32
). Longitudinal data are needed to determine whether this peak in positive attitudes among adults in their late 50s and early 60s reflects a developmental change for adults of this age or a cohort effect. Regardless of which of these explanations is true, as this group ages we are likely to see increasing numbers of them seeking mental health services so long as their help-seeking attitudes remain positive.
Age was the only demographic variable in our model that predicted attitudes, having a stronger influence than other demographic factors that have consistently been linked to positive attitudes, including Black race/ethnicity (26
) and female gender (20
). The only other variable in our model that was related to attitudes was past-year mood or anxiety disorder. Our finding that the presence of a mood or anxiety disorder in the past year was associated with negative attitudes toward seeking professional help replicates similar findings among U.S. military personnel (35
) and older Korean Americans (36
). This unsettling finding of negative help-seeking attitudes among those individuals with the greatest mental health needs might be due to the negative cognitive bias seen in mood and anxiety disorder patients (37
). Importantly, negative attitudes among those with mood or anxiety disorders does not appear to be due to inadequate mental health care or dissatisfaction with treatment, as prior help-seeking did not emerge as a significant predictor in this model. Additional research is needed to better understand this potentially significant barrier to service use that the data suggests is equally likely to affect younger and older individuals.
With respect to treatment beliefs, there was very little variation across the lifespan with the exception of especially positive beliefs about treatment efficacy among the youngest age group. This peak in positive treatment beliefs among 18 to 24 year-olds is especially puzzling considering that they evidenced the least positive help-seeking attitudes out of any other age group in this study. Given increases in both the prevalence of disorders and help-seeking across our two youngest age groups, it may be that additional experience with mental health problems and associated treatments among 25 to 34 year-olds lead them to become increasingly open to the need to seek help and somewhat more sceptical about the benefits of doing so. With the exception of the youngest age group, however, the absence of strong age effects on treatment beliefs is consistent with other studies that have failed to find differences between younger and older adults’ beliefs about the effectiveness of mental health services (10
In contrast to the relatively modest effect of age on treatment beliefs, we found significantly more positive ratings of the effectiveness of seeing a mental health professional among women, White participants, individuals who did not meet criteria for a mental disorder in the past year, and those who had previously sought help. As was the case with attitudes, having a mood or anxiety disorder in the past year was associated with negative treatment beliefs. Such beliefs do not appear to be due to dissatisfaction with treatment given that prior help-seeking in this study, and in Jorm and colleagues’ (24
), was associated with positive treatment beliefs. These encouraging results suggest that the increasing prevalence of mental health service use over time (3
), especially among baby boomers (32
), may be responsible for improvements in beliefs about the effectiveness of mental health services (38
). Longitudinal research is needed to test this hypothesis and to examine whether older adults are especially likely to exhibit such improvements. With respect to our finding of less positive treatment beliefs among racial and ethnic minorities, similar results were reported by Bystritsky and colleagues (23
). However, beliefs about pharmacotherapy and psychotherapy should be examined separately given a recent internet study of 78,753 adults which found that White participants held especially positive treatment beliefs concerning medication, whereas racial and ethnic minorities held more positive beliefs about counselling (33
). Importantly, previous help-seeking, race/ethnicity, and the other covariates in our model did not interact with age, suggesting that their influences on treatment beliefs are relatively stable across the lifespan, or at least across various age cohorts.
This study’s findings that help-seeking attitudes and treatment beliefs are unlikely contributors to older adults’ disproportionate underutilization of mental health services should be interpreted in light of the following limitations. First, although survey instruments exist that reliably measure distinct aspects of help-seeking attitudes and treatment beliefs with multiple questions (23
), the National Comorbidity Surveys examine them as unitary constructs with very few questions, likely because attitudes and beliefs were not primary outcomes. Doing so introduces unreliability into the measurement of these constructs, as evidenced by the low internal consistency of the attitude composite score, and limits our ability to explore them, and their relationships with age, in complex ways. Furthermore, according to the theory of planned behaviour (14
), attitudes toward seeking mental health services affect such service use in concert with perceived control over potential barriers to seeking help and perceived social pressure to seek or not seek help. Attitudes, perceived control, and subjective norms are influenced, in turn, by behavioral, normative, and control beliefs, as well as a host of background factors. Clearly, this theoretical model suggests that the assessment of attitudes and beliefs in the NCS-R is limited, and that additional research is needed to explore age differences in more nuanced aspects of the relationship between help-seeking, attitudes, and beliefs. A second limitation is that treatment beliefs in this survey were measured by asking participants what percentage of people who see professionals for serious emotional problems are helped. Although this question provides very useful general information, longitudinal research is needed to examine changes in treatment beliefs as a result of advances in therapy, such as the introduction of selective serotonin reuptake inhibitors into the U.S. market in 1988 (40
), or as a result of personal experience with mental health service providers. Third, the cross-sectional nature of the NCS-R does not allow us to determine whether age differences in help-seeking attitudes are due to lifespan development, birth cohort effects, or a combination of these factors. Finally, because the NCS-R excluded institutionalized individuals, including those living in nursing homes, our results are only generalizable to community-dwelling younger and older adults.
Together, evidence of increasing prevalence of mental disorders over time (41
), increasing health care costs associated with mental illness, and increases in the proportion of older individuals in the population (42
), highlights the importance of better understanding older adults’ mental health needs and enhancing their use of mental health services. Attitudes toward seeking help are key determinants of whether or not individuals use mental health services, having a stronger influence than even psychiatric disorders among individuals who perceive a need for help (16
). Given their strong influence on service utilization, our results suggest that predisposing attitude and belief factors, according to Andersen’s (8
) model, are not barriers to mental health service use for a majority of older adults (at least 70% of whom had positive help-seeking attitudes and treatment beliefs in the NCS-R). Our findings suggest that research aimed at understanding and ameliorating older adults’ underutilization of mental health services should focus on enabling resources, such as access to properly trained geriatric mental health professionals, as well as objective and perceived indicators of need for help. While it is essential that we continue working toward meeting older adults’ mental health needs, their positive attitudes and beliefs in this study remind us of the importance of viewing old age as a time of strength, openness, and resilience, as opposed to a time of weakness, conservatism, and frailty (43