Age, gender, and the underutilization of mental health

0 downloads 0 Views 83KB Size Report
cians (Bartels, 2003; Klap, Tschantz Unroe, &. Unutzer, 2003; Norquist ..... Holden, R. R., Starzyk, K. B., McLeod, L. D., & Edwards, M.J.. (2000). Comparisons ...
Aging & Mental Health, November 2006; 10(6): 574–582

ORIGINAL ARTICLE

Age, gender, and the underutilization of mental health services: The influence of help-seeking attitudes

C. S. MACKENZIE, W. L. GEKOSKI, & V. J. KNOX Department of Psychology, Queen’s University, Kingston, Ontario, Canada

(Received 22 August 2005; accepted 20 January 2006) Abstract The objectives of this study were to explore age and gender differences in attitudes toward seeking professional psychological help, and to examine whether attitudes negatively influence intentions to seek help among older adults and men, whose mental health needs are underserved. To achieve these objectives 206 community-dwelling adults completed questionnaires measuring help-seeking attitudes, psychiatric symptomatology, prior help-seeking, and intentions to seek help. Older age and female gender were associated with more positive help-seeking attitudes in this sample, although age and gender interacted with marital status and education, and had varying influences on different attitude components. Age and gender also influenced intentions to seek professional psychological help. Women exhibited more favourable intentions to seek help from mental health professionals than men, likely due to their positive attitudes concerning psychological openness. Older adults exhibited more favourable intentions to seek help from primary care physicians than younger adults, a finding that was not explained by age differences in attitudes. Results from this study suggest that negative attitudes related to psychological openness might contribute to men’s underutilization of mental health services. Help-seeking attitudes do not appear to be a barrier to seeking professional help among older adults, although their intentions to visit primary care physicians might be. These findings suggest the need for education to improve men’s help-seeking attitudes and to enhance older adults’ willingness to seek specialty mental health services.

Introduction Large-scale epidemiological surveys (Bland, Newman, & Orn, 1997; Henderson, 2002; Kessler et al., 1994; Norquist & Regier, 1996) clearly demonstrate that the mental health needs of individuals within and outside of North America are not being adequately met. Mental illness is prevalent; roughly 30–50% of people will experience a mental disorder in their lifetimes and 15–30% will experience a mental disorder in the past year. In addition to documenting high rates of mental illness, these surveys have highlighted comparatively low rates of mental health service use. In the 1990s, approximately 65–80% of individuals with diagnosable mental health problems did not receive professional help. Despite evidence that mental health service utilization is on the rise, the majority of people with mental disorders still do not receive treatment (Kessler et al., 2005). A variety of demographic groups are particularly unlikely to receive professional psychological help;

the current study focuses on older adults and men. In an attempt to understand low rates of mental health service use among these groups, a great deal of attention has been devoted to exploring various personal, interpersonal, and professional barriers to their use of services (e.g., Bartels, 2003; Rhodes, Goering, To, & Williams, 2002). The current study continues this exploration, focusing on help-seeking attitudes as one of several potential personal barriers. In order to clarify whether attitudes have a negative impact on service use this study has two objectives: To determine whether older adults and men have more negative help-seeking attitudes than younger adults and women, and to examine the impact of attitudes on intentions to seek professional psychological help among these underserved populations. Age and gender differences in help-seeking attitudes Whereas men have consistently been shown to have less positive attitudes toward seeking mental health services than women (Addis & Mahalik, 2003;

Correspondence: Corey S. Mackenzie, PhD, Department of Psychology, University of Manitoba, 190 Dysart Road, Winnipeg, Manitoba, Canada, R3T 2N2. Tel: þ1 (204) 474-6790. Fax: þ1 (204) 474-7599. E-mail: corey_mackenzie@ umanitoba.ca ISSN 1360-7863 print/ISSN 1364-6915 online/06/060574–582 ß 2006 Taylor & Francis DOI: 10.1080/13607860600641200

The influence of help-seeking attitudes Ang, Lim, & Tan, 2004; Morgan, Ness, & Robinson, 2003; Vogel & Wester, 2003), age differences in helpseeking attitudes are less clear. Older adults are often thought to have negative help-seeking attitudes and to be especially sensitive to stigma associated with mental illness (e.g., Estes, 1995; Lebowitz & Niederehe, 1992). Studies that have addressed this question empirically, however, suggest that older adults’ attitudes toward seeking help are generally positive (Currin, Schneider, Hayslip, & Kooken, 1998; Robb, Haley, Becker, Polivka, & Chwa, 2003); perhaps even more so than younger adults’ (Berger, Levant, McMillan, Kelleher, & Sellers, 2005; Rokke & Scogin, 1995; Sirey et al., 2001). We expect to replicate previously demonstrated gender differences in attitudes, and to show that older adults’ attitudes are as or more positive than younger adults’. The current study expands upon earlier investigations of age and gender differences in helpseeking attitudes in two ways. First, we examine attitudes in a more nuanced way than they have been studied previously. Investigations of helpseeking attitudes have typically either created new items to measure help-seeking attitudes without examining their reliability or validity, or used the Attitudes Towards Seeking Professional Psychological Help Scale (Fischer & Turner, 1970). Because this scale has poor-to-moderate subscale reliabilities, however, help-seeking attitudes have only been measured globally. The current study examines age and gender differences in attitudes using a newly developed inventory that reliably assesses three distinct help-seeking attitude components: Psychological Openness, which reflects openness to acknowledging psychological problems and the possibility of seeking professional help for them; Help-seeking Propensity, which reflects willingness and ability to seek help; and Indifference to Stigma, which reflects concern about how important people in one’s life would react to help-seeking (Mackenzie, Knox, Gekoski, & Macaulay, 2004). Second, we explore the direct effects of age and gender on help-seeking attitudes, as well as the interaction between age, gender, marital status, and education, as these latter variables have received very little attention in the mental health service utilization literature. Predicting intentions to seek psychological help Intentions are the most immediate determinant and strongest predictor of behaviours such as help-seeking (Ajzen, 1985; Sutton, 1998). Female gender has been associated with intentions to seek help in some studies (Deane & Todd, 1996; Morgan et al., 2003) but not in others (Kelly & Achter, 1995; Vogel & Wester, 2003). Although there is a dearth of research examining age differences in intentions as a result of reliance on undergraduate samples,

575

a recent study found no difference between younger and older adults’ willingness to seek professional psychological help (Segal, Mincic, Coolidge, & O’Riley, 2005). In addition, there is evidence that older adults are very accepting of pharmacological and psychological treatments for mental health problems (Landreville, Landry, Baillargeon, Guerette, & Matteau, 2001) and report positive intentions to use a variety of psychological services, especially talking to primary care physicians about mental health concerns (Arean, Alvidrez, Barrera, Robinson, & Hicks, 2002). Help-seeking attitudes have been the most consistent and strongest predictor of intentions to seek psychological help (Cepeda-Benito & Short, 1998; Kelly & Achter, 1995; Morgan et al., 2003; Vogel & Wester, 2003). Prior help-seeking and psychological distress have been shown to affect intentions in some studies (e.g., Cepeda-Benito & Short, 1998; Morgan et al., 2003) but not in others (Arean et al., 2002; Vogel & Wester, 2003). The current study builds upon existing research, which has typically examined intentions in a general way using the Intentions to Seek Counselling Inventory (Cash, Begley, McCown, & Weise, 1975) , by examining intentions to seek professional psychological help from two distinct providers: primary care physicians and mental health professionals. This distinction is critical considering that a substantial proportion of younger and especially older adults with mental health problems are treated by primary care physicians (Bartels, 2003; Klap, Tschantz Unroe, & Unutzer, 2003; Norquist & Regier, 1996), even though mental disorders are less likely to be recognized and treated in the medical sector (McQuaid, Stein, Laffaye, & McCahill, 1999) and treatment may be less effective when provided by non-psychiatrist physicians (Howard et al., 1996; Seligman, 1995; Wang, Berglund, & Kessler, 2000). Because of potential differences in the way individuals’ mental health needs are met by primary care physicians and mental health professionals, it is important to understand the factors that influence intentions to seek treatment from one or the other provider. Older adults and men are especially unlikely to seek professional help when they need it for a variety of reasons. Although help-seeking attitudes are thought to contribute to low rates of mental health service use for these groups, this notion has been supported in a general way for men and tentatively refuted for older individuals. In the current study we explore the impact of age and gender on three specific help-seeking attitude components using a community sample. We also examined whether attitudes influenced participants’ intentions to seek psychological help from primary care physicians and mental health professionals.

576

C. S. Mackenzie et al.

Methods Participants and procedure Data collection took place at the train station of a small city in Ontario, Canada. This recruitment location provided access to community adults across the age range who were waiting for passengers or trains, thereby increasing their likelihood of complying with requests for research participation. Over four successive weekends, the principal investigator approached individuals who were alone and who appeared to be waiting, asking them to take part in a study examining attitudes toward seeking mental health services. Attempts were made to sample equal numbers of men and women from a wide age range by collecting data on willing participants’ gender and estimated age, and over-sampling according to these characteristics as necessary as we approached our target of 200 participants. Individuals were ensured of the confidentiality of their responses. Those who agreed were given a questionnaire package that could be completed immediately or mailed back in a postage-paid envelope. A total of 165 men and 157 women were approached to participate and 120 men (72.7%) and 126 women (80.2%) agreed. Of those who agreed to participate, questionnaires were returned by 106 men, 100 women, and four individuals who were excluded from analyses because they did not provide demographic information or were under the age of 18, representing an overall response rate of 64.6%. The sample included 105 men and 99 women who ranged in age from 18–89, with mean of 46.1 (SD ¼ 17.7). Of the 24.5% of participants aged 60 and above, 56% were female. In terms of marital status, 35.9% of participants were single, 45.2% were married or common-law, and 17.5% were previously married. In terms of education, 36.1% of participants had less than or equal to a high school education, 40.6% had post-secondary education, and 23.3% had postgraduate education. When compared to the Canadian population using 2001 census data, our sample is similar in terms of marital status, but is more highly educated. In addition, 92.7% of participants were White, indicating that our sample was somewhat less ethnically diverse than the Canadian population, which is 86.6% White (Statistics Canada, 2006). Measures The first section of the questionnaire package included a description of the purpose of the project, instructions for completing questions, and a request for demographic information. The second section included questions regarding past and future use of mental health services. Participants were asked whether they had ever discussed psychological problems with a: (a) primary care physician; (b) mental health professional (e.g., psychologist,

psychiatrist, or social worker); (c) member of the clergy; and (d) family member or friend. Participants were then asked to rate, on a seven-point rating scale ranging from very unlikely to very likely, their likelihood of considering these four options, as well as the likelihood of taking care of problems on their own, if they were to experience significant psychological problems in the future (they were not asked if they had ever taken care of psychological problems on their own in the past because we assumed that everyone would have done so at some point in their lives). The third section included the helpseeking attitude and psychiatric symptomatology inventories.

Help-seeking attitudes. Attitudes were measured using the Inventory of Attitudes toward Seeking Mental Health Services (IASMHS; Mackenzie et al., 2004). The current study was carried out as part of the development of this inventory, which was presented to participants as 41 items, 24 of which were retained as items for the IASMHS. This 24item attitude measure has three factor subscales, Psychological Openness, Help-seeking Propensity, and Indifference to Stigma, that were replicated with 293 undergraduate students. Alpha coefficients for the subscales range from 0.76 to 0.82, and internal consistency for the full inventory is 0.87. Test-retest reliability at three weeks, using a sample of 23 senior undergraduate students, is high for Psychological Openness (r ¼ 0.86) and Indifference to Stigma (r ¼ 0.91), and moderate for Help-seeking Propensity (r ¼ 0.64). Each inventory subscale includes items assessing components of Ajzen’s (1985) Theory of Planned Behaviour, which was developed for the explicit purpose of predicting behaviour and behavioural intention from attitudes. Convergent validity was demonstrated by effectively differentiating those who had and had not previously used mental health services, and those who would and would not use such services in the future.

Psychiatric symptomatology. The Holden Psychological Screening Inventory (HPSI; Holden, 1996) is a 36-item measure of the three dimensions of psychopathology underlying the Minnesota Multiphasic Personality Inventory: Psychiatric Symptomatology (PS), Social Symptomatology (SS), and Depression (DE). Subscale internal consistencies in this sample, and in other clinical and non-clinical populations, range from 0.73 to 0.84. When compared to the widely used Brief Symptom Inventory (Derogatis, 1993), the HPSI is similarly reliable and has a factor structure that is more stable (Holden, Starzyk, McLeod, & Edwards, 2000).

The influence of help-seeking attitudes Analyses Multiple regression was used to examine the influence of demographic factors on help-seeking attitudes, and of demographic factors, help-seeking history, psychiatric symptomatology, and help-seeking attitudes on intentions to seek professional psychological help. For each regression analysis predictor and criterion variables were rescaled from zero to one to allow the interpretation and comparison of unstandardized regression coefficients across variables measured on different metrics. Doing so is preferable to the interpretation of standardized beta coefficients, where the variance of each predictor variable is artificially forced to one. Continuous predictor variables were centred, allowing for the meaningful interpretation of first-order terms in the presence of interactions (Aiken & West, 1991). For the hierarchical analyses predicting intentions to seek help, demographic characteristics were entered in step one, help-seeking history was added in step two, and psychiatric symptomatology and help-seeking attitudes were added in a final step. Conducting the analyses in this way allowed us to examine the contribution of factors thought to affect help-seeking intentions causally (i.e., with demographics as the most distal influence, help-seeking history as the next most distant, and current attitudes and symptomatology as the most immediate influence). These stepwise regressions also demonstrated whether attitudes add to our ability to predict intentions after controlling for the influence of other factors. Residual plots for each regression analysis indicated that the assumptions of the regression model were met.

Results Overall, participants scored 69.0 (SD ¼ 14.32) out of 96 on the full-scale IASMHS, indicating reasonably positive general attitudes toward seeking mental health services. Subscale scores were similar for Help-seeking Propensity (M ¼ 24.0; SD ¼ 5.40) and Indifference to Stigma (M ¼ 23.32; SD ¼ 6.24), both of which were significantly more positive than Psychological Openness (M ¼ 21.72; SD ¼ 6.77) scores; for both comparisons t (201)43.39, p50.01. Demographic predictors of help-seeking attitudes Four regression analyses were conducted in which age, gender, education, marital status, and two-way interactions among these variables were used to predict general help-seeking attitudes, as has been done in prior research, as well as three specific attitude factors. The first analysis predicted overall IASMHS scores. Demographic characteristics accounted for 24% of the variance in participants’ attitudes toward seeking psychological help, F(14, 182) ¼ 4.36, p50.001. Older participants

577

exhibited more positive attitudes than younger participants (b ¼ 0.33, SEb ¼ 0.13), and women exhibited more positive attitudes than men (b ¼ 0.09, SEb ¼ 0.04). In addition to the main effects of age and gender, significant interactions were found between age and marital status, and between gender and education. Following Aiken and West’s (1991) procedures for interpreting interactions between categorical and continuous variables, age had a significant positive influence on attitudes for single participants only (b ¼ 0.45, SEb ¼ 0.14). Regarding the interaction between gender and education, the positive effect of education on attitudes was only found for male participants (b ¼ 2.19, SEb ¼ 1.22). Regression analyses with the three IASMHS subscales examined the relationship between demographic factors and help-seeking attitudes in greater detail. Demographic variables accounted for 32% of the variance in Help-seeking Propensity scores, F(14, 182) ¼ 6.04, p50.001. Participants who were older (b ¼ 0.50, SEb ¼ 0.14) and better educated (b ¼ 0.21, SEb ¼ 10) exhibited a greater propensity to seek psychological help. As was the case with general attitudes, age interacted with marital status so that the positive influence of age on Propensity scores was only found for single participants (b ¼ 0.41, SEb ¼ 0.15). In a third regression analysis, demographic factors accounted for 16% of the variance in participants’ Psychological Openness scores, F(14, 182) ¼ 2.53, p50.01. More favourable Openness scores were associated with female gender (b ¼ 0.16, SEb ¼ 0.06) and higher levels of education (b ¼ 0.30, SEb ¼ 0.13). A significant interaction between age and marital status resulted from a positive influence of age on attitudes for single participants (b ¼ 0.82, SEb ¼ 0.20) and a negative effect for participants who were partnered (b ¼ 0.82, SEb ¼ 0.20). A fourth regression analysis accounted for 15% of the variance in Indifference to Stigma scores, F(14, 182) ¼ 2.36, p50.01, although none of the predictor variables was significant. Predicting intentions to seek professional psychological help Participants reported their intentions to use three non-professional and two professional options for managing mental health problems. Mean intention ratings for each option are presented in Table I. The most likely choice involved talking to family or friends, followed by talking to a mental health professional, primary care physician, taking care of the problem oneself, and finally, talking to a member of the clergy. Using paired-samples t-tests, three significant differences emerged between intention ratings. Intentions to talk to a mental health professional were more favourable than intentions to talk to a primary care physician, t(206) ¼ 2.15, p50.05.

578

C. S. Mackenzie et al.

Table I. Mean intention ratings and frequencies of past use of professional and non-professional options for dealing with mental health concerns. Intentions

Talk to mental health professional Talk to primary care physician Talk to family or friend Talk to member of clergy Take care of it yourself

Frequency of past use

Mean

SD

5.39 5.05 5.61 2.65 4.39

1.87 2.09 1.62 2.02 2.03

Yes 97 85 149 32

No (47%) (41%) (72%) (16%)

110 122 58 175

(53%) (59%) (28%) (84%)

Intention ratings can range from 1 (very unlikely) to 7 (very likely).

Table II.

Predicting intentions to seek professional help for mental health concerns.

Step 1 Marital status Married/common law Previously married Age Gender (0 ¼ male, 1 ¼ female) Education R2 Step 2 Marital status Married/common law Previously married Age Gender (0 ¼ male, 1 ¼ female) Education Past use of predicted behaviour R2 Step 3 Marital status Married/common law Previously married Age Gender (0 ¼ male, 1 ¼ female) Education Past use of predicted behaviour Psychiatric symptomatology Help-seeking propensity Psychological openness Indifference to stigma R2 R2

Mental health professional

Primary care physician

b

SEb

b

SEb

0.05 0.06 0.11 0.04 0.06

0.05 0.14 0.38** 0.07 0.11

0.05 0.07 0.13 0.04 0.07

0.03 0.18** 0.01 0.10** 0.10 0.09**

0.02 0.13 0.03 0.08* 0.06 0.15**

0.16**

0.04 0.06 0.11 0.04 0.06 0.14

0.02 0.06 0.36** 0.04 0.11 0.19**

0.08**

0.00 0.08 0.13 0.04 0.01 0.08* 0.31 0.65** 0.13 0.04

0.05 0.07 0.12 0.04 0.07 0.04 0.09**

0.04 0.06 0.11 0.03 0.06 0.04 0.21 0.12 0.09 0.10

0.03 0.06 0.34* 0.04 0.10 0.20** 0.02 0.01 0.08 0.02

0.05 0.07 0.13 0.04 0.07 0.04 0.25 0.14 0.11 0.25

0.17**

0.00

0.34**

0.25**

The previously married marital status category includes those who are separated, divorced, or widowed. *p50.05; **p50.01.

Intentions to talk to a primary care physician were more favourable than intentions to take care of problems oneself, t(206) ¼ 2.88, p50.01. Finally, intentions to take care of problems oneself were more favourable than intentions to talk to a member of the clergy, t(207) ¼ 8.61, p50.01. Two regression analyses predicted intentions to seek professional psychological help. Correlations among the various predictor and outcome variables ranged from 0.07 to 0.50, with an average correlation of 0.25, indicating an absence of multicollinearity. The first of these analyses, which are presented

in Table II, examined participants’ intentions to talk to a mental health professional. Demographic factors accounted for 9% of the variance in step one of this analysis, F(5, 189) ¼ 3.94, p50.01. More favourable intentions were associated with female gender and with being previously married. Having seen a mental health professional in the past was added to the model in step two, accounting for an additional 8% of the variance, F(1, 188) ¼ 17.82, p50.001. Finally, psychiatric symptomatology and helpseeking attitudes were added to the model in a final step, with Help-seeking Propensity accounting

The influence of help-seeking attitudes for nearly as much additional variance as was explained by the first two steps, F(4, 184) ¼ 11.69, p50.001. In this final step, gender was no longer a significant predictor, suggesting that gender differences in intentions to visit a mental health professional are due to differences between men’s and women’s perceived ability and willingness to seek help. Together, demographic factors, past use of mental health professionals, psychiatric symptomatology, and attitudes accounted for 34% of the variance in participants’ intentions to visit a mental health professional, F(10, 184) ¼ 9.49, p50.001. A second regression analysis examined factors associated with intentions to seek professional psychological help from a primary care physician. Demographic factors in the first step of this analysis accounted for 16% of the variance, F(5, 188) ¼ 7.11, p50.001. More favourable intentions to talk to a physician about psychological problems were associated with being older. Adding whether or not individuals had spoken to a physician about psychological problems in the past in step two accounted for an additional 9% of intention variance, F(1, 187) ¼ 22.50, p50.001. The addition of psychiatric symptomatology and help-seeking attitudes in step three did not improve the prediction of this intention option, F(4, 183) ¼ 0.14, p ¼ 0.97. Together, predictor variables accounted for 25% of the variance in intentions to talk to a primary care physician about mental health concerns, F(10, 193) ¼ 6.15, p50.001. The absence of help-seeking attitudes as a significant predictor in this analysis is in sharp contrast to the strong predictive effect of Help-seeking Propensity on intentions to seek help within the specialty mental health sector. Furthermore, age remained a significant predictor when attitudes were added to the model, suggesting that differences between younger and older individuals’ intentions to seek psychological help from primary care physicians are not due to age differences in attitudes.

Discussion The goal of this study was to examine age and gender differences in attitudes toward seeking professional psychological help, and the influence of attitudes on help-seeking intentions. This goal is important considering that the need for mental health services is roughly equivalent for men and women of all ages, that men and older adults use disproportionately fewer mental health services than women and younger people, and that the role of attitudes as a potential barrier to help-seeking is currently unclear. As predicted, older adults and women held more positive attitudes toward seeking help than younger adults and men. These generalizations were tempered, however, with the knowledge that age and gender interacted with other

579

demographic characteristics, and had varying influences on different help-seeking attitude components. Older adults’ help-seeking attitudes were generally more positive than younger adults’, adding to a small but growing body of evidence challenging the ageist assumption that older individuals avoid seeking professional help because of stigma and negative attitudes. Age differences were most noticeable for single participants and for one of the three attitude factors, help-seeking propensity. The fact that our single older participants exhibited especially positive attitudes is consistent with the fact that never-married individuals are more likely than married individuals to seek help from mental health professionals (Kessler et al., 2005). Although our study did not address reasons why older adults in our sample who had never married were more open to seeking mental health services, it may be because without the support of a spouse they have had to seek professional help in the past. With respect to the positive impact of age on help-seeking propensity, perhaps older adults are more likely to endorse items from this attitude subscale, such as ‘I would want to get professional help if I were worried or upset for a long period of time’ and ‘It would be relatively easy for me to find the time to see a professional for psychological problems’, because they are less likely than younger individuals to endorse social roles emphasizing strength and self-reliance, or because life experience has taught them the value of seeking help when they need it. On the other hand, this finding may be an artefact of our relatively well-educated sample if older educated individuals are especially likely to have the financial and lifestyle resources that are needed to seek professional help. Women exhibited especially positive help-seeking attitudes, regardless of how well educated they were. In contrast, men’s attitudes were positively influenced by higher levels of education. This finding is encouraging; it suggests that educational interventions designed to improve attitudes toward seeking psychological help might be most effective for the demographic group they would hope to target—men. Whereas age affected Help-seeking Propensity scores, gender differences were only evident for Psychological Openness, indicating that women in our sample were more willing to acknowledge psychological problems and the need for help than men, but that they did not differ from men in terms of their propensity to seek help or the extent to which they associate stigma with professional help-seeking. Women’s openness to acknowledging mental health problems is consistent with research suggesting that they are more likely than men to recognize and label emotional distress (Kessler, Brown, & Bowman, 1981). This finding also suggests that educational initiatives aimed at increasing men’s use of mental health services should focus on increasing psychological openness, rather than

580

C. S. Mackenzie et al.

targeting attitudes related to stigma or willingness to seek help. Our examination of demographic variation in help-seeking attitudes suggests that gender differences in help-seeking attitudes pertaining to psychological openness might contribute to low rates of mental health service use among men, but that age differences in attitudes are an unlikely contributor to older adults’ disproportionate low rates of service utilization. To answer this question more directly, we turn to our second objective of examining the influence of attitudes on age and gender differences in intentions to seek professional psychological help. With respect to predictors of help-seeking intentions we found, once again, that age and gender played significant roles. The key finding from this portion of the study was that the influence of demographic factors and attitudes depended on whether the intended source of help was a mental health professional or a primary care physician. Intentions to visit a mental health professional were affected by gender but not by age. Women in this study were more likely than men to say that they would talk to a mental health professional, even when prior help-seeking was taken into consideration. This gender difference disappeared, however, when help-seeking attitudes were added to the model, suggesting that our female participants would be especially likely to visit a mental health professional because of their openness to helpseeking and to acknowledging psychological problems. In contrast, the likelihood of intending to visit a primary care physician for psychological help was affected by age, but not by gender. Older adults were much more likely than younger adults to say that they would talk to a physician, and this preference was not explained by age differences in prior help-seeking or attitudes. Older adults in this study held more positive attitudes toward seeking professional psychological help than younger adults, they said that they would be as likely as younger participants to seek help from a mental health professional, and they said they would be even more likely to seek psychological help from a primary care physician. We see two possible explanations for the apparent paradox between older participants’ positive help-seeking attitudes and intentions, and their well documented underutilization of mental health services. One possibility is that our results may not generalize to the broader population of older adults considering that participants in this study were generally well educated and ethnically homogeneous. The Canadian sample may also limit generalizability to the USA and elsewhere, although access to mental health services is, for the most part, similar throughout North America (Olfson, Kessler, Berglund, & Lin, 1998). Additional research is required to investigate whether our findings are replicated in other

non-Canadian, ethnically diverse, and less welleducated samples. A second possibility is that while older adults view mental health services favourably, other personal, interpersonal and professional barriers are hindering their use of services. In terms of professional barriers, our older adults’ preference for managing their mental health needs within the general medical sector could contribute to their low rates of mental health service use considering that primary care physicians are less likely to recognize, treat, and refer older than younger individuals with mental health problems (Bartels, 2003; Klap et al., 2003; Mackenzie, Gekoski, & Knox, 1999). In terms of interpersonal barriers, participants in this study reported that if they were to experience significant mental health problems their first choice of help would be family or friends, which is consistent with other research demonstrating that the social support network is the first contacted and preferred source of help for those with psychological problems (e.g., Howard, 1996). Although relatively little research has been conducted to examine the influence of the social network on age differences in help-seeking, there is some evidence that older adults are less likely than younger adults to receive advice to seek professional help from family and friends (Mackenzie, Knox, Smoley, & Gekoski, 2004). In conclusion, various personal, interpersonal, and professional barriers might prevent those in need of mental health services from receiving them. The influence of attitudes on service use in general, and for underserved populations such as older adults and men in particular, has proven to be complex. In the current study, men were less open than women with respect to acknowledging mental health problems and the possibility of seeking professional help. This finding suggests that attitudes concerning psychological openness may be a barrier to men’s use of mental health services, and a potential target of interventions aimed at reducing gender differences in service use. Conversely, older participants, especially those who were single, reported being significantly more willing and able to seek professional psychological help than younger participants. This finding suggests that for older adults, factors other than attitudes, such preferences for discussing psychological problems with primary care physicians, might be more of a barrier to their receiving professional psychological help. The potential negative impact of older adults’ preference for primary care physicians when faced with psychological problems suggests that their mental health needs might be better met through education; for physicians to improve their detection, treatment, and referral of older adults with psychological disorders, and for older adults to help them understand when and how to advocate for specialty mental health referrals.

The influence of help-seeking attitudes References Addis, M. E., & Mahalik, J. R. (2003). Men, masculinity, and the contexts of help seeking. American Psychologist, 58, 5–14. Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting interactions. Newbury Park. CA: Sage Publications.. Ajzen, I. (1985). From intentions to actions: A theory of planned behaviour. In J. Kuhl & J. Beckman (Eds.), Action-control: From cognition to behaviour (pp. 11–39). Heidelberg, Germany: Springer. Ang, R. P., Lim, K. M., & Tan, A. (2004). Effects of gender and sex role orientation on help-seeking attitudes. Current Psychology:Developmental, Learning, Personality, 23, 203–214. Arean, P. A., Alvidrez, J., Barrera, A., Robinson, G. S., & Hicks, S. (2002). Would older medical patients use psychological services? The Gerontologist, 42, 392–398. Bartels, S. J. (2003). Improving the system of care for older adults with mental illness in the United States: Findings and recommendations for the President’s New Freedom Commission on Mental Health. American Journal of Geriatric Psychiatry, 11, 486–497. Berger, J. M., Levant, R., McMillan, K. K., Kelleher, W., & Sellers, A (2005). Impact of gender role conflict, traditional masculinity ideology, alexithymia, and age on men’s attitudes toward psychological help-seeking. Psychology of Men & Masculinity, 6, 73–78. Bland, R. C., Newman, S. C., & Orn, H. (1997). Help-seeking for psychiatric disorders. Canadian Journal of Psychiatry, 42, 935–942. Cash, T. F., Begley, P. J., McCown, D. A., & Weise, B. C. (1975). When counselors are heard but not seen: Initial impact of physical attractiveness. Journal of Counselling Psychology, 22, 273–279. Cepeda-Benito, A., & Short, P. (1998). Self-concealment, avoidance of psychological services, and perceived likelihood of seeking professional help. Journal of Counselling Psychology, 45, 58–64. Currin, J. B., Schneider, L. J., Hayslip Jr B., & Kooken, R. A. (1998). Cohort differences in attitudes toward mental health services among older persons. Psychotherapy, 35, 506–518. Deane, F. P., & Todd, D. M. (1996). Attitudes and intentions to seek professional psychological help for personal problems or suicidal thinking. Journal of College Student Development, 10, 45–59. Derogatis, L. R. (1993). Brief symptom inventory (BSI): Administration, scoring, and procedures manual. Minneapolis, MN: National Computer Systems. Estes, C. L. (1995). Mental health services for the elderly: Key policy elements. In M. Gatz (Ed.), Emerging issues in mental health and aging (pp. 303–328). Washington, DC: American Psychological Association. Fischer, E. H., & Turner, J. LeB. (1970). Orientations to seeking professional help: Development and research utility of an attitude scale. Journal of Consulting and Clinical Psychology, 35, 79–90. Henderson, S. (2002). The National Survey of Mental Health and Well-Being in Australia: Impact on policy. Canadian Journal of Psychiatry, 47, 819–824. Holden, R. R. (1996). Holden psychological screening inventory manual. North Tonawanda, NY: Multi-Health Systems. Holden, R. R., Starzyk, K. B., McLeod, L. D., & Edwards, M.J. (2000). Comparisons among the Holden Psychological Screening Inventory (HPSI), the Brief Symptom Inventory (BSI), and the Balanced Inventory of Desirable Responding (BIDR). Assessment, 7, 163–175. Howard, K. I., Cornille, T. A., Lyons, J. S., Vessey, J. T., Lueger, R. J., & Saunders, S. M. (1996). Patterns of mental health service utilization. Archives of General Psychiatry, 53, 696–703.

581

Kelly, A. E., & Achter, J. A. (1995). Self-concealment and attitudes toward counselling in university students. Journal of Counselling Psychology, 42, 40–46. Kessler, R. C., Brown, R. L., & Broman, C. L. (1981). Sex differences in psychiatric help-seeking: Evidence from four large-scale surveys. Journal of Health and Social Behaviour, 22, 49–64. Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, J. A., Walters, E. E., et al. (2005). Prevalence and treatment of mental disorders, 1990 to 2003. The New England Journal of Medicine, 352, 2515–2523. Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. F., Hughes, M., Eshleman, S., et al. (1994). Lifetime and 12-month prevalence of DSM-III-R disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 8–19. Klap, R., Tschantz Unroe, K., & Unutzer, J. (2003). Caring for mental illness in the United States. American Journal of Geriatric Psychiatry, 11, 517–524. Landreville, P., Landry, J., Baillargeon, L., Guerette, A., & Matteau, E. (2001). Older adults’ acceptance of psychological and pharmacological treatments for depression. Journal of Gerontology: Psychological Sciences, 56B, P285–P291. Lebowitz, B. D., & Niederehe, G. (1992). Concepts and issues in mental health and aging. In J. E. Birren, R. B. Sloane, & G. D. Choen (Eds.), Handbook of mental health and aging (2nd ed., pp. 11–26). San Diego, CA: Academic Press. Mackenzie, C. S., Gekoski, W. L., & Knox, V. J. (1999). Do family physicians treat older patients with mental disorders differently from younger patients? Canadian Family Physician, 45, 1219–1224. Mackenzie, C. S., Knox, V. J., Gekoski, W. L., & Macaulay, H. L. (2004). An adaptation and extension of the Attitudes toward Seeking Professional Psychological Help scale. Journal of Applied Social Psychology, 34, 2410–2435. Mackenzie, C. S., Knox, V. J., Smoley, J., & Gekoski, W. L. (2004). The influence of age and gender on advice given to depressed people. Journal of Mental Health and Aging, 10, 311–324. McQuaid, J. R., Stein, M. B., Laffaye, C., & McCahill, M. E. (1999). Depression in a primary care clinic: The prevalence and impact of an unrecognized disorder. Journal of Affective Disorders, 55, 1–10. Morgan, R., Ness, D., & Robinson, M. (2003). Students’ help-seeking behaviours by gender, racial background, and student status. Canadian Journal of Counselling, 37, 151–166. Norquist, G. S., & Regier, D. A. (1996). The epidemiology of psychiatric disorders and the de facto mental health care system. Annual Review of Medicine, 47, 473–479. Olfson, M., Kessler, R. C., Berglund, P. A., & Lin, E. (1998). Psychiatric disorder onset and first treatment contact in the United States and Ontario. American Journal of Psychiatry, 155, 1415–1422. Rhodes, A., Goering, P., To, T., & Williams, J. I. (2002). Gender and outpatient mental health service use. Social Science & Medicine, 54, 1–10. Robb, C., Haley, W. E., Becker, M. A., Polivka, L. A., & Chwa, H.-J. (2003). Attitudes towards mental health care in younger and older adults: Similarities and differences. Aging & Mental Health, 7, 142–152. Rokke, P. D., & Scogin, F. (1995). Depression treatment preferences in younger and older adults. Journal of Clinical Geropsychology, 1, 243–257. Segal, D. L., Mincic, M. S., Coolidge, F. L., & O’Riley, A. (2005). Beliefs about mental illness and willingness to seek help: A cross-sectional study. Aging & Mental Health, 9, 363–367.

582

C. S. Mackenzie et al.

Seligman, M. E. P. (1995). The effectiveness of psychotherapy: The Consumer Reports study. The American Psychologist, 50, 965–974. Sirey, J. A., Bruce, M. L., Alexopoulos, G. S., Perlick, D. A., Raue, P., Friedman, S. J., et al. (2001). Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression. American Journal of Psychiatry, 158, 479–481. Statistics Canada (2006). Visible minority population, by provinces and territories (2001 Census). Available http:// www40.statcan.ca/z01/cs0002_e.htm.

Sutton, S. (1998). Predicting and explaining intentions and behaviour: How well are we doing? Journal of Applied Social Psychology, 28, 1317–1338. Vogel, D. L., & Wester, S. R. (2003). To seek help or not to seek help: The risks of self-disclosure. Journal of Counselling Psychology, 50, 351–361. Wang, P. S., Berglund, P., & Kessler, R. C. (2000). Recent care of common mental disorders in the United States. Journal of General Internal Medicine, 15, 284–292.