Treating and Preventing Adolescent Mental Health Disorders: Treating and Preventing Adolescent Mental Health Disorders

Book Title: Treating and Preventing Adolescent Mental Health Disorders > pp. [535]-[539]

UNDEFINED: AUTHORS

Treating and Preventing Adolescent Mental Health Disorders

Print ISBN 9780195173642, 2005
pp. [535]-[539]

young adults (ages 16–24) who were HIV positive. In a series of studies, Sirey and colleagues found that perceived stigmatization predicted medication adherence and treatment continuation (in older adults only) among individuals with depression. These findings indicate that stigma may impact the course of the illness by interfering with commitment to treatment.

Reluctance to seek psychological or psychiatric treatment is especially relevant to adolescents, because numerous disorders, such as major depression, bipolar disorder, anxiety disorders, anorexia and bulimia, and schizophrenia begin in late adolescence or early adulthood. Such delays in seeking treatment have important prognostic implications for individuals in this age group. Post, Leverich, Xing, and Weiss (2001) found that individuals with a greater number of affective episodes prior to receiving pharmacotherapy had a less favorable prognosis than individuals who began medications after fewer episodes. In schizophrenia, it has been hypothesized that the duration of untreated psychotic episodes prior to illness onset is associated with poorer long-term prognosis (Lieberman et al., 2001; Norman & Malla, 2001). Thus, the role of stigma in delaying treatment may contribute to greater severity of illness among adolescents with a newly diagnosed disorder.

SURVEY EVIDENCE FOR THE ROLE OF STIGMA ON HELP SEEKING

To determine the role of unfavorable stereotypes on help seeking behavior, we examined the extent to which youth who had experienced symptoms of depression or suicidal ideation in the past 12 months had failed to seek help from a variety of sources as a function of negative beliefs about mental health treatment. A revised version of the NARSY conducted a year after the first survey (2003) included questions to examine this question. In this survey, we again identified a large number of respondents (N = 211; 23.4%) who had experienced symptoms of depression or suicidal ideation. Hence, we focused on the stigma associated with this disorder.

We also assessed perceptions of the effectiveness of treatment. We did so under the hypoth esis that the stigma associated with mental illness should be reduced if the disorder has been successfully treated (see discussion of interventions below). If stigma continues to be attached to those who have been successfully treated, then persons with symptoms could be inhibited from seeking help. Hence, perceived treatment effectiveness could be an important moderator of stigma's effects on help seeking.

To determine the effects of potential treatment, we asked respondents the following question: “If you had major depression, do you think you could get the help you need from any of the following:” (a) “a doctor,” (b) “your friends,” (c) “your parents,” (d) “a counselor,” (e) “an Internet site,” and (f) “a telephone helpline.”

Actual help-seeking behavior on the part of respondents who had experienced depressed symptoms or suicidal ideation was assessed by asking, “Have you ever done any of the following to try to get help?” Responses were grouped into four categories based on a factor analysis that indicated that help seeking tended to occur in the following ways:

•	Gone to a doctor or nurse; or, taken medication prescribed by a doctor;
•	Gone to a counselor;
•	Talked to a friend; or talked to a parent, and
•	Gone to an Internet site; or used a telephone helpline.

Respondents were scored as having tried any category if they had sought help from any of the sources within the category. In addition, treatment effectiveness scores were created for each category on the basis of ratings of each source.

Perceptions of treatment effectiveness (Table 27.2) indicated that seeing a doctor was viewed as most effective, whereas going to an Internet site or using a telephone helpline were viewed as the least effective. Although the differences are small in magnitude, seeing a doctor was viewed as significantly more effective in the entire sample than seeing a counselor, t(814) = 3.02, p < .01, or talking to a parent, t(814) = 2.53, p < .02. Other differences that are larger in magnitude are even more statistically discernable.

With the exception of seeking help from parents, the rank order of perceived effectiveness of

end p.535

PRINTED FROM Treating and Preventing Adolescent Mental Health Disorders (www.oup.com/amhi-treatingpreventing)
© Copyright Oxford University Press, 2006. All Rights Reserved

Table 27.2 Perceptions of Efficacy of Sources of Help for Depression by Those With or Those Without Symptoms Associated With Depression

	Respondents Who Reported
Help Source	Symptoms of Depression or Suicidality (N = 180) (%)	No Symptoms of Depression or Suicidality (N = 635) (%)	Total (N=815) (%)
Doctor	77.7	90.6	87.8
Counselor	74.6	86.1	83.5
Friend	73.6	79.6	78.3
Parent	71.0	87.6	83.9
Telephone helpline	34.7	47.2	44.5
Internet site	25.2	28.0	27.4

Data include only those who were aware of major depression and were weighted to match national demographics; unweighted Ns were 191 for depressed group and 619 for others (total = 810).

the help sources was comparable between those with and without symptoms of depression. Nevertheless, there were differences between the groups. With the exception of one help source (the Internet), persons with symptoms were less likely to perceive any of the help sources as effective. Therefore, perceived treatment ineffectiveness is a source of concern in itself for youth with symptoms of mental disorder (Shaffer et al., 1990).

Analysis of Help Seeking

To determine the role of stigma on help seeking, we conducted regression analyses of the relation between stereotypes of depression and reported help seeking for respondents with symptoms of major depression or suicidality. Stereotypes were defined as the average of three beliefs associated with mental disorder in the first NARSY: violence, suicidality, and good performance in school (reversed scored). The scale ranged from (1) less likely than the average person to have the undesirable trait to (3) more likely than the average person to have the trait. We used probit regression because it is appropriate for dichoto mous outcomes and because it also provides an estimate of the percentage change in the probability of the outcome given a unit change in the predictor for an average respondent, e.g., as the change in probability of seeing a counselor vs. not seeing one for a unit change in stereotypes (Agresti, 1990; Greene, 1993).

Table 27.3 has the descriptive statistics of the variables used in the analysis. The four dichotomous outcome variables indicate that talking to parents or friends is the most common help sought (88.6%), followed by seeing a doctor or taking medication (45.4%), getting counseling (40.7%), and going to the Internet or using a telephone helpline (16.1%). The expected help results show a somewhat similar ordering; most respondents with symptoms of major depression expect help from physicians, followed by counselors, parents and friends, and lastly from the Internet and helplines.

Table 27.4 summarizes the regression results for each of the four outcomes holding constant demographic variables (not shown). Except in two cases (counseling and seeing a physician/taking medications), there were no effects of any demographic characteristic on help seeking for these young respondents. Stereotypes of depression were negatively related to help seeking in three out of the four cases (the small positive effect is for seeing a doctor or nurse or taking medication). The effect of stereotypes on counseling was about −12%, and the effect of stereotypes on talking to parents or friends was about −6%, but these effects were not reliably different from zero. The strongest observed effect was for the impact of stereotypes on using the Internet or calling a helpline, which was almost −14%. Note that in two cases (counselors and Internet/helplines), expected efficacy of the treatment modality and help seeking were positively and significantly related, indicating that young people are more likely to seek help from sources that are seen as effective.

The results of this survey suggest that young people need not attach stigma to help seeking when the source of help is seen as particularly effective, as in the case of seeing a doctor or nurse or taking medication. For the other less effective sources of help, by contrast, stereotypes tended to be negatively related to help seeking

end p.536

PRINTED FROM Treating and Preventing Adolescent Mental Health Disorders (www.oup.com/amhi-treatingpreventing)
© Copyright Oxford University Press, 2006. All Rights Reserved

Table 27.3 Descriptive Statistics for Help Seeking–Dependent Variables Predicted by Stigma, Expectations of Positive Help by Source, and Demographic Data

Variable	N	Mean	Standard Deviation
Help seeking: doctor/nurse/meds (%)	191	.454	.499
Help seeking: counselor (%)	191	.407	.492
Help seeking: parents/friends (%)	191	.886	.318
Help seeking: Internet/helplines (%)	191	.161	.368
Stereotype scale	190	2.53	.471
Expected help from physician (%)	191	.785	.411
Expected help from parents/friends	185	.748	.35
Expected help from counselor (%)	191	.769	.422
Expected help from Internet/helplines	191	.291	.383
Age (years)	191	17.672	2.38
Male (%)	191	.383	.487
Education (1 to 5 years)	190	4.8	2.745
African American (%)	191	.199	.4
Asian (%)	191	.028	.166
Other ethnicity (%)	191	.113	.318

Doctor/nurse/meds: seeing a physician or nurse or taking medications. Counselor: seeing a counselor. Parents/friend: talking to parents or friends. Internet/help: going to an Internet Web site or calling a helpline. Stereotype: mean stereotype score on 1 to 3 scale. Expected Help: expected help from specified sources. When expected help sources were multiple, the average of the two scores was used.

and most reliably so for the least effective sources, the Internet and telephone helplines. The findings are also consistent with recently reported results from a large (N = 1,387) national survey conducted with adults in the United Kingdom, which found that the most common reason that individuals with “neurotic disorders” did not seek treatment was that they didn't think anyone could help them (reported by 22% of the sample; Meltzer et al., 2003).

Increasing the perceived effectiveness of appropriate treatment may be an important strategy for reducing the effects of unfavorable stereotypes associated with mental disorder and for increasing help seeking in general. It is noteworthy that our sample of youth with symptoms of depression reported poorer perceptions of treatment effectiveness for all but one of the sources of help compared to youth without those symptoms (Table 27.2). Hence increasing the perceived effectiveness of appropriate treatment among this vulnerable youth segment could be a strategy to increase their help seeking.

FACTORS THAT CONTRIBUTE TO STIGMA

Given the role of stigma on help-seeking behavior in youth, it is critical to identify the factors that contribute to stigma. In this section, we summarize the research on factors that contribute to stigma in both the general population and among youth. A comprehensive review of this literature is beyond the scope of this chapter, so a brief summary is provided. In general, factors contributing to stigma include (a) labels; (b) symptoms and/or anomalous behaviors associated with labels and mental illness; (c) attributions about mental illness; (d) misinformation about mental illness and negative images promulgated by the mass media; and (e) lack of contact with persons who have been successfully treated for mental illness.

According to the modified labeling theory, labels are one of a number of factors that contribute to stigma, perhaps via their association with specific behaviors, media accounts, or experiences (Link & Phelan, 1999; Phelan & Link,

end p.537

PRINTED FROM Treating and Preventing Adolescent Mental Health Disorders (www.oup.com/amhi-treatingpreventing)
© Copyright Oxford University Press, 2006. All Rights Reserved

Table 27.4 Results of Probit Regressions Predicting Four Help-Seeking Outcomes ^a

	Δ in Prob^b	Z ^c	P\|z\|	95% Confidence Interval for Prob. Δ
1.Doctor/Nurse/Medication
(Pseudo R-squared = .042, N = 189)
Stereotype	.055	0.69	0.49	−.101	.211
Expected help	.119	1.25	0.211	−.067	.306
2.Counselor
(Pseudo R-squared = .115, N = 189)
Stereotype	−.116	−1.43	0.153	−.274	.043
Expected help	.374	3.76		.18	.567
3.Parents/Friends
(Pseudo R-squared = .097, N = 183)
Stereotype	−.059	−1.28	0.201	−.149	.03
Expected help	.087	1.61	0.108	−.019	.193
4. Internet/Helplines
(Pseudo R-squared = .212, N = 179)
Stereotype	−.135	−2.63	0.009	−.238	−.032
Expected help	.278	4.49		.141	.401

^a All coefficients are adjusted for gender, ethnicity, age, and education.

^b Δ in Prob is the change in the probability of the outcome given a one-unit change in the predictor.

^c Z = ratio of probit coefficient to its standard error.

Significance tests refer to probit estimates, not change in probability values (Δ) for an average respondent. For outcomes (1) and (2) there is a significant negative effect of the “other” ethnicity category. For all other outcomes and all other demographic variables, there are no discernable effects.

1999). This is especially true for pejorative labels, such as “schizo,” “psycho,” “wacko,” and so on, which may be linked with violent and erratic behavior. Therefore, labels may be stigmatizing in their own right.

Labels clearly do not exist in a vacuum, but derive meaning from their relationship with characteristics of the disorder, both real (e.g., hearing voices) and exaggerated (e.g., being a homicidal maniac). Thus, the behaviors associated with mental illness may be stigmatizing in their own right. Evidence in support of this hypothesis is garnered from studies showing that the social behaviors of individuals with depression can elicit negative reactions from others (reviewed in Segrin, 2000), and that the social skill deficits present in schizophrenia (Mueser & Bellack, 1998) may increase stigma, even beyond the contribution of symptoms (Penn, Kohlmaier, & Corrigan, 2000).

Research on the role of attributions on stigma has its roots in the work of Weiner and colleagues (Weiner, 1993; Weiner, Perry, & Magnusson, 1988) and asserts that our explanations for mental and physical illness (i.e., in terms of controllability and responsibility) will affect our attitudes toward these disorders. Tests of this model applied to severe mental illnesses, such as schizophrenia, indicate that when such conditions are seen as under the person's control and something for which she or he is responsible, the tendency to blame and stigmatize that individual increases (Corrigan, 2000). Interestingly, ascribing causality to biological factors (e.g., genetics) leads to lower responsibility attributions, but in addition, to beliefs that the problem cannot be changed and that family members may have similar problems (i.e., a courtesy stigma; Phelan, Cruz-Rojas, & Reiff, in press).

Perhaps the most consistent predictors of

end p.538

stigma are misinformation about mental illness. This is not surprising in view of the large role of the mass media in providing information about mental illness. In fact, the media are the most frequent source of information about mental illness for people in this country (Wahl, 1995). This suggests that the media have an important role in shaping public perception of mental illness.

Interestingly, there has been scant research directly linking media images of mental illness to stigma. There is evidence that greater exposure to the media, particularly television viewing, is associated with greater intolerance toward persons with mental illness (Granello & Pauley, 2000). However, there is convincing evidence that the media depict persons with SMI in a negative rather than positive light. Persons with SMI are disproportionately portrayed in films, television, and newspapers as violent, erratic, and dangerous (Angermeyer & Schulze, 2001; Diefenbach, 1997; Granello, Pauley, & Carmichael, 1999; Hyler, Gabbard, & Schneider, 1991; Monahan, 1992; Nairn, Coverdale, & Claasen, 2001; Signorielli, 2001; Wahl, 1995; Wahl & Roth, 1982; Williams & Taylor, 1995). As noted by Wahl (2002), media depictions of the violence committed by persons with a SMI are more graphic and disturbing than that depicted in persons without a SMI.

In an analysis of 31 major U.S. newspapers over a period of 2 months during the year 2000, APPC found that 64.7% of the stories about persons with schizophrenia had an association with violence. While associations with violence in stories about persons with bipolar disorder (29.1%) and depression (15.2%) were lower, these rates still exaggerate the incidence of violence in persons with SMI (Silver, 2001). These negative and inaccurate depictions of persons with SMI are not limited to adult media, but are unfortunately present in children's media as well (Wahl, 2002; 2003; Wahl, Wood, Zaveri, Drapalski, & Mann, 2003; Wilson, Nairn, Coverdale, & Panapa, 2000).

The role of the mass media is potentially increased because of the relative lack of direct contact with individuals who have been successfully treated for mental illness. Although there are exceptions, the research generally supports a re- lationship between greater retrospective self-reported contact with persons with mental illness and less stigmatizing attitudes (Couture & Penn, 2003). Although retrospective reports have inherent flaws, such as being influenced by memory biases, the consistency of the findings is compelling.

Most of the research on stigma has been conducted with adult and community samples. However, findings from one of our own laboratories reveal that labels, previous contact, and anomalous behaviors also influence the attitudes of older adolescents (i.e., college-age samples) toward persons with mental illness. For example, labels that varied in “political correctness” (e.g., “schizophrenic” vs. “consumer of mental health services”) exerted similar effects on the attitudes of undergraduates and a community adult sample (Penn & Drummond, 2001). Regarding contact effects, most of our studies (Penn & Corrigan, 2002; Penn et al., 1994; Penn, Kommana, Mansfield, & Link, 1999), as well as those in other laboratories (reviewed in Couture & Penn, 2003), replicate the findings with adults that greater self-reported contact is associated with lower stigma. Therefore, it appears that the factors that contribute to stigma development in adulthood are also important in adolescence.

Our review of the factors that influence stigma of mental illness suggests that one approach with potential for influencing the attitudes of adolescents toward mental illness is the use of mass media. Adolescents are heavy consumers of mass media. It has been estimated that approximately 2 3 of individuals between the ages of 8 and 18 have a television in their bedroom (Roberts, Henriksen, & Foehr, in press; Woodard & Gridina, 2000). Television viewing averages approximately 31 2 hours daily in 11-to 14-year-olds (Roberts, Henriksen, & Foehr, in press), which decreases to 21 2 hours daily by late adolescence (15–18; Brown & Witherspoon, 2001; Roberts, Henriksen, & Foehr, in press). However, these numbers may underestimate media exposure, as adolescents also devote a great deal of time (and money) to movies, video rentals, and the Internet (Brown & Witherspoon, 2001; Roberts & Foehr, in press).

The attitudes and behaviors of adolescents are influenced by exposure to the mass media. Re

end p.539

doi:10.1093/9780195173642.003.0028