Does stigma against mental illness increase as people get older?

Want to feel old? Then continue living.

Want to feel old?
Then continue living.

Some say that children are our future. This seems like nonsense given that in the future, all the children will be old people. Are old people the future? This is clearly a facetious point, albeit one with tangential relevance given the trend in Western society for people to live longer. In the United Kingdom, there are currently about 10 million people who are over 65 years old and it is predicted that this number will increase to 19 million by 2050. The phrases “grumpy old man” and “grumpy old woman” may just have to become “grumpy man” and “grumpy woman” simply due to commonality. Or ultimately, “man” and “woman” as grumpiness becomes the ground state. This is rubbish and I hate it.

One concern in an ageing society is mental health care. There are an increasing number of older adults in need of psychological care and it has been identified that cultural and organisational aspects of mental health care in later life present some of the main barriers to quality services. Stigma can be described as a sign of disgrace setting a person apart from others and Erving Goffman, defined stigma as “the process by which the actions of others spoils normal identity.” Stigma against people with mental illness can result in a lack of funding for services, and difficulty gaining employment, a mortgage or holiday insurance. Feelings of shame from perceived stigma can also cause people to delay seeking help or even deny the existence of their symptoms. Stigma surrounding mental illness has therefore been identified as one of the primary barriers to providing sufficient mental health care.

It seems obvious that attitudes and perspectives change throughout life with identifiable trends. The perspectives of a 20-year-old are unlikely to be exactly the same as those of a 90-year-old, whether this is due to differences in lived experience or due to age itself. So perhaps attitudes towards people with mental health change as we age. If attitudes towards people with mental illness improve as we age, then great. Let’s see why and see if we can use what we learn in anti-stigma interventions for younger people. Older people really are the future. Someone should write a song. If attitudes towards people with mental illness worsen and become more stigmatising as we get older then not great. Nobody should write that song. Not even if it contains the line “Oh. Think twice. Just another day for you and me with prejudice.” However, at least if it is known that stigmatising attitudes against people with mental illness worsen with increasing age then interventions against stigma can be targeted towards older people. Why? Because of the reasons we’ve discussed e.g. stigma is bad and causes bad things to happen to vulnerable people.

To investigating these issues, a study was carried out with the aim of determining whether stigmatising attitudes towards people with mental illness increased with age. This study will be described here.

Method

Three surveys were given to German citizens aged over 18 years in 1990, 2001 and 2011. Individuals taking the surveys were selected randomly and once they had provided consent, were interviewed face-to-face.

Data were collected through face-to-face interviews. This picture probably isn't representative of that process.

Data were collected through face-to-face interviews. This picture probably isn’t representative of that process.

During the interviews, participants were presented with short stories describing either a person with schizophrenia or major depression. The stories did not specifically state the diagnosis of the person, although the symptoms described fulfilled the criteria set out by the World Health Organization’s (WHO) Diagnostic and Statistical Manual of Mental Disorders (DSM) III. During the 1990 and 2011 interviews, the sex of the individual within the story was varied at random. However, during the 2001 interviews, only responses to stories describing a male with mental illness were recorded. As a result, only responses recorded in reaction to stories containing males were included in the analysis. Once again, there doesn’t seem to be much that men won’t try to take control of.

Stigmatising attitudes against people with mental illness were measured using a social distance scale. That is to say, the participants’ willingness to engage in various everyday activities with a person with a mental illness was measured. Such activities included working together, being a neighbour, recommending for a job and letting them take care of a small child. Willingness was rated on a scale of 0−5 and combined across all activities into an overall social distance score out of 28. A higher score indicates a higher desire for greater social distance, and potentially greater stigmatising attitudes.

The effects of age, birth-cohort (group that was born at a similar time) and time period on social distance (the measure of stigmatising attitude against people with mental illness) were then analysed. Maths was involved. What are the chances?

Results

Participants

  • 7,835 participants aged 18 to 93 years
  • 3,925 participants heard the story describing the person with symptoms of schizophrenia and 3,910 heard the story describing the person with symptoms of major depression.
  • Age groups included were 18 to 30 years, 30 to 39 years, 40 to 49 years, 50 to 59 years, 60 to 69 years and equal or over than 70 years.
  • The number of participants within each age group were reasonably evenly matched, with slightly fewer within the equal or over than 70 years population.

Effects

Age

For both illnesses described, there was a significant effect of age, with a higher social distance score with increasing age.

Social distance scores and therefore attitudes towards people with mental illness become more negative (higher social distance scores) with growing age.

Attitudes towards people with mental illness become more negative (higher social distance scores) with growing age.

Cohort

Cohort only appeared to have an effect in relation to the story describing someone with symptoms of major depression and not regarding the story describing someone with symptoms of schizophrenia. People born in later years showed lower social distance scores towards the person with symptoms of major depression, regardless of the effects of age or time period.

Time Period

Time period effects were examined for 1990, 2001 and 2011. Time period appeared to have a significant effect on social distance, with people from more recent time periods displaying higher social distance scores against people with symptoms of mental illnesses.

Conclusions

The authors concluded that over the life-span, social distance scores and therefore attitudes towards people with mental illness become more negative (higher social distance scores) with growing age. The effect of cohort seems to differ across disorders, although only two sets of diagnostic criteria were examined within this study. People from more recent time periods tended to display higher social distance scores (and therefore potentially more negative attitudes) against people with symptoms of mental illnesses.

The authors state that the findings of increasing negative attitudes towards people with mental illness with increasing age is due to a tendency for conservative attitudes to grow with age and to the preference of older participants to prefer familiar social partners who are less likely to trigger negative feelings. It may also have been the case that as the person featuring in both stories was of working age, social distance score may have increased with age simply due to a perceived age difference between the participant and the person being described.

It’s ultimately concluded that stigma against people with mental illness in old age is amplifying burden in a population that is already vulnerable to social isolation and that this is likely to contribute to more negative health outcomes.

Limitations

No “control” story describing a person without symptoms of mental illness was included as part of the interviews.

No “control” story describing a person without symptoms of mental illness was included as part of the interviews.

Only one story was presented to each participant. Attitudes recorded may therefore represent those held towards the individual within the one story with that particular set of symptoms rather than stigma towards people with mental illness as a whole. Having said that, people with mental illness represent a highly varied population, you know, because they’re people, and asking a study to narrow down one particular set of attitudes towards this entire population may be too much to ask. However, it may have been useful to include responses to more than one story, describing symptoms of more than one recognised mental illness diagnosis to attempt to capture attitudes to a broader range of people.

No “control” story describing a person without symptoms of mental illness was included as part of the interviews. As such, there is no baseline score for social distance score and how it changes with increasing age. For example, it may be that social distance score increases with age due to the greater risk of social isolation that has been reported with age. There is no way to determine from these results whether attitudes relate specifically to people with mental illness.

As the study was conducted solely in Germany, the attitudes concerning people with mental illness that were revealed at most may only hold in similar cultures e.g. Western industrialised countries, or at least just within Germany. Further study across varying cultural groups would be required to determine whether the attitude trends identified exist cross-culturally.

The study doesn’t mention the composition of the participant population in terms of sex. This seems an oversight given that only stories featuring males were included and attitudes regarding gender and/or sex from different genders and/or sexes can be highly complex. In addition, we can’t necessarily assume that the participant population was approximately 50% female and 50% male, as the study includes people across a wide range of ages. In Western cultures, with increasing age, the proportion of males tends to decrease. However, as it stands, there is no way to determine whether the attitudes towards the person with mental illness within the story were influenced by the sex of the person described or the sex of the participant.

There seems to be no attempt to describe whether participants in the study had any history of mental illness or any experience with people with mental illness. This would undoubtedly affect attitudes towards mental illness. The authors state that the effect of contact could not be included as information regarding this variable was not consistently elicited. Given how common mental illness is, it could be argued that with increasing age, probability of encountering someone with experience of mental illness and/or experiencing it personally increases, and examining how this interacts with attitudes and increasing age is vital for future studies.

Summary

Take two of these twice a day and stop being prejudice. Seek doctors' advice if you're a member of UKIP.

Take two of these twice a day and stop being prejudiced.
Seek doctors’ advice if you’re a member of UKIP.

The findings describe how attitudes towards people with mental illness become more negative with growing age. However, the limitations of this study mean that this cannot be stated from these results with any degree of certainty.

Ultimately we do know that stigma against people with mental illness is a real problem with real negative impact in terms of mental distress and various life and health outcomes. While more research is needed to examine whether stigma towards people with mental illness increases with age and if so, why, the growing proportion of older people within Western societies means that tackling stigma in more elderly people may be a priority regardless.

References

Schomerus G, Van der Auwera S, Matschinger H, Baumeister SE, Angemeyer MC. Do attitudes towards persons with mental illness worsen during the course of life? An age-period-cohort analysis. Acta Psychiatr Scand 2015;1−8 [PubMed]

Sartorius N. Iatrogenic Stigma of Mental Illness. BMJ 2002:324:1470−71 [PubMed]

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