Denial and Its Association With Mental Health Care Use A Study of Island Puerto Ricans Alexander N. Ortega, PhD Margarita Aiegria, PhD Abstract In clinical practice, denial has long been thought to be a determinant of treatment initiation and retention; however, little empirical research has focused on denial as a mechanism. For example, denial has not been standardized or operationalized in epidemiological studies for mental health services research and, thus, the magnitude of the effects of denial on mental health care use are unknown. This study makes use of the "Mental Health Care among Puerto Ricans " study, a 3-wave island-based probability epidemiological study conducted from 1992 to 1998. For all the 3 waves, 2928 individuals participated (81.5% response). The analyses were limited to only those participants who were objectively determined to have a severe needfor mental health care (n = 742). The findings from this study show that admitting to a mental health problem is related to the increased odds of using any mental health care, any specialty care, psychotropic drugs, and retention in mental health care, after adjusting for potential confounding. Similar patterns were observed even after the data were limited to those participants who did not previously seek mental health care, and the trends persisted when determining changes from denial to admitting a mental health problem. The study confirms that denial is a significant factor for treatment initiation and retention, particularly for Puerto Ricans, and denial should be considered an important mechanism in planning interventions to eliminate mental health care disparities.
Improvitig access to atid utilization of tnental health setA'ices has been a setious health policy concern in the United States. This concern comes from growing awareness that many people who meet diagnostic criteria for psychiatric disorders do not seek professional services. The Surgeon General's Supplement, Mental Health: Culture, Race and Ethnicity, notes that racial and ethnic minorities have less access to mental health services than whites, and they are less likely to receive needed care and to stay in care.' Specifically, Latinos in the United States are less likely than whites to seek mental health treatment, after accounting for differing risks for mental illness, which largely explains their underrepresentation in mental health services.^-^ Studies have begun to investigate the personal motivators and incentives for using mental health care, and most of these studies have focused on
Address correspondence to Alexander N. Ortega, PhD, associate professor. Department of Health Services, School of Public Health, University of California, Los Angeles, CA 90095. E-mail:
[email protected]. Margarita Alegria, PhD, is professor and director at the Center for Multicultural Mental Health Research, Department of Psychiatry, Cambridge Health Alliance/Harvard Medical School, Sommerville, Mass. Joumal of Behavioral Health Services & Research, 2005, 32(3), 320-331. © 2005 National Council for Community Behavioral Healthcare.
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predisposing, enabling, and need factors.'*'^ Recent studies that have focused on Latinos have started to examine personal coping factors, such as self-reliance and social networks, as determinants for mental health service use.^*^ A potentially important mechanism for understanding motivators for mental health service use in ethnic and racial minority populations is the self-perception or recognition of mental health problemsJ'^ Perceptions of mental health not only include symptom perceptions but also attitudes, beliefs, and knowledge of health and illness, and they are typically fused with perceived need for treatment. For example, discussing problems with friends and family appears to play a role in problem recognition, after adjusting for need of mental health care.' Denial is part of the perception of illness domain and is often viewed as a defense mechanism in psychiatry and psychology."'" Russell notes that denial, although unrealistic to the observer, may help the individual cope with adversity.'^ Denial of mental health problems, while a well-recognized mechanism for treatment initiation and retention,'^'" surprisingly has not been empirically studied in mental health services research. Moreover, the measurement of denial has not been standardized, and only a handful of studies have attempted to operationalize or measure it. Over 20 years ago, Breznitz embarked on a concerted effort to describe denial and its relation to stress. Breznitz described denial as "a defense mechanism . . . through which a person attempts to protect himself [or herself] from some painful or frightening information related to external reality."'^ Denial may also be viewed as an extension of avoidance. Problem-focused coping, which involves active behavioral strategies such as seeking services, is often used when a situation is viewed as manageable or amenable to change.'* Emotion-focused coping, such as denial, avoidance, or distancing, is often used when an issue is viewed as uncontrollable or as something that must be endured.'* Thus, denial might act as a coping mechanism to deal with a situation that is perceived as less controllable and that externally elicits the psychiatric symptoms (eg, divorce, unemployment) rather than an internal pathology. While it is ideal to be able to distinguish denial from perception of mental health need, measuring denial as a separate construct is difficult. It requires being able to differentiate poor symptom recognition from the acknowledgment of mental health problems when symptoms and need are objectively known to exist. While denial is generally considered a factor related to whether a patient chooses to seek help, little is known about the effects of denial in help-seeking or of changes in denial on changes in help-seeking (ie, going from denying to admitting an emotional or mental health problem). Thus, in this article, the general relationships between denial and mental health service use will not only be determined but also whether changes in denial over time are associated with changes in help-seeking, after accounting for individual-level predisposing (ie, demographics, attitudes), enabling (ie, health insurance), and need (ie, objective need) factors.
Methods The present study makes use of the "Mental Health Care among Puerto Ricans" study.^*'''^ The study uses a 3-wave survey on a random islandwide probability sample of adults (aged 18-69 years in 1992) living in low-income regions of Puerto Rico. Random selection of 4029 housing units were dispersed among 354 sampled clusters. Each cluster contained approximately 14 housing units in the urban areas and 20 housing units in the rural areas. Households were selected for inclusion in the study if they had an adult between the ages of 18 and 60 at the time of enumeration. Excluded from the sample were homeless or transient people, people living temporarily away from home for more than 6 months, and those living in institutions at the time of enumeration. Eligible adults were identified in 4027 housing units, and enumeration was completed for 3869 individuals (96.1 % of these units). Standard Kish selection methods were then used in selecting one adult from each unit.'^ Of the 3869 eligible households, face-to-face interviews were completed for 3504, yielding a total response rate of 90.6% at baseline (1992-1993). In wave 2 (1993-1994), 3263 (93.1 %) respondents
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were reinterviewed, and in wave 3 (1996-1998), 2928 (83.6%) interviews were conducted. For the 3-wave period, the overall response rate was 81.5%. Since the focus of this article is on changes in service use in relation to changes in denial of existing mental health problems, the data for testing the models were constrained to only severe needers for a total sample of 742 respondents in need of mental health services. The mental need health measure has been described in a separate published report.' Mental health need was based on 4 assessed dimensions: level of psychological distress, diagnosis of psychiatric disorders, functional impairment in role performance or severity of underlying illness, and current illicit drug use. The categorical measure of need for alcohol, drug abuse, and mental health services in a community sample classifies individuals in the general population into 3 mutually exclusive categories: severe needers, those individuals with serious mental health problems who need services; moderate needers, those who possibly need mental health services but are not severely mentally ill; and those in mild or no need of services. Participants were characterized as "severely," "moderately," or in "no need of mental health services" depending on how they were characterized on the level of psychological distress, diagnosis of psychiatric disorders, functional impairment in role performance or severity of underlying illness, and current illicit drug use. Severe alcohol, drug abuse, and mental health (ADM) need requires a functional impairment/severity score of at least 2 and either a psychiatric diagnosis or elevated psychiatric symptoms (2 standard deviations above the population mean) or current illicit hard-core drug use. Moderate need requires either a functional impairment/severity score of at least 2 and moderate psychiatric symptoms (1 standard deviations above the population mean) or a psychiatric disorder or illicit hard-core drug use and a score of 1 or less in the functional impairment/severity scale. All others are designated as in "mild or no need" of mental health services. The classification of mild or no need represents those participants who according to available indicators of need appear to require no ADM services. To determine nonadmission of mental health problems, respondents had to say that there was never any moment during the last year when they thought they had a nervous, emotional, drug, or alcohol problem, but they self-reported severe need (as indicated by their endorsement to disorder, symptom, or impairment probes). The denial could be due to ignorance of what are mental health, drug, or alcohol problems; having a higher tolerance for psychiatric symptoms; seeing symptoms as a way of life; or confusing mental health symptoms with physical symptoms. Independent of the reason, the response still refiects denial or lack of admission of a mental health problem. If the respondent described himself or herself in severe need and admitted having either a mental, emotional, nerve, alcohol, or drug problem, the respondent was classified "in admission" of having a mental health problem. Because of the longitudinal feature of the study design, at each wave respondents were assessed again about their need level and whether they denied having a mental health problem. This allowed for the classification of respondents according to their denial or admission status for each wave and to construct a measure of whether there was a change from denial to admission of mental health problems. Instruments and measures This study analyzed the effects of denial/admission status with 5 service use outcomes: any formal mental health service use, any specialty use, any general health care use for mental health problems, retention in mental health care (4 or more visits within a 1-year period), and use of psychotropic medication. Any formal mental health care use during the previous year was defined as use of the general health sector or the specialty sector for mental health problems. Specialty sector use was defined as treatment by a psychiatrist, psychologist, social worker, or counselor, or treatment by a professional in a mental health setting (eg, hospital psychiatric clinic). General health care use was mental health care provided by a physician other than a psychiatrist, or care received in a community health center or private office, or treatment by a physical health care provider when the respondent
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stated that the visit included discussing his or her mental health problems. Retention in care was assessed on the basis of whether the respondent had at least 4 visits or more over a 1 -year period. For a more detailed description see Ortega and Alegria.^ Use of psychotropic medications was evaluated by asking respondents if they were taking any medication for a nervous condition, anxiety, or emotional problem. All of these outcomes are contrasted against no use of mental health care. Several covariates were deduced from our previous investigations of mental health service utilization as well as the results of our bivariate analyses, and were used as controls: age, sex, years of education, poverty level, availability of private health insurance coverage, self-perception of mental health, personal attitudes toward mental health care, family's attitude toward mental health care, and use of any mental health care in the past year. These included sex, a dummy variable with a value of 1 if the individual was a woman; age, a continuous variable; and education, the respondent's years of schooling. Insurance coverage was represented with 2 dummy variables: no insurance with a value of 0 if the individual did not have any health insurance and public insurance with a value of 1 if the individual had public insurance or Medicare; private insurance was the reference group. Total annual family income was used to designate people as poor or nonpoor (poverty) using a dummy variable with a value of 1 if the person was poor. For each wave, the US Bureau of Census's definition of poverty was used to classify respondents as poor or nonpoor on the basis of their family composition (for a family of 2 adults and 2 children, the criteria for 1992: $14,654; 1993: $15,029; 1997: $16,276). Annual household incomes (without government assistance) in the sample ranged from $0 to $ 156,000 with a mean of $ 13,892. The variables for attitudes toward mental health were dummy variables that take a value of 1 when the participant, the participant's family, or the participant's friends had a positive attitude toward mental health care. To classify the participant's attitude as positive, he or she had to respond to 1 of 3 questions in the following manner: if he or she had a serious emotional problem, he or she would definitely seek professional help; he or she would feel very comfortable talking about his or her personal problems to a professional; and if 100 persons needed professional help for an emotional problem but decided not to seek help, he or she would believe that less than 25 will get better. The choice to construct the personal attitude scale as 1 of 3 positive responses was to make it parallel to the other family and friends' attitudes toward mental health measures, which were limited to single items. Furthermore, because the internal consistency of the 3-item scale was high (Cronbach a of .79), the final measure was constructed dichotomously. For family and friends' attitudes, the participant's responses had to be that they would feel not at all uncomfortable if their family/friends knew they were receiving professional help for an emotional problem for it to be considered a "good" family/friend attitude. A lagged dummy variable for admission was included to measure the change in behavior. A dummy variable for any previous use of mental health services was also included as a covariate to control for the possible effect of previous use on current admission of a mental health problem. This variable takes a value of 1 if the respondent reported using any health service for a mental health problem in the previous wave or if the respondent claimed to have ever used mental health services. The descriptive analyses were conducted using the total sample of wave 1 by admission status only for individuals with severe need. The distribution of the following characteristics was studied: sex, age, marital status, education, health insurance, zone of residence, and income. Age was measured in 6 (18-24; 25-34; 35^14; 45-54; 55-64; 65 or more) categories. Marital status was classified into never married, married (for those self-identified as married or in consensual union), and disrupted marriage (for those who identified themselves as separated, widowed, or divorced). Education was divided into 4 (0-6; 7-11; 12; 13 or more) categories. Health insurance was categorized into having no insurance, having public insurance, having private insurance or Medicare. Income was split into 5 (04999; 5000-9999; 10,000-14,999; 15,000-19,999; 20,000 or more) ranges. Attitudes toward mental health care of the individual, the individual's family, and the individual's friends were categorized as being either positive or negative.
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Statistical analyses For wave 1, the distributions of sociodemographic, attitudinal, and service use characteristics by recognition or denial of having a mental health problem across individuals who had severe need for mental health services were compared. Chi-square (x^) test was used to determine whether the distribution of the characteristics of individuals who denied having a mental health problem was different from those who admitted having a mental health problem. This same test was used to test for differences in whether the individual admitted or denied having a mental health problem by the 4 indicators of mental health service use. The groups were also classified according to changes in denial or admittance of mental health problems (present deniers-past deniers, present admitterspast deniers, present deniers-past admitters, and present admitters-past admitters) and compared in terms of the different components of their baseline levels of need (diagnosis, functioning, distress, and illicit drug use). Then, the first set of logistic regression analyses were conducted comparing current admitters with current deniers and past admitters with past deniers, when predicting the 4 dependent measures of mental health services. In these logistic regressions, 1 dummy variable represented current admission of mental health problems, a second dummy variable represented past admission, and a third dummy variable tested the interaction of past denial by current admission. Then, the last analyses were repeated for participants in waves 2 and 3, but the sample was limited to only those participants who had never used mental health care in the previous waves (Table 3). Finally, the effects of changes in admission/denial on entry into mental health care in the next time period were assessed by separate regression analyses with the dependent variable as changes from no use to use (Table 4; coded as 1, 0 if otherwise); these analyses were repeated for those who had no previous report of mental health service use (Table 5). The data were stacked, with 742 respondents who had severe need in either wave 2 or wave 3. Those respondents who had severe need in both waves were kept in the data set to allow computing the confidence intervals using robust estimates for the standard errors. Robust standard errors corrected for the possible problem of the error term not being identically distributed or for observations being correlated, as in our case. The sociodemographic variables for each observation were the values for wave 1, such as sex, age, education, poverty status, health insurance, personal attitude toward mental health, and family's attitudes toward mental health.
Results Recall that the data for all the analyses were limited to those who were determined to have severe need for mental health care. Table 1 shows the descriptive comparisons of participants by whether they were classified as deniers or admitters in wave 1. No significant differences were found in sociodemographic or attitudinal characteristics between deniers and admitters. However, Table 1 shows differences in mental health service use by denying versus admitting mental health problems. Significant differences were found for any formal use of mental health services, use of specialty services, psychotropic medication use, and retention in mental health care. As expected, in each case, admitters were more likely to use mental health care than deniers. No difference was found between admitters and deniers for any general use of mental health services. Preliminary, separate analyses of changes in denial by the components of need revealed that those who were past deniers and remained in denial (past deniers-present deniers) were significantly less likely to have high levels of psychiatric symptoms (3.6%) as compared to the past deniers-present admitters (8.5%), the past admitters-present deniers (17.4%) and the past admitters and present admitters (24.1%). The past deniers-present deniers (17.9%) and past deniers-present admitters (24.5%) were significantly less likely to have higher depressive symptoms at baseline (CES-D > 23) than those past admitters-present deniers (43.5%) or past admitters-present admitters (53.4%). The same trend was observed with decreased likelihood of a diagnosis of last year major depression.
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Table 1 Percent distribution of sociodemographic, attitudinal, and service use characteristics by deniers and admitters with severe need for mental health services, wave 1
Characteristics Sex Females Males Age range, y 18-24 25-34 35^W 45-54 55-64 65 or older Marriage Never married Married Divorced Years of education by range 0-6 7-11 12 13 or more Insurance No insurance Public insurance Private insurance Medicare Income range $0-4999 $5000-9999 $10,000-14,999 $15,000-19,999 $20,000 or more Personal attitude toward mental health care Good Bad Family attitude toward mental health care Good Bad Friends' attitude toward mental health care Good Bad
Denied mental Admitted mental Total sample health problem health problem (N = 3500)* (n = 91)* (n = 345)*
xHdf) P value
2085(53.1) 1415 (46.9)
47 (47.0) 44 (53.0)
224 (59.4) 121 (40.6)
x ' = 3.3(1) .0680
463(21.2) 945 (25.7) 868 (20.6) 624(15.3) 507(12.2) 93(5.1)
16(28.4) 23 (24.0) 21 (17.6) 16(14.4) 13(11.6) 2(4.1)
28(15.2) 79 (22.9) 90 (22.3) 72(19.6) 73(18.7) 3(1.4)
X'=6.3(5) .2804
716(25.0) 2161 (59.6) 622(15.4)
27 (34.2) 45 (48.4) 19(17.4)
64 (22.2) 181 (51.8) 100(26.0)
X'=4.4(2) .1130
701 (19.1) 839(24.1) 954 (27.9) 1006(28.9)
22 (22.4) 25 (29.3) 23(26.1) 21 (22.2)
96 (25.7) 110(30.3) 79 (24.0) 60 (20.0)
x'-0.6(3)
752 (22.0) 1014(28.5) 1441 (40.2) 274 (9.3)
29 (34.8) 30(31.8) 25 (25.2) 7 (8.3)
68 (20.6) 137 (37.3) 93 (28.8) 45(13.3)
X' = 5.4 (3) .1457
1023 (28.6) 1077(31.2) 582(16.9) 324 (9.0) 494(14.2)
34(31.0) 25 (28.8) 10(14.0) 7 (7.0) 15 (19.2)
144 (39.7) 106(31.1) 60(18.6) 16(4.0) 19(6.5)
X'=6.1(4) .1931
2893(81.8) 598(18.2)
69 (67.9) 21 (32.1)
278 (79.3) 66 (20.7)
X' = 2.4(1) .1237
2913 (84.8) 490(15.2)
65 (73.8) 20 (26.3)
260 (79.0) 68(21.0)
X' = 0.7(1) .3894
2913(84.8) 490(15.2)
65 (73.8) 20 (26.3)
260 (79.0) 68(21.0)
X ' = 0.7(1) .3894
.9075
{continues) >enial and Its Association WithMental Health Care Use
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Table 1 Percent distribution of sociodemographic, attitudinal, and severe use characteristics by deniers and admitters with severe need for mental health services, wave 1 (Continued) Denied mental Total sample health problem (A^ = 3500)* in = 91)*
Characteristics Any use of services Yes No General use of services Yes No Specialist use of services Yes No Psychotropic medication use Yes No Retention in mental health care use Yes No
Admitted mental health problem (« = 345)*
P value
X'idf)
462 (12.7) 3038 (87.3)
24 (24.6) 67 (75.4)
178 (50.2) 167 (49.8)
X^= 16.3(1) .0001
132 (3.6) 3368 (96.4)
9 (8.8) 82(91.2)
39(11.3) 306 (88.7)
X ' = 0.5(1) .4873
330(9.1) 3170(90.9)
15(15.8) 76 (84.2)
139 (38.9) 206(61.1)
x ' = 17.8(1) .0000
285 (7.4) 3215 (92.6)
13(11.4) 78 (88.6)
138 (37.3) 207 (62.7)
x2 = 23.8(1) .0000
273 (7.5) 3227 (92.5)
9 (9.3) 82 (90.7)
128 (34.7) 217 (65.3)
X^ = 21.8(1) .0000
'Values represent n (%). or of a diagnosis of last year dysthymia, or lower functional impairment for past deniers-present deniers and for past deniers-present admitters as compared to past admitters-present deniers or past admitters-present admitters. There was no difference across the denier-admitter groups with regard to alcohol abuse, and/or dependence disorders, or illicit drug use. However, those who were past deniers and remained in denial (past deniers-present deniers) were significantly more likely to fulfill last year criteria for antisocial personality disorder at baseline (11.9%) than any of the other groups (7.5% for past deniers-present admitters, 6.5% for past admitters-present deniers, and 4.4% for past admitters-present admitters). Table 2 shows the analyses that compare current admitters with current deniers and past admitters with past deniers, after adjusting for sex, age, education, poverty status, insurance status, personal attitude toward mental health care, and family's attitude toward mental health care. Similar to the results of the bivariate analyses, no associations were found for any general use of mental health care and any of the independent variables. When comparing current admitters to current deniers, associations were found for any mental health care use (Odds ratio [OR] = 3.25, 95% CI = 2.05-5.17), any specialty care use (OR - 2.93,95% CI = 1.77-4.85), psychotropic medication use (OR = 2.31, 95% CI = 1.42-3.77), and retention in mental health care (OR = 3.24, 95% CI = 1.90-5.53). In each case, current admitters were on average 2 to 3 times more likely to use mental health care than current deniers, even after adjusting for all the covariates and previous use of mental health care. The associations were different for past admitters versus past deniers, where no significant differences were found. In separate preliminary analyses, the same set of regressions were conducted (data not shown), but instead tested whether there was a significant interaction between being a past denier and becoming a current admitter compared to the other groups (remaining an admitter, remaining a denier, or going from admission to denial). The interaction representing a change
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Table 2 Logistic regression results by type of use for all respondents with severe need for mental health services in waves 2 and 3: Odds ratio (95% confidence interval*) Independent variables
Any mental health care use
Any general healthcare use
Retention in Any specialty Psychotropic healthcare use healthcare use medication use (4 or more visits)
Current admit 3.25 (2.05; 5.17) 1.91 (0.90; 4.05) 2.93 (1.77; 4.85) 2.31 (1.42; 3.77) 3.24 (1.90; 5.53) Current deny 1.0 1.0 1.0 1.0 1.0 Past admit 0.95 (0.66; 1.38) 0.86 (0.50; 1.48) 1.02 (0.69; 1.49) 1.32 (0.91; 1.92) 1.01 (0.69; 1.46) Past deny 1.0 1.0 1.0 1.0 1.0 Previous use 3.90 (2.72; 5.59) 1.20 (0.69; 2.08) 4.16 (2.86; 6.05) 3.00 (2.04; 4.42) 3.17 (2.18; 4.61) of mental health care No previous 1.0 1.0 1.0 1.0 1.0 use of mental health care Observations 742 742 742 742 742 'Confidence intervals computed using robust standard errors. Reference groups are as follows: deny in the current wave, deny in past wave, and no previous use of mental health care ever. The regression also controls for sex, age, education, poverty status, health insurance, personal attitude toward mental health service use, and family's attitude toward mental health service use.
from denial to admission was significant for any specialty use (OR = 3.83, 95% CI = 1.27-11.59) and for psychotropic medication use (OR = 3.45, 95% CI = 1.20-9.92). The analyses reported in Table 2 were repeated, but the sample was limited to only those participants, in waves 2 and 3, who had not used mental health care in the previous waves to account for the potential bias of admission being a function of previous engagement in mental health care (see Table 3). In this case, current admitters had increased odds of using any mental health care (OR = 8.78,95% CI = 3.41-22.58), any specialty care (OR = 17.85,95% CI = 3.90-81.61), psychotropic medication use (OR = 7.21,95% CI = 2.38-21.83), and to be retained in mental health care (OR = 9.05, 95% CI = 3.06-26.77). Two significant estimates were found comparing past admitters with past deniers. Past admitters were less likely to have used any mental health care and any specialty care. The findings for past admitters were somewhat expected, given that past admitters who previously used mental health care were excluded from the analyses and only those who did not seek care remained. To examine whether a change in denial from one wave to the next was associated with an increase in mental health care use, 3 dummy variables representing change in denial status (past denial to current denial was the reference category) were incorporated into models that adjusted for the same covariates. For these regressions, the dependent variable was a change from no use to use (coded as 1) as compared to all others (coded as 0) assessed in 4 of our 5 outcomes. Retention in care was excluded because it was difficult to differentiate whether this was a different or the same episode of care. As can be observed in Table 4, remaining in denial over the study periods as compared to changing from past denial to current admission, remaining in admission, or even going from admission to denial predicted decreased odds of using any mental health services, any specialty care, and of using psychotropic medications. Similar to the analyses presented in Table 3, the results shown in Table 5 demonstrate that changes in denial are significantly associated to changes from no use to use when the sample is restricted to respondents with severe need of mental health services who had no previous use of mental health services.
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Table 3 Logistic regression results by type of use for all respondents with severe need for mental health services and with no previous report of mental health service use in waves 2 and 3: Odds ratio (95% confidence interval*) Independent variables
Any mental health care use
Any general healthcare use
Any specialty healthcare use
Psychotropic medication use
Retention in healthcare use (4 or more visits)
Current admit 8.78 (3.41; 22.58) 2.18 (0.77; 6.17) 17.85 (3.90; 81.61) 7.21 (2.38; 21.83) 9.05 (3.06; 26.77) Current deny 1.0 1.0 1.0 1.0 1.0 Pastadmit 0.52 (0.30; 0.91) 0.80 (0.35; 1.84) 0.48 (0.25; 0.94) 0.85 (0.47; 1.53) 0.57 (0.31; 1.05) Past deny 1.0 1.0 1.0 1.0 1.0 322 322 322 Observations 322 322 'Confidence intervals computed using robust standard errors. Reference groups are as follows: deny in the current wave and deny in past wave. The regression also controls for sex, age, education, poverty status, health insurance, personal attitude toward mental health service use, and family's attitude toward mental health service
Discussion Given the documented disparities in mental health service utilization, even after need is considered at the individual level, it is important to gain a better understanding of the personal coping mechanisms that may explain service use disparities between Latinos and whites, so that effective interventions to get patients engaged in care may be implemented. Based on a review of the literature, it appears that this is the first study that attempted to operationalize the concept of denial and measure its association with mental health care use in a community sample of Puerto Ricans. In the current empirical analyses, it was found that denial of mental health problems, once objective severe need was considered, is also a barrier to mental health care. Denial may be viewed as either adaptive (ie, coping, resilience) or maladaptive (ie, avoidance).^'"''^•" Wheeler and Lord
Table 4 Logistic regression results of increase in use by type of use for all respondents with severe need for mental health services in waves 2 and 3: Odds ratio (95% confidence interval*) Independent variables
Change in any mental health care use
Change in any general healthcare use
Change in any specialty healthcare use
Change in psychotropic medication use
From past deny to 4.61 (2.35; 9.05) 1.24 (0.50; 3.04) 6.51 (2.74; 15.47) 4.78 (2.16; 10.59) current admit From past admit to 6.42 (3.37; 12.22) 1.32 (0.56; 3.10) 9.01 (3.87; 21.01) 7.71 (3.56; 16.69) current admit From past admit to 2.78 (1.16; 6.69) 0.22 (0.03; 1.81) 5.63 (2.00; 15.85) 5.86 (2.18; 15.71) current deny From past deny to 1.0 1.0 1.0 1.0 current deny Observations 742 742 742 742 'Confidence intervals computed using robust standard errors. Reference group is deny in the past wave to deny in the current wave. The regression also controls for sex, age, education, poverty status, health insurance, personal attitude toward mental health service use, and family's attitude toward mental health service use.
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Table 5 Logistic regression results of increase in use by type of use for all respondents with severe need for mental health services and with no previous report of mental health service use in waves 2 and 3; Odds ratio (95% confidence interval*) Independent variables
Change in any mental health
care use
Change in any general healthcare use
Change in any specialty healthcare use
Change in psychotropic medication use
From past deny to 9.43 (3.60; 24.66) 2.14 (0.70; 6.57) 19.33 (4.22; 88.66) 8.12 (2.78; 23.68) current admit From past admit to 5.15 (1.90; 13.97) 2.01 (0.62; 6.51) 9.48 (1.94; 46.24) 5.61 (1.82; 17.28) current admit Other 1.0 1.0 1.0 1.0 Observations 742 742 742 742 'Confidence intervals computed using robust standard errors. Reference group includes the following: deny in the past wave to deny in the current wave; and admit in the past wave to deny in the current wave. The regression also controls for sex, age, education, poverty status, health insurance, personal attitude toward mental health service use, and family's attitude toward mental health service use.
examined definitions of denial and reported that the concept was not only related to avoidance but also to unrealistic hopefulness and repression.^" However, Robinson posited that denial is not always negative but could be an effective coping strategy, particularly when the respondent might feel he or she exerts limited control over the circumstances.-^' Why would respondents in severe need of mental health services be in denial about having mental health problems? There are several potential explanations. Denial may enable individuals to continue functioning in their roles without disruption to the family environment and consequently be continuously reinforced within the family context. In this way, it could be an adaptive mechanism to cope with unchangeable circumstances. Denial may also result when respondents experience intermittent episodes of recurrence and remission of mental illness, whereby denial allows for stability within participants' lives. Denial may also help participants with severe need to avoid the "sick role," allowing them to sustain their self-esteem and sense of control. Denial may also lead to negative coping if it enables people to distance themselves from integrating negative feedback from their networks of families and friends regarding psychiatric illness. Denial may also be related to the type of psychiatric illness with increased likelihood of persistent denial in the presence of severe need for services for those who exhibit antisocial personality disorder. Understanding the contribution of denial to help seeking seems a potential point of intervention to increase the use of mental health services. However, assessing denial in a clinical setting may be difficult given its various aspects, its close relations with other adaptive or maladaptive coping strategies, and its somewhat amorphous manifestation.^^ Moreover, the clinical challenge will be to identify when denial is effective or when denial is maladaptive and thus warrants intervention. The analyses presented in this study of island Puerto Ricans suggest that, at least for people with severe need, attitudes of denial may need to be targeted for intervention to engage high-risk patients into treatment. For example. Wing and Hammer-Higgins noted that denial was a barrier to recovery for alcoholics.^^ Subsequent comparative analyses may help us in clarifying whether denial operates similarly for minority versus nonminority groups or is different across ethnic and racial groups. In the context of mental health care access and use, differences in denial of mental health problems between minorities and nonminorities may be one individual factor that may explain mental health care use disparities. Of course, many potential patient, provider, and system factors may influence mental health services
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use. For instance, researchers have been investigating the role of enabling (ie, health insurance and provider availability) and need (ie, diagnosis and severity) factors in mental health service use for decades. There has also been recent attention to the roles of predisposing factors such as personal health beliefs and social structure in predicting service use as well as ethnic disparities in use.'*"* Health beliefs such as attitudes, knowledge, and perceptions of mental illness and mental health care, could influence individual decision making. Attitudes and perceptions could influence or be influenced by the method of coping, such as denial, self-efficacy, and self-reliance. It is important for researchers and clinicians to focus on those determinants that are most proximal to service use and mutable for intervention. To begin to recommend and implement policies aimed at improving access to mental health care and reducing disparities in care, investigators must examine the complex relations among not only structural and enabling factors but also ethnically or socioeconomically based predisposing factors. Improving access to services is not merely predicated on improving insurance coverage or geographic access, as examples, but also depends on changing attitudes and perceptions to get patients engaged and retained in care. This is particularly relevant for patients with severe levels of need such as the participants included in the current study. Focusing on denial, given its bidirectional relations with mental health beliefs, may provide useful information to improve use of mental health services for minority populations.
Study Limitations Limitations of the study should be noted. First, this was a study of respondents living in lowincome areas in Puerto Rico, and thus the results may not be generalizable to other Latinos on the US mainland or other groups of people with different characteristics. Second, because the most conservative criterium for the denial measure was used, the measure only considers those with severe mental health need; it is unknown how denial determines service use in participants with lower levels of need. More important, a single-item dichotomous measure of denial was used, which might not capture the full spectrum of denial. This article focuses on denial of having a mental health problem without addressing why individuals do not think that they have a mental health problem. It may be that denial is more prevalent among people who have higher levels of functioning that are not captured by our 5-item measures of functioning. Finally, the literature suggests that denial may have adaptive properties that the present study did not assess. Russell has argued that denial "protects the integrity of the self concept by distorting reality in a self-enhancing way, promoting a sense of mastery and control; this in turn leads to lower levels of anxiety, which may enhance decision making under conditions of stress."'^ Thus, the current article suggests the importance of denial in help seeking but not the mechanism by which denial operates.
Implications for Behavioral Health In the context of increasing concerns about health service inequalities among ethnic groups in the United States, mental health services researchers and policymakers have begun to recognize the need for multilevel interventions necessary to eradicate disparities in treatment access and use. There is growing recognition that providers, patients, and health care systems all contribute to health care disparities.^-' Latinos are less likely to access and use mental health services than non-Latino whites, even after the consideration of need. As researchers begin to disentangle the mechanisms that may explain these disparities, their conceptual models need to account for individual and personal coping styles with illness that may affect medical decision making for different ethnic groups. To that end, there are few comprehensive studies of coping preferences of ethnic minorities for dealing with mental health problems. The present study suggests the significant role of denial as a coping mechanism for mental illness for Puerto Ricans and its impact on accessing and using mental health services. Understanding the role of denial of mental illness for this population appears crucial in
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making correct assumptions about the reasons for not seeking formal care and devising outreach as part of treatment planning. The US system of mental health services that is currently in place falls short in providing for the vast majority of minorities in need of care, mainly because of its one-size-fits-all approach in service delivery.' Attention to cultural coping preferences of different ethnic groups may have significant implications for the design and implementation of community mental health programs and interventions. There are several reasons why the design of mental health services should focus attention on the special needs of Latinos. Latinos are now the largest ethnic minority group in the United States, and their predisposing health beliefs, attitudes, and coping strategies may differ substantially from those of the mainstream population. Furthermore, while it is essential for systems to eliminate financial and structural barriers to mental health care, especially for those who severely need care, such efforts may have attenuated effects if interventions are not both ecological and culturally relevant. Thus, interventions should aim at improving both individual- and communitylevel perceptions of mental health and the effectiveness of care. Interventions should not only consider constructs such as self-efficacy and social networks but also the individual and community levels of readiness to change, which will likely be determined by culturally and individually based coping strategies. Denial is an important coping mechanism to consider in mental health services research, especially for Puerto Ricans, as this study suggests that denial is associated with service use and retention among individuals with severe need for services.
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