Although many studies have examined the association between race, attitudes about mental health treatment, and treatment seeking behaviors, to date, very few investigations have addressed the impact of stigma on these relationships. Even fewer have examined these relationships in a sample of older adults with depression. This investigation bridges the gap by presenting data on the impact of stigma and race on the mental health treatment seeking attitudes and behaviors of older adults with depression.
The first hypothesis that mental health treatment seeking attitudes differ by race was supported in the current study. African American survey participants endorsed significantly less positive attitudes about mental health services than their White counterparts. While this finding is inconsistent with some other studies that have found no racial differences in attitudes about mental health treatment(18
), the current study has found divergent results for, at least, three reasons. First, this sample included African American and White older adults who may have more negative attitudes about seeking mental health services than younger adults. Therefore, our findings may more accurately represent attitudes of older adults with depression, identifying an age-cohort effect.
Second, attitude toward services was assessed utilizing the Attitudes Toward Mental Health Treatment Scale (ATMHT), a modified version of the Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS)(38
). The modified ATMHT(44
) includes questions related to racial and ethnic match and comfort seeking services from a therapist of a different race or of a different age group. These questions reflect issues that may impact attitudes toward mental health treatment held by racial/ethnic minorities, as well as aging populations.
Lastly, having never sought mental health treatment was significantly related to negative attitudes about mental health treatment, and the majority of the African Americans in the current study had never sought mental health treatment while the majority of the White participants had sought treatment. Therefore, some of the differences in attitudes may be attributable to actual treatment experiences. While the mean differences between older African Americans and Whites attitudes toward treatment were statistically significant, the moderate effect size suggests that this difference may not be clinically significant. Additional analysis of individual items on the ATMHT scale, however, identified key differences between the two racial groups even when controlling for previous treatment experiences. The majority of African American survey participants identified mistrust in mental health services and believed that mental health treatment was not the most effective strategy to reduce mental health symptoms. Additionally, White older adults were more likely than their African American counterparts to feel comfortable seeing a mental health professional who was from a different racial background as well as seeing a therapist who was younger than them. This suggests that if they choose to seek treatment, African American older adults prefer a therapist who is more ‘like’ them in the domains of race and age. In general however, treatment seeking attitudes held by older adults are generally positive, which is consistent with additional research in this area (45
The second hypothesis that African American older adults would be less likely to intend to seek or be engaged in mental health treatment was partially supported. For the purpose of this paper we included seeking mental health treatment from any source, recognizing that older adults often seek depression treatment from their primary care physician. Contrary to prediction, there were no significant differences by race on intentions to seek mental health treatment or on current engagement in mental health treatment. Neither African American nor White survey participants were likely to intend to seek or be currently engaged in mental health treatment. Consistent with prior studies however(11
), African Americans were significantly less likely than their White counterparts to have ever sought mental health treatment. In fact, while the vast majority of African American older adults had never sought mental health treatment, more than half of the White older adults had sought treatment at some point in their lives. These findings were consistent even when controlling for depressive symptoms and education.
The third hypothesis that perceptions of and experiences of stigma differ by race was partially supported in the current study. It should be noted that without a measure of perceived need for treatment, it is possible individuals who did not endorse items on the ISMI did so not because they didn't internalize stigma, but rather because they did not endorse the label of being depressed. The hypothesis that African American older adults would experience more internalized stigma than their White counterparts was supported. These results are consistent with previous research, which suggests that African Americans are more concerned about mental illness stigma(33
), are more likely to experience stigma about mental illness(49
), and live in communities that may be more stigmatizing towards mental illness(50
). Interestingly, the hypothesis that African American older adults would perceive more public stigma than their White counterparts was not supported by the results. In order to understand this finding, it is important to report that the total sample reported moderate to high public stigma scores (M= 2.79, SD= .30), suggesting perceived public stigma may be higher among older adults in general.
The fourth hypothesis that high levels of self-reported public and internalized stigma would be related to more negative mental health treatment seeking attitudes was partially supported in this study. For both African American and White older survey participants, higher level of internalized stigma was significantly related to less positive attitudes about mental health treatment. This finding supports previous research that identifies an inverse relationship between stigma and treatment related attitudes and behaviors(28
). While the relationship between internalized stigma and attitudes was significant for the total sample, this relationship was stronger and more negatively correlated among the African American participants. This finding suggests that in addition to being endorsed at a greater level, internalized stigma also had a greater impact on attitudes toward seeking mental health treatment among African American survey participants in the current study.
While there was a significant relationship between internalized stigma and intention to seek mental health treatment, this relationship was in the opposite direction than hypothesized. This finding suggests that older adult survey participants with higher levels of internalized stigma were significantly more likely to intend to seek mental health treatment. This result diverges from other research studies, which have found that both greater perceived public stigma and internalized stigma reduced the likelihood of seeking help from all sources(51
). One reason for this finding is that individuals in the current study with higher levels of internalized stigma were also likely to have severe depressive symptoms. Therefore, despite less positive attitudes about seeking mental health treatment, and their high levels of internalized stigma, these individuals were also in greatest need and therefore more likely to seek mental health treatment, despite these barriers. This also suggests that individuals with lower depressive symptoms may not identify with the label of depression and do not therefore perceive a need to seek treatment. Unfortunately, without a measure of perceived need we can only speculate that individuals with greater depressive symptoms were also more likely to view themselves as depressed and in need of treatment. Therefore, these variables need to be further tested in a larger study.
While there was a trend towards a relationship between higher perceived public stigma and more negative attitudes toward mental health treatment, for both African American and White survey participants, this relationship was not statistically significant. Therefore, it is not merely perceiving or experiencing stigma from others that has a detrimental impact; rather, it is when one internalizes those negative beliefs held by the general public and applies them to oneself that has an impact on their attitudes. This finding is interesting in that public stigma scores were higher among older adults than internalized stigma scores, yet it was internalized stigma that was significantly related to treatment seeking attitudes and behaviors. This is consistent with findings from other studies highlighting the impact of internalized stigma on individuals with mental illness(44
The final hypothesis, that stigma partially mediates the relationship between race and treatment seeking attitudes and behaviors, was partially supported. Internalized stigma partially mediated the relationship between race and attitudes toward seeking mental health treatment, suggesting that while there is still a direct and negative relationship between being African American and having negative attitudes about service utilization, part of this is mediated by higher internalized stigma. This mediation model was not significant for public stigma, again suggesting that the true mediation mechanism may lie in how an individual internalizes stigma that directly impacts ones' attitudes toward mental health treatment. Mediation models for treatment engagement were non-significant. In fact, stigma never seemed to have a significant impact of treatment seeking behaviors, except through attitudes. This is consistent with the work of Vogel and colleagues, which found internalized stigma impacted treatment engagement through the mediating mechanisms of public stigma and attitudes toward treatment(52
). This model was unable to be replicated in this study, but should be tested in future investigations.
The results of this study should be viewed within the context of its limitations. It is likely that the individuals who chose not to participate in the current study had greater public and internalized stigma, or a variety of other reasons, which led to their reluctance to be surveyed. Therefore, the African Americans that participated in the current study may have endorsed less stigma than the eligible population. The effect sizes for many of the conducted analyses are moderate despite small differences in means and there was little variability on the study measures despite significant sample heterogeneity. These issues cast some doubt on the clinical significance of the results. The measures of service utilization focused exclusively on mental health care that was provided by a physician or mental health professional, excluding informal sources of care such as the church, family or friends, which is highly utilized in racial/ethnic minority populations. Perhaps the most significant limitation to the study is a lack of a measure of perceived need by the participants rather than inferred need by depressive symptom severity. We did find that in the two weeks prior to being surveyed, 85% of participants endorsed having had depressed mood for at least several days, and 42% felt depressed down or hopeless at least half the days. However, this is not a proxy for self-identification of a clinical depression, and with out assessing perceived need for treatment it is difficult to know whether individuals surveyed actually viewed themselves as having depression, which likely impacted study results. Another limitation is that our attitudes scale does not differentiate attitudes about seeking treatment in a specialty mental health setting versus a primary care setting. While the ATMHT scale benefits from including treatment seeking from all sources, it cannot detect possible differences in attitudes based on treatment setting. The cross sectional nature of the study additionally limits the ability to determine changes in treatment seeking attitudes and behaviors over time. Despite the limitations, this study has several strengths and provides a unique look at the relationship among age, race, stigma and attitudes toward treatment which has not been addressed in the literature. Therefore, it provides a useful starting place to address these complex relationships in future studies.
This investigation suggests older adults experience a great deal of stigma, and that experiencing the label of ‘depression’ can become a barrier to seeking mental health treatment. Therefore, in order to engage older adults in mental health treatment, it is necessary to identify strategies to reduce the stigma of receiving treatment. Sirey and colleagues (53
) have successfully developed a Treatment Initiation and Participation program (TIP) that serves to target and mitigate barriers to care, including perceived stigma, to improve depression treatment adherence among older adults. Internalized stigma however, may be a more useful and modifiable clinical indicator to monitor and attempt to change than public stigma or exposure to stigmatizing experiences. Decreasing internalized stigma can be addressed as a treatment goal, or as the target of separate psychosocial intervention. Treatment might focus on helping the individuals to overcome self-endorsed aspects of stigma(54
). In addition, tailoring treatment for stigma reduction to different patient groups, such as older adults, African Americans and other racial/ethnic minorities, and those with co-morbid medical illness, may be an efficient, effective, and culturally competent strategy.
This study also has implications for additional research required in the field. According to this investigation there are four major areas, which represent a gap in the existing literature on stigma and depression. To narrow this gap, further research should focus on: 1) the continued empirical assessment of the complex interrelationships among perceived public stigma, internalized stigma, race, and mental health treatment seeking attitudes and behaviors, 2) develop and test strategies on facilitating attitude change among older adults followed by longitudinal studies that address how attitude change impacts mental health treatment seeking behavior over time, 3) the development and evaluation of community-based health education campaigns and psycho-therapeutic interventions to reduce mental illness stigma in clinical settings and in the community and to increase the utilization of mental health services, and 4) examining the impact of multiple stigmas experienced simultaneously on treatment seeking attitudes and behaviors, particularly among African American older adults.