As predicted, respondents with more severe mental illnesses, a history of depression or anxiety, and/or a history of chronic physical illnesses and alcohol abuse and/or dependence symptoms were more likely to perceive a need for MHC. Past experience with illnesses and treatment, in addition to symptom severity, may influence individuals’ perceptions of control over depression and anxiety and thus influence perceptions of need for formal MHC according to the CSM (Diefenbach & Leventhal, 1996
A history of depression or non-GAD anxiety was associated with higher odds of perceived need. This suggests that older adults whose mental health condition has improved according to diagnostic criteria may still experience distress or feel they could benefit from further treatment. Alternatively, according to the CSM, those who met past-year diagnostic criteria for depression or anxiety and have a history of the disorder may draw on past experience with the condition to evaluate how they might rid themselves of the symptoms most quickly and be more likely to perceive a need for MHC (Howard Leventhal, personal communication, October 15, 2008); their past experience may affect assessment of their present condition. From these data, we could not determine the relationship of history and perceived need for those with past-year depression and/or anxiety nor could we determine whether respondents had received treatment for the specific past episodes they reported.
People meeting diagnostic criteria for MDD or GAD had higher odds of perceived need than those with subsyndromal conditions, but subthreshold GAD and number of depression and anxiety symptoms were still significantly associated with perceived need. These results, along with the fact that perceived need for MHC is associated with psychological distress and suicidality regardless of whether one meets diagnostic criteria for a disorder (Sareen et al., 2005
), suggest that diagnostic criteria may not always reflect individual assessments of depression and anxiety. Although diagnostic criteria are correlated with perceived need, these results indicate that individuals’ perceptions of need are also affected by subclinical symptoms. Perceptions of severity or the extent to which symptoms interfere with daily life for those not meeting past-year criteria for MDD or GAD may lead older adults to perceive a need for care. Increased symptom intrusiveness into daily life is associated with greater distress for physical conditions (Delahanty et al., 2007
), but little is known about the relationship between mental illness intrusiveness and perceived need for care among older adults.
Perceived need was significantly more likely when individuals reported a lifetime occurrence of more chronic physical conditions. Respondents who needed chronic care in the past likely have more experience receiving care in formal settings and may be more accepting of medical treatment. This in turn may increase the likelihood of viewing psychological symptoms as a target for care from a primary care provider or mental health specialist. Those with fewer problems may be more likely to rely on themselves or informal resources for emotional support. This is supported by the fact that none of the more general measures of physical health status were significantly related to perceived need in multivariate analyses; it is not the physical health status, but the experience with medical care that is related to perceived need.
The relationship between alcohol abuse and/or dependence and perceived need was not affected by depression, but it was affected by anxiety. When alcohol use was examined as an interaction term with past-year GAD, alcohol abuse and/or dependence was only significantly associated with perceived need for those with past-year GAD. From these results, it seems that alcohol abuse may be a reason for perceived need on its own or perhaps when used as ineffective self-medication for anxiety. Because alcohol abuse symptom reports might have been reduced by social desirability bias, those who reported any symptoms likely had worse experiences with alcohol. It remains to be seen whether older adults who have some, but not many, symptoms of alcohol abuse are less likely to perceive a need for care because they are self-medicating.
Future studies should include more specific measures of the decision-making process leading to perceived need for care. They should include individuals’ assessments of symptom “identity, timeline, cause, controllability, and consequences” (as stipulated in the CSM; Diefenbach & Leventhal, 1996
, p. 20), along with measures of the impact of social networks and general attitudes toward mental health on individual assessments. If people with more supportive social networks are less likely to perceive a need for care, it will be important to determine the relative benefits of supportive social networks versus
formal MHC in addressing mental health issues. If social networks are inhibiting members from receiving care that may potentially improve their symptoms, educational interventions about the benefits of formal MHC may be useful.
Many respondents who met past-year diagnostic criteria for MDD or GAD did not perceive a need for care. There are several reasons why this may have occurred: they may have negative attitudes about mental illness and MHC, they might feel their interactions with social networks are suitable substitutes for formal MHC, or their interactions with social networks may lead them to have negative attitudes toward care. Although our data set did not allow us to examine these relationships, it is an important area for future research.
Individuals’ perceptions of symptoms and severity are related to whether they perceive need for MHC, and perceived need is an important determinant of whether individuals decide to seek care (Mechanic, 1978
). Understanding the type and development of these perceptions is central to developing an effective care plan and strategy for working with older people with depression and anxiety.
Our analyses are limited by the cross-sectional nature of the data; we cannot show causal associations. Because we used secondary data, some useful information was unavailable due to differing skip patterns for some questions in the components of the merged data set (e.g., self-rated physical health was not available for all respondents). Past-year chronic conditions and symptom counts, attitudes toward care, and consistent social support measures are not available in all components of the CPES. It would have been ideal to have consistent time frames for measures of past-year physical and mental health. Furthermore, because of the relatively low prevalence of minor depression and dysthymia, this study had limited power to examine some relationships between illness characteristics and perceived need. An ideal model would have also included measures of self-assessed physical and mental health, attitudes toward care, quality of social support, and more health measures specific to the past 12 months. Finally, the results of this study cannot be extended to individuals with cognitive disabilities or dementia who have proxies making health care decisions. The CPES data used in this study, however, are the most comprehensive data related to MHC in older adults.
Few studies have examined perceived need for mental health services in older adults. This study examines the relationships between perceived need for care, patient mental and physical illness, and sociodemographics in the framework of the common sense model.
Histories of MDD and non-GAD anxiety were related to perceived need. Among respondents who did not meet diagnostic criteria for depression or anxiety, the number of depression symptoms ever experienced was related to perceived need. This suggests that providers should be sensitive to symptom reports and individual assessments, even if they do not meet the diagnostic threshold for depression. Conversely, many who met diagnostic criteria for depression or anxiety disorders in the past year did not perceive a need for MHC. It is important for these patients to understand the importance of care for depression and anxiety, as these conditions are related to poor physical health outcomes and increased mortality risk.
Depression and anxiety symptoms are experienced by a considerable portion of community-dwelling older individuals, but symptoms are not a sufficient condition for perceived need. Future studies should focus on how individual perceptions of mental illness and social network interaction influence whether individuals perceive a need for care and whether they seek treatment. Future studies also should examine the association between perceived need and utilization and whether need and utilization are related to illness characteristics and psychosocial factors in similar ways. Understanding processes that lead older adults to perceive need for treatment and decide whether to seek treatment could improve MHC utilization rates, which could lead to improved physical and mental health status as well as reduced health care costs.