Correlates of Perceived Need for and Use ofMental Health Services by Older Adults in
the Collaborative Psychiatric EpidemiologySurveys
Corey S. Mackenzie, Ph.D., Jina Pagura, M.A.,Jitender Sareen, M.D.
Objectives: Older adults are especially unlikely to seek mental health services, butlittle is known about whether their perceptions of need for help contribute to thisproblem. The objectives of this study were to compare perceived need across the lifes-pan and to examine sociodemographic and mental health correlates of whether olderadults sought professional help, perceived the need for help without seeking it, andsought help from specialty mental health professionals. Methods: The authors exam-ined help-seeking and perceived need with the Collaborative Psychiatric Epidemiol-ogy Surveys, focusing on 3,017 adults aged 55 years and older. Logistic regressionspredicted help-seeking and perceived need from sociodemographic factors, past-yearpsychiatric disorders, and past-year suicidal behaviors. Individuals who perceived theneed for help without receiving it also reported barriers to help-seeking. Results: Lev-els of perceived need were highest among 25-44 year olds and lowest among adultsaged 65 years and older. Among older adults with psychiatric disorders, 47.1% didnot perceive a need for professional help. Diagnoses and suicidal behaviors werestrong predictors of whether individuals perceived need, whereas among those whoperceived the need for help, only older age was positively associated with help-seeking.Few factors clearly distinguished those who did and did not seek help from specialtymental health professionals with the exception of having three or more psychiatricdiagnoses. Finally, the most common barrier to help-seeking was a desire to handleproblems on one’s own. Conclusions: A lack of perceived need for mental health ser-vices and self-sufficiency beliefs are significant barriers to older adults’ use of mentalhealth services. (Am J Geriatr Psychiatry 2010; 18:1103–1115)
Key Words: Mental health service utilization, perceived need, help-seeking
T he majority of individuals with diagnosablemental health problems do not seek professional
Received May 22, 2009; revised January 4, 2010; accepted February 18, 2010. From the Departments of Psychology (CSM, JP) and Psychia-try (JS), University of Manitoba, Winnipeg, Manitoba, Canada. Send correspondence and reprint requests to Corey S. Mackenzie, Ph.D., De-partment of Psychology, University of Manitoba, P313 Duff Roblin Building, 190 Dysart Road, Winnipeg, Manitoba, Canada R3T 2N2. e-mail:corey [email protected]
mental health services by older adults is particularlytroubling for three reasons. First, the North Ameri-can population is both growing and aging, so that20%–25% of individuals are expected to be 65 yearsof age or older by the year 2030.5,6 Second, there isgood reason to suspect a greater increase in rates ofmental health problems among older adults, in com-parison with younger individuals, within this sametimeframe.7 Third, psychological and pharmacolog-ical treatments are highly effective in treating men-tal health problems in older individuals.8,9 The pro-jected growth in the number of older adults who willnot access effective treatments when they need themhas lead prominent scholars to declare an emerg-ing crisis in older adults’ mental healthcare7 andto call for additional research aimed at understand-ing and ameliorating age inequities in service use.The goals of this study are to meet this call byinvestigating age differences in perceived need formental health services and exploring correlates ofolder adults’ perceived need for and use of profes-sional help.
Older adults do not seek mental health services fora variety of reasons, only some of which are known.According to Andersen’s10 behavioral model ofhealth services use, there are contextual and individ-ual determinants of help-seeking. Contextual factorsare known to impede older adults’ access to mentalhealth services. For example, older adults are lesslikely to receive advice to seek help from social sup-port members11 and more likely to encounter mentalhealth policies that impede access to care.12 Nonethe-less, if older adults do seek help, they face a lack ofprofessionals with geriatric mental health training13
and, perhaps as a result, primary care physiciansand mental health professionals with ageist atti-tudes, beliefs, and practices.14,15 With respect toindividual-level factors, Andersen’s model suggeststhat help-seeking is determined by predisposingvariables such as age and gender, enabling resourcessuch as social support, and objective and subjectiveindicators of need for help. Research examining theinfluence of predisposing and enabling characteris-tics on older adults’ help-seeking suggests that lowerlevels of service use are associated with older age,16
ethnic minority status,17 and poor mental healthliteracy.18 In contrast, stigma does not seem to be asignificant barrier to older adults’ use of services.19,20
With respect to need, research clearly shows that
objective indicators of psychopathology, includingdiagnosis and suicidal ideation, are the strongestpredictors of mental health service use among olderadults.1,2,16
Although need is clearly a strong driver of men-tal health service use, objective indicators such asdiagnosis offer a restricted view of this importantconstruct. Equating diagnosis with need fails tocapture individuals with significant symptoms whodo not meet diagnostic criteria, many of whom seekmental health services.21 As a result, there is grow-ing appreciation for the importance of expandingdefinitions of need to include perceptions of it.22 Forexample, perceived need has been shown to be a bet-ter predictor of physician visits for health concernsthan self-reported health status23 and in the overalladult population, perceived need for mental healthservices is positively associated with distress andpsychopathology, female gender, younger age, andpoor quality of life.24–26 Research with older adultsindicates that they have lower levels of perceivedneed than younger individuals,2 that perceived needis positively associated with past-year and lifetimegeneralized anxiety disorder and major depressivedisorder diagnoses, more symptoms of depression,and history of chronic physical conditions,27 and thatlimited perceived need may be an important barrierto their use of mental health services.1 This studybuilds on these findings using a large nationally rep-resentative sample of older adults. Our first objectivewas to replicate earlier research demonstrating thatolder adults have lower levels of perceived needthan younger adults.2 Our second objective wasto examine sociodemographic and mental healthcorrelates of need among older adults in two ways:as it has typically been defined in terms of whetherolder adults seek help for mental health services,and using a broader definition of need that includesolder adults who sought help as well as those whoperceived the need for help but did not receiveit. Our third objective was to explore correlates ofwhether older individuals sought help once theyperceived the need for it. Our final objectives were toexplore sociodemographic and mental health factorsassociated with decisions to seek help from mentalhealth specialists versus general healthcare providersand to examine self-reported barriers to help-seekingamong those who perceived a need for help withoutseeking it.
The Collaborative Psychiatric Epidemiologic Sur-veys (CPES)28 comprised three surveys conductedbetween 2001 and 2003: the National ComorbiditySurvey Replication (NCS-R, N = 9,282), the NationalSurvey of American Life (NSAL, N = 6,082), and theNational Latino and Asian American Study (NLAAS,N = 4,649). The three surveys are representative of theU.S. adult population and they empolyed very simi-lar methodologies, including using trained lay inter-viewers to conduct interviews primarily in person.The average response rate of the CPES is 72.7%. De-tails of each survey can be found elsewhere.28,29
The overall CPES sample includes 20,013 respon-dents. Help-seeking and perceived need questionswere examined in subsets of each of the surveys,including Part 2 respondents in the NCS-R (N =5,692), a random 75% of respondents in the NLAAS(N = 3,499), and black respondents of African andCaribbean descent in the NSAL (N = 5,008). There-fore, a total of 14,199 CPES respondents completedassessments of help-seeking and perceived need.
Most of our analyses are restricted to CPES respon-dents older than 54 years of age (N = 4,888). Thesample for this study includes 3,137 individuals aged55 years and older who were in the subsets of eachsurvey that completed assessments of help-seekingand perceived need. This includes Part 2 respondentsin the NCS-R (N = 1,372), a random 75% of respon-dents in the NLAAS (N = 657), and black respondentsof African and Caribbean descent in the NSAL (N =1,108). As was the case in other recent studies,19,30 wefocused on adults aged 55 years and older to com-pare young–old, middle–old, and old–old groups; toincrease our sample size; and because the traditionalcutoff of 65 years is becoming less relevant as individ-uals increasingly retire before that age or work wellpast it.
Measures
Dependent Variables. This study defined help-seeking based on contact with the following health-care providers for mental health concerns in thepast year: psychiatrists, psychologists, social work-ers, medical doctors, nurses, counselors, other health
professionals, spiritual advisers, and healers. Wecategorized psychiatrists, psychologists, and socialworkers as mental health professionals, in line withprevious research.26
Respondents’ perceived need for mental health-care in the past year was assessed with the follow-ing question: “Was there ever a time during the past12 months when you felt that you might need to see aprofessional because of problems with your emotionsor nerves or your use of alcohol or drugs?” Individu-als who endorsed help-seeking in the past year wereassumed to have perceived a need for help. We usedthese perceived need and help-seeking questions tocreate four dependent measures. First, we differenti-ated individuals with help-seeking from any sourcein the past year from individuals who had not soughthelp in the past year. Second, we differentiated indi-viduals who had either perceived a need for care orsought help in the past year from a reference groupwho neither sought help nor perceived a need forhelp in the past year. Third, we differentiated individ-uals who perceived a need for and sought help from areference group who perceived a need for help with-out seeking it. Finally, we differentiated individualswho sought help from mental health professionals inthe past year from a reference group who sought helpfrom other health providers.
Independent Variables. We examined the follow-ing sociodemographic correlates of help-seeking andperceived need: age (55–64, 65–74, and 75+ years),gender, race/ethnicity (non-Hispanic white, Asian,Hispanic, black, and other), education (0–11 years,12 years, 13–15 years, and 16+ years), maritalstatus (married/cohabiting, separated/widowed/divorced, and never married), and annual householdincome (<$12,000, $12,000–$26,999, $27,000–$54,999,and $55,000+).
Trained lay interviewers used the World MentalHealth Composite Diagnostic Interview31 to diag-nose the following psychiatric disorders according toDSM-IV-TR32 criteria: major depression, dysthymia,generalized anxiety disorder, panic disorder, agora-phobia, social phobia, posttraumatic stress disorder,alcohol abuse and dependence, and drug abuse anddependence. From these diagnoses, we generated in-dependent variables reflecting any anxiety disorder,any mood disorder, any substance disorder, any dis-order, and number of psychiatric disorders (0, 1, 2,and 3 +) in the past year.
Suicidal behaviors were assessed with three ques-tions in each survey: “Have you ever seriouslythought about committing suicide?,” “Have you evermade a plan for committing suicide?,” and “Haveyou ever attempted suicide?” Respondents who en-dorsed each question were then asked if that behaviorhad occurred at any time in the past 12 months. As aresult of their low levels of endorsement among olderadults in the CPES, we combined suicidal ideation,plans, and attempts to reflect any suicidal behaviorin the past year.
Barriers to Help-Seeking. Respondents who did notseek help but perceived a need for help for at least1 month in the past year were asked whether theyexperienced a list of barriers to seeking help.
Analytic Strategy
We used the Taylor Series Linearization method33
in SUDAAN34 for variance estimation purposes toaccount for the complex sampling design of thesurveys. Statistical weights and stratification in-formation are provided for analysis of the CPESas a whole and we applied these in all analy-ses to ensure the data were representative of thegeneral population.
We calculated the prevalence of perceived needwithout help-seeking, perceived need with help-seeking, and help-seeking from mental health profes-sionals among individuals with psychiatric disordersusing cross-tabulations. We examined these preva-lence estimates across the adult lifespan with sevenage categories using cross-tabulations and χ2 tests.We then focused on adults aged 55 years and olderand examined sociodemographic characteristics,past-year psychiatric disorders, and past-year suici-dal behaviors in cross-tabulations and logistic regres-sion models with each dependent variable describedabove. We entered each sociodemographic factor,past-year psychiatric disorder variable, and past-yearsuicidal behavior variable in a bivariate unadjustedlogistic regression model with each dependent vari-able. We also examined sociodemographic factors inlogistic regression models adjusted for past-year psy-chiatric disorders and suicidal behaviors. Finally, wecalculated the prevalence of barriers to help-seekingusing cross-tabulations. As a result of the large num-ber of comparisons tested, we adopted a conservativep < 0.01 value to indicate significant associations.
RESULTS
In terms of the weighted demographic makeup ofour sample, 41.1% were 55–64 years of age, 32.4%were 65–74 years, and 26.5% were 75 years and older.The majority of individuals were female (56.8%) andnon-Hispanic white (80.8%). In addition, 9.7% wereblack, 5.3% were Hispanic, 2.6% were Asian, and1.5% reported an “other” race/ethnicity. With respectto education, 26.3% had less than 12 years, 33.2%had 12 years, 21.3% had 13–15 years, and 19.2% had16 years or more. The majority of individuals weremarried or common law (60.7%), whereas 2.8% werenever married, and 36.6% were separated, divorced,or widowed. Finally, 14.9% of individuals had an an-nual household income of less than $12,000, 24.9%made $12,000–$26,999, 27.8% made $27,000–$54,999,and 32.4% made $55,000 or more.
Table 1 demonstrates that 420 (9.5%) older adultsaged 55 years and older had at least 1 anxiety, mood,or substance use disorder in the past year. Overall,41% of these individuals received mental health ser-vices (15.7% saw specialty mental health profession-als and 25% saw other health professionals), and anadditional 12% perceived the need for help with-out receiving it, so that 53% of those with disordersperceived a need for help. In addition, 7% of olderadults without mood, anxiety, or substance disordersperceived a need for professional help, regardless ofwhether they received it or not. Importantly, the typeof disorder and psychiatric comorbidity affected:(a) the percentage of individuals who perceived aneed for help but did not seek it, (b) the percentagewho perceived need and sought it, and (c) the per-centage who sought help from mental health profes-sionals. With respect to type of disorder, individualswith anxiety disorders had the lowest prevalence ofall three outcomes. Conversely, individuals with sub-stance use disorders, although relatively uncommon,had the highest prevalence of perceived need andspecialty mental health service use. Not surprisingly,as the level of disorder comorbidity increased, so didthe likelihood of perceiving the need for help (χ2 =4,83, df = 3, p = 0.003), seeking professional help (χ2 =28.56, df = 3, p < 0.001) and visiting specialty mentalhealth providers (χ2 = 12.78, df = 3, p < 0.001). Amongindividuals with psychiatric disorders, Table 2 indi-cates a hill-shaped curve with respect to the influence
aReported Ns are for the sample, whereas percentages are weighted to be representative of the U.S. population.
of age on perceived need for professional help, withthe highest rates among 25–44 year olds and the low-est rates among those older than 65 years of age.
Correlates of Perceived Need AmongOlder Adults
We began by exploring correlates of whether olderadults used mental health services, which is a narrowdefinition of perceived need. With respect to demo-graphic differences between these groups, reported inTable 3, a greater likelihood of seeking professionalhelp was associated with younger age, female gen-der, being previously married, and having an annualhousehold income of less than $12,000. However, af-ter adjusting for psychopathology, the only associa-
tion that remained significant was household income.In contrast, the type of disorder, number of disor-ders, and presence of suicidal behaviors had muchstronger effects on help-seeking, with odds ratiosranging from 8.5 to 25.3.
Our next analysis, reported in Table 4, examinedcorrelates of an expanded definition of perceivedneed, in terms of whether individuals either soughthelp or needed help but did not receive it. Once again,being younger, female, previously married, and hav-ing an annual household income of less than $12,000had a positive effect on perceived need, and all de-mographic effects except for income disappeared af-ter adjusting for psychopathology. Past-year disor-ders and suicidal behavior had an even strongereffect on whether individuals perceived a need for
aAORs are for adjusted for any past-year anxiety, mood, or substance disorder and for any past-year suicidal behavior.bWald t tests (and associated p) with df = 180 for the unadjusted ORs.cp ≥ 0.01.dp ≥ 0.001.
aAORs are for adjusted for any past-year anxiety, mood, or substance disorder and for any past-year suicidal behavior.bWald t tests (and associated p) with df = 180 for the unadjusted ORs.cp ≤ 0.01.dp ≤ 0.001.
help using this broad definition, with odds ratiosranging from 8.0 to 47.9.
Correlates of Help-Seeking Among Older AdultsWith Perceived Need
We also examined correlates of whether olderadults sought help once they perceived the need forit. We used logistic regression to compare 323 olderadults with perceived need who sought professionalhelp to 74 with perceived need who did not seekhelp. The only demographic or mental health vari-able that significantly differentiated these groups wasage. Older adults were more likely to seek help oncethey perceived the need for it; the odds ratio of seek-ing help was 8.24 (adjusted for psychopathology; 95%CI: 2.79–24.29, p < 0.001) for adults 75 years and olderin comparison with 55–64 year olds (Wald t[180] = 7.40,p < 0.001).
Our final analysis examined correlates of whethermental health services were sought from mentalhealth professionals versus other care providers. Asreported in Table 5, younger age was the only de-mographic factor positively associated with specialtymental health service use in our unadjusted modeland that finding was no longer significant after ad-justing for psychopathology. With respect to psychi-atric effects, neither suicidal behavior nor the pres-ence of a mood, anxiety, or substance disorder wasa significant predictor of where older adults soughthelp. Psychiatric comorbidity increased the odds ofspecialty mental healthcare, but only for those withthree or more disorders.
Barriers to Seeking Help Among Older AdultsWith Perceived Need
Table 6 provides the frequencies with which olderadults who perceived the need for help without re-ceiving it reported barriers to help-seeking. The mostfrequent attitudinal barrier, reported by 69% of re-spondents, was a desire to handle problems on theirown. The most commonly reported structural barri-ers had to do with financial concerns and knowledgeabout appropriate providers, which were endorsedby ∼45% of respondents. Concerns related to stigma,dissatisfaction with previous treatment, the availabil-ity of services, and problems with access were en-dorsed by fewer than 25% of respondents.
DISCUSSION
This study examined perceived need for mentalhealth services using a large, representative sampleof Americans aged 55 years and older. Fortunately,most of the individuals in this study who perceivedthe need for help sought it; that is, 53% of olderadults with past-year mood, anxiety, or substance-related disorders perceived the need for professionalhelp and 41% sought it. On the other hand, thesedata also demonstrate that approximately half of theolder individuals with a clear objective indicator ofneed for professional help (i.e., a psychiatric diagno-sis) did not perceive it. Perception of need is, there-fore, a very significant barrier to older adults’ use ofmental health services. Furthermore, similar to Klapet al.,2 we found that among individuals with psy-chiatric disorders, older adults were much less likelyto perceive the need for mental health services thanmiddle-aged or younger individuals.
Why did so many older adults with clinically sig-nificant mental health problems report that they didnot feel the need to see a professional? The CPES pro-vides some insight into this question by providinga list of potential barriers to respondents with per-ceived need who did not seek professional help inthe past year. By far, the most common reason fornot seeking help following perceptions of need wasthat respondents wished to handle the problem them-selves. A sizable percentage of individuals appearedable to do so, given that 37% reported that their prob-lem did not require help or went away on its own and27% reported that their problem did not bother themvery much. In addition to this attitudinal barrier, asignificant number of participants endorsed financialconcerns and knowledge of where to go and whoto see as structural barriers to seeking help. Theseresults are consistent with findings from the Cana-dian Community Health Survey, which also foundthat knowledge and self-reliance beliefs were particu-larly strong barriers to professional help among olderadults.35 At the same time, it is important to notethat these barriers are not unique to older adults, asthese same attitudinal and structural barriers werethe most commonly endorsed by younger adults inother epidemiologic surveys.36 Additional research isrequired to examine age differences in barriers to per-ceiving the need for help and to receiving help once
Notes: AORs are for adjusted for any past-year anxiety, mood, or substance disorder and any past-year suicidal behavior.aAORs are for adjusted for any past-year anxiety, mood, or substance disorder and any past-year suicidal behavior.bWald t tests (and associated p-values) with df = 180 for the unadjusted ORs.cCell sizes <5 are not reported or analyzed.dp ≤ 0.01.ep ≤ 0.001.
TABLE 6. Barriers to Help-Seeking Among Older Adults WithPerceived Need Who Did Not Seek Help in thePast Year
No. (%)No. Respondents RespondentsWho Were Asked Who Endorsed
Barriers to Help-Seeking the Question Each Barrier
Attitudinal barriers1. I wanted to handle the 36 23 (69.2)
problem on my own2. I thought the problem 36 15 (41.3)
would get better byitself
3. I did not think treatment 36 13 (38.9)would work
4. The problem went away 58 21 (36.7)by itself, and I did notreally need help
5. The problem didn’t 36 10 (26.6)bother me very much
6. I was concerned about 36 9 (23.9)what others might thinkif they found out I wasin treatment
7. I received this treatment 36 9 (23.8)before and it did notwork
8. I was not satisfied with 36 5 (9.7)available services
9. I was scared about being 36 4 (6.4)put into a hospitalagainst my will
Structural barriers1. I was unsure about 36 17 (44.8)
where to go or who tosee
2. I was concerned about 36 19 (44.2)how much money itwould cost
3. I thought it would take 36 11 (33.3)too much time or beinconvenient
4. Insurance would not 58 19 (28.2)cover this type oftreatment
5. I had problems with 36 8 (22.6)things liketransportation, childcare,or scheduling that wouldhave made it hard to getto treatment
6. I could not get an 36 2 (1.4)appointment
Notes: Respondents who answered affirmatively to the italicizedbarriers were not asked about the remaining barriers.
the need is perceived, perhaps using a combinationof qualitative and quantitative methods,37 rather thanassuming what the potential barriers are in advance.
In terms of correlates of perceived need, diagno-sis and suicidal behavior were the strongest predic-
tors. This was true when we defined need accordingto whether older adults sought help and was espe-cially true when we defined it more broadly to in-clude both help-seeking and the need for help with-out seeking it. It is interesting to note that in termsof diagnosis, help-seeking is typically most likelyfor mood disorders, less likely for anxiety disorders,and even less likely for substance disorders.2,38,39 Inthis study, however, substance disorders were es-pecially likely to result in perceived need for pro-fessional help, regardless of whether it was soughtor not. Hence, although substance disorders werequite rare among older adults in this study, whenthey existed, they were very likely to be perceivedas requiring professional help. In comparison withthe very strong influence of objective need indica-tors on perceptions of need, sociodemographic fac-tors had a more modest influence. Using both nar-row and broad definitions, perceived need for mentalhealth services was more likely among the young–old, women, those who were previously married,and those with annual household incomes less than$12,000. With respect to income, it may be that help-seeking and perceived need are highest among espe-cially poor individuals because they are most likely tobe eligible for Medicaid and to suffer from poverty-related mental health concerns. The fact that incomeremained a significant predictor of need after adjust-ing for psychopa-thology suggests that individualswith very low incomes experience a host of personal,interpersonal, financial, and environmental stressorseven in the absence of threshold psychopathology.40
The odds ratios for sociodemographic variableswere, however, much smaller than for the men-tal health need variables, which mirrors previousresearch.1,16
As was the case in the study by Mojtabai et al.,26
for individuals who perceived the need for profes-sional help, psychopathology had very little impacton whether they sought help. In our study, the onlyfactor that increased the likelihood of help-seekingamong individuals who perceived the need for helpwas older age. Very few adults aged 75 years andolder who perceived the need for help did not seekit. This finding suggests that perceptions of need forhelp and help-seeking are closely linked among theoldest old and that we need to understand why thisrelationship is more likely to break down amongyounger individuals.
Sixteen percent of older adults who sought men-tal health services did so from mental health profes-sionals. This finding is consistent with previous re-search, suggesting that older adults in particular havea preference for meeting their mental health needswithin the general medical sector of the healthcaresystem.3,4,41 The only sociodemographic character-istic that positively affected specialty mental healthservice use was younger age. In terms of the influ-ence of psychopathology on whether older adultssought help from mental health professionals, wewere somewhat surprised that neither psychiatric di-agnosis nor suicidal behavior increased the likeli-hood of specialty mental health service use and thatonly having significant comorbidity (3+ disorders)increased the odds of seeing a mental health pro-fessional. On the one hand, although it was a rareoccurrence, it is reassuring that older adults withhighly comorbid, and therefore complicated clini-cal presentations, were more likely to receive spe-cialty mental health treatment. On the other hand,it is quite likely that some proportion of the 84%of older adults who sought mental health servicesfrom other health professionals could have benefitedfrom mental health expertise, especially consider-ing that psychological or psychiatric treatment maybe less effective when provided by nonpsychiatristphysicians.42,43
The findings from this study must be interpretedin light of several limitations. First, the CPES exam-ined perceived need with a single question, whichis necessarily less reliable, valid, and comprehensivethan psychometrically sound instruments such asthe Perceived Need for Care Questionnaire44 that as-sesses need for information, medication, psychother-apy, social intervention, and skills training. Second,we would have liked to examine the influence ofinsurance on perceived need for mental health ser-vices. However, one of the three CPES surveys (theNSAL) did not assess Medicare separately and, in-stead, included it with other forms of governmentinsurance such as Medicaid and military health in-surance. We felt that a general government insurance
category was inappropriate and potentially mislead-ing for an older adult sample and, therefore, excludedinsurance from our analyses. Third, caution is neededin generalizing our findings to institutionalized olderadults because they were not sampled in the CPES.Fourth, caution is also required when interpretinganalyses with small subgroups, such as older adultswith substance disorders. Finally, the CPES does notallow for an examination of factors such as help-seeking attitudes that have previously been shown toinfluence perceptions of need for help.26
Despite these limitations, this study provides com-pelling evidence that many older adults with seri-ous mental health problems do not seek professionalhelp because they fail to perceive the need for it. Per-ceived need in this study was more likely amongyounger, previously married, female, and poor de-mographic groups. It was also more likely amongolder adults with psychiatric diagnoses and suici-dal behavior. One possible implication of these find-ings is that by understanding why certain groups ofolder adults often fail to perceive the need for help,we can greatly enhance their use of effective mentalhealth services. Another possible implication, how-ever, is that some proportion of older adults withmental health concerns do not perceive the need forhelp because they do not require it, perhaps becausetheir symptoms are mild or transient,45 because ofresilience or effective coping,46 or because of a highthreshold for when professional help is necessary. Re-gardless, these data highlight the need for additionalresearch exploring the nature and consequences ofperceived need for professional mental health ser-vices among older adults.
This work was supported by the University of Mani-toba University Research grants Program (to CSM), bya Canadian Institutes of Health Research New Investiga-tor Award 152348 (to JS), and by a graduate fellowshipfrom the Social Sciences and Humanities Research Councilof Canada (SSHRC) (to JP). The Collaborative PsychiatricEpidemiologic Surveys (CPES) are funded by the NationalInstitute of Mental Health (NIMH).
References
1. Karlin BE, Duffy M, Gleaves DH: Patterns and predictors of mentalhealth service use and mental illness among older and youngeradults in the United States. Psychol Serv 2008; 5:275–294
2. Klap R, Unroe KT, Unutzer J: Caring for mental illness in theUnited States: a focus on older adults. Am J Geriatr Psychiatry2003; 11:517–524
3. Bartels SJ: Improving system of care for older adults with mentalillness in the United States. Findings and recommendations forthe President’s New Freedom Commission on Mental Health. AmJ Geriatr Psychiatry 2003; 11:486–497
4. Bogner HR, de Vries HF, Maulik PK, et al: Mental health servicesuse: Baltimore Epidemiologic Catchment Area Follow-up. Am JGeriatr Psychiatry 2009; 17:706–715
5. Belanger A, Martel L, Caron-Malenfant E: Population Projectionsfor Canada, Provinces and Territories, 2005–2031. Catalogue 91–520. Ottawa, Canada, Statistics Canada, 2005
6. Day JC: Population Projections of the United States by Age, Sex,Race, and Hispanic Origin: 1995 to 2050. Washington, DC, USGovernment Printing Office, 1996
7. Jeste DV, Alexopoulos GS, Bartels SJ, et al: Consensus state-ment on the upcoming crisis in geriatric mental health: researchagenda for the next 2 decades. Arch Gen Psychiatry 1999; 56:848–853
8. Bartels SJ, Dums AR, Oxman TE, et al: Evidence-based prac-tices in geriatric mental health care: an overview of system-atic reviews and meta-analyses. Psychiatr Clin North Am 2003;26:971–990
9. Gatz M: Commentary on evidence-based psychological treat-ments for older adults. Psychol Aging 2007; 22:52–55
10. Andersen RM: National health surveys and the behavioralmodel of health services use. Med Care 2008; 46:647–653
11. Mackenzie CS, Knox VJ, Smoley J, et al: Influence of age andgender on advice given to depressed people. J Ment Health Aging2004; 10:311–323
12. Karlin BE, Duffy M: Geriatric mental health policy: impact onservice delivery and directions for effecting change. Prof PsycholRes Pract 2004; 35:509–519
13. Palinkas LA, Criado V, Fuentes D, et al: Unmet needs for ser-vices for older adults with mental illness: comparison of views ofdifferent stakeholder groups. Am J Geriatr Psychiatry 2007; 15:530–540
14. Teasdale AC, Hill CE: Preferences of therapists-in-training forclient characteristics. Psychother Theor Res Pract Train 2006;43:111–116
15. Callahan CM: Quality improvement research on late life depres-sion in primary care. Med Care 2001; 39:772–784
16. Crabb R, Hunsley J: Utilization of mental health care servicesamong older adults with depression. J Clin Psychol 2006; 62:299–312
17. Ayalon L, Arean PA, Linkins K, et al: Integration of mental healthservices into primary care overcomes ethnic disparities in accessto mental health services between black and white elderly. Am JGeriatr Psychiatry 2007; 15:906–912
18. Farrer L, Leach L, Friffiths KM, et al: Age differences in mentalhealth literacy. BMC Public Health 2008; 8:125
19. Mackenzie CS, Scott T, Mather M, et al: A comparison of olderand younger adults’ help-seeking attitudes and treatment beliefsconcerning mental health problems. Am J Geriatr Psychiatry 2008;16:1010–1019
20. Pepin R, Segal DL, Coolidge FL: Intrinsic and extrinsicbarriers to mental health care among community-dwellingyounger and older adults. Aging Ment Health 2009; 13:769–777
21. Druss BG, Wang PS, Sampson NA, et al: Understanding mentalhealth treatment in persons without mental diagnoses: resultsfrom the National Comorbidity Survey Replication. Arch Gen Psy-chiatry 2007; 64:1196–1203
22. Aoun S, Pennebaker D, Wood C: Assessing population need formental health care: a review of approaches and predictors. MentHealth Serv Res 2004; 6:33–46
23. Fernandez-Olano C, Hidalgo JD, Cerda-Diaz R, et al: Factors asso-ciated with health care utilization by the elderly in a public healthcare system. Health Policy 2006; 75:131–139
24. Meadows G, Burgess P, Bobevski I, et al: Perceived need for men-tal health care: influences of diagnosis, demography and disability.Psychol Med 2002; 32:299–309
25. Sareen J, Cox BJ, Afifi TO, et al: Perceived need for mental healthtreatment in a nationally representative Canadian sample. Can JPsychiatry 2005; 50:643–651
26. Mojtabai R, Olfson M, Mechanic D: Perceived need and help-seeking in adults with mood, anxiety, or substance use disorders.Arch Gen Psychiatry 2002; 59:77–84
27. Garrido MM, Kane RL, Kaas M, et al: Perceived need for mentalhealth care among community-dwelling older adults. J GerontolB Psychol Sci Soc Sci 2009; 64B:704–712
28. Pennell BE, Bowers A, Carr D, et al: The development and im-plementation of the National Comorbidity Survey Replication,the National Survey of American Life, and the National Latinoand Asian American Survey. Int J Methods Psychiatr Res 2004;13:241–269
29. Heeringa SJ, Wagner M, Torres NH, et al: Sample designs andsampling methods for the Collaborative Psychiatric Epidemi-ology Studies (CPES). Int J Methods Psychiatr Res 2004; 13:221–240
30. Cairney J, McCabe L, Veldhuizen S, et al: Epidemiology of so-cial phobia in later life. Am J Geriatr Psychiatry 2007; 15:224–233
31. Kessler RC, Ustun TB: The World Mental Health (WMH) Sur-vey Initiative Version of the World Health Organization (WorldHealth Organization) Composite International Diagnostic Inter-view (CIDI). Int J Methods Psychiatr Res 2004; 13:93–121
32. American Psychiatric Association: Diagnostic and Statistical Man-ual of Mental Disorders: DSM–IV. 4th ed. Washington, DC, Amer-ican Psychiatric Association, 1994
33. Levy PS, Lemeshow S: Sampling of Populations. New York, JohnWiley & Sons, 1999
34. Shah BV, Barnswell BG, Bieler GS: SUDAAN User’s Manual: Re-lease 9.0, Research Triangle Park, NC, Research Triangle Institute,2004
35. Wetherell JL, Kaplan RM, Kallenberg G, et al: Mental health treat-ment preferences of older and younger primary care patients. IntJ Psychiatry Med 2004; 34:219–233
36. Sareen J, Jagdeo A, Cox BJ, et al: Perceived barriers to mentalhealth service utilization in the United States, Ontario, and theNetherlands. Psychiatr Serv 2007; 58:357–364
37. Creswell JW: Research Design: Qualitative, Quantitative, andMixed Methods Approaches. 3rd ed. Thousand Oaks, CA, Sage,2009
38. Alonso J, Angermeyer MC, Bernert S, et al: Use of mental healthservices in Europe: results from the European Study of the Epi-demiology of Mental Disorders (ESEMeD) project. Acta PsychiatrScand Suppl 2004: 47–54
39. Wang PS, Lane M, Olfson M, et al: Twelve-month use of mentalhealth services in the United States: results from the NationalComorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:629–640
40. Weich S, Lewis G: Material standard of living, social class, andthe prevalence of the common mental disorders in Great Britain.J Epidemiol Community Health 1998; 52:8–14
41. Mackenzie CS, Gekoski WL, Knox VJ: Age, gender, and the under-utilization of mental health services: the influence of help-seekingattitudes. Aging Ment Health 2006; 10:574–582
42. Howard KI, Cornille TA, Lyons JS, et al: Patterns of mental healthservice utilization. Arch Gen Psychiatry 1996; 53:696–703
43. Wang PS, Berglund P, Kessler RC: Recent care of common mentaldisorders in the United States: prevalence and conformance withevidence-based recommendations. J Gen Intern Med 2000; 15:284–292
44. Meadows G, Burgess P, Fossey E, et al: Perceived need for mentalhealth care, findings from the Australian National Survey of MentalHealth and Well-being. Psychol Med 2000; 30:645–656
45. Spitzer RL: Diagnosis and need for treatment are not the same.Arch Gen Psychiatry 1998; 55:120
46. Reichstadt J, Depp CA, Palinkas LA, et al: Building blocks ofsuccessful aging: a focus group study of older adults’ perceivedcontributors to successful aging. Am J Geriatr Psychiatry 2007;15:194–201
