The Stigma Receptivity Scale and Its Association With Mental Health Service Use Among Bereaved Older Adults

Abstract

The purpose of this article was to determine whether the Stigma Receptivity Scale (SRS) predicts use of mental health services among community-dwelling bereaved older adults. We analyzed interviews of 135 people in Connecticut to evaluate whether three subscales and 12 SRS items were associated with access to any mental health service in the past 60 days using logistic regression analysis. Two SRS items predicted recent use of mental health services among bereaved individuals with and without complicated grief: receptivity to a bereavement support group (adjusted OR = 5.14; 95% CI, 1.11, 23.85) and individuals who were not concerned about meeting criteria for a mental illness (adjusted OR = 0.07; 95% CI, 0.01, 0.58). The SRS significantly predicted recent access to mental health treatment among bereaved elderly people. This type of measure could be used to determine those most likely in need of education and support to increase their likelihood of accessing mental health services.

According to the 1999 Surgeon General's report on mental health, stigma is the most formidable obstacle to further progress in the arena of mental illness and health (United States Department of Health and Human Services, 1999). Stigma is frequently defined using Goffman's (1963) definition, which states that stigma is an “attribute that is deeply discrediting” and that it reduces the bearer “from a whole and usual person to a tainted, discounted one.” Stigma remains the main obstacle to a better life for millions of people suffering from mental disorders (Sartorius, 2002). Stigma can affect whether people with mental illness seek and adhere to treatment and influence their self-esteem and social adjustment.(Trude and Stoddard, 2003) Stigma creates a barrier preventing help-seeking because people avoid the label of mental illness. Prospective studies are needed to determine how negative perceptions influence care-seeking when a person needs mental health services.(Corrigan, 2004)

While decades of research examine how stigma burdens the mentally ill and how stigma may affect treatment seeking and adherence (Corrigan, 2004), little research has focused on objectively measuring how stigma influences use of mental health services. The Stigma Receptivity Scale (SRS; Prigerson, 2003) was developed to examine respondent attitudes towards a cluster of symptoms called complicated grief (CG; Prigerson et al., 1996). CG symptoms include disruptive levels of yearning for the deceased, an inability to accept the death, feeling detached from others, being on edge since the death, feeling that one's current life has no meaning, experiencing bitterness over the loss, and having difficulty moving on with one's life. This study examines whether the SRS predicts recent use of mental health services among bereaved, community-dwelling older adults, among those who do and those who do not meet diagnostic criteria for CG.

Methods

Data for this study come from the Yale Bereavement Study (YBS). Additional details about the YBS can be found elsewhere (Chen et al., 2005). The YBS conducted three waves of structured interviews with bereaved persons residing in Bridgeport, Fairfield, and New Haven, Connecticut, from 1999 to 2003. The SRS was administered to participants in wave 3 only. Wave 3 interviews were conducted with 265 individuals at an average of 19.7 months postloss (83.6% of the 317 who completed wave 1). Because the SRS was a late addition to the study, it was administered only to the final 135 of the 265 (50.9%) subjects enrolled in the study during its inclusion. The YBS was approved by the Human Investigation Committee at Yale University School of Medicine, and informed consent was obtained from all subjects prior to study participation.

Participant responses included the following independent variables: age, diagnosis of CG (assessed using the validated rater-administered version of the Inventory of Complicated Grief-Revised (Prigerson and Jacobs, 2001), education level, gender, and an indicator for the presence of any psychiatric disorder assessed using the Structured Clinical Interview for the DSM-IV (First et al., 1995). Psychiatric disorders included agoraphobia, generalized anxiety disorder, major depressive disorder, obsessive-compulsive disorder, panic disorder, panic disorder with agoraphobia, posttraumatic stress disorder, simple phobia, and social phobia.

The SRS was the independent variable of interest in each analysis (Table 1). Twelve SRS items were administered to participants (Cronbach α = 0.64). (Two of these items contained four parts; the remaining 10 questions involved only one part.) One subscale (5 items; Cronbach α = 0.45) assesses attitudes and feelings about the severity of grief symptoms. The second subscale (6 items; Cronbach α = 0.52) assesses receptivity to treatment of a mental disorder. The third subscale (7 items; Cronbach α = 0.69) asks respondents what reactions they would expect from others if they hypothetically met criteria for CG.

Table 1. SRS Predictors of Recent Mental Health Service Use.

Outcome variable: During the past 60 days have you gone to any hospitals, or clinics, or talked with a doctor, nurse, counselor, or other health professional for help with a psychological or emotional problem? (Y/N)
Question	Unadjusted OR	Adjusted ORc
Attitudes/identification subscale (subscale 1)	0.402 (0.189, 0.854)	0.337 (0.152, 0.748)
Considering your current bereavement related distress, would you feel better knowing you had a mental condition for which effective treatment is available, rather than being told you were normal and that there was no need for any outside intervention to help you?	0.403 (0.111, 1.465)	0.390 (0.089, 1.699)
If a mental health professional told you that you met criteria for Complicated Grief (a complex of symptoms indicating difficult adjustment to the death of someone close), would you be:	—b	—b
Relieved to know you were not going crazy?	1.462 (0.155, 13.787)	0.392 (0.020, 7.613)
Relieved to know you had a recognizable problem?	1.462 (0.155, 13.787)	0.618 (0.024, 15.612)
Not worried because you would not take this to mean you were going crazy?	—a	—a
Not worried by meeting criteria for a mental illness?	0.085 (0.011, 0.657)	0.065 (0.007, 0.581)
Reaction subscale (subscale 2)	0.650 (0.415, 1.019)	0.808 (0.450, 1.451)
If you met the criteria for Complicated Grief, do you think your family would be less understanding of what you are going through?	0.336 (0.029, 3.893)	0.440 (0.034, 5.617)
Do you think that if you met the criteria for Complicated Grief, your family would be more likely to blame you for how you are now?	0.241 (0.038, 1.544)	0.831 (0.068, 10.171)
Do you think that, if others outside your family knew you were diagnosed with Complicated Grief, they would be less understanding and ridicule you?	0.312 (0.071, 1.366)	0.257 (0.041, 1.606)
Have your family members or friends told you that you are exaggerating or overreacting with your grief?	0.495 (0.093, 2.648)	0.893 (0.122, 6.526)
Have your family members or friends told you that you are using grief as an excuse to be lazy?	0.509 (0.050, 5.152)	0.959 (0.074, 12.419)
Have your family members or friends told you that you are using grief to get attention?	0.509 (0.050, 5.152)	0.930 (0.055, 15.860)
Have your family members or friends told you that you are feeling sorry for yourself?	0.258 (0.056, 1.177)	0.804 (0.122, 5.278)
Receptivity subscale (subscale 3)	0.908 (0.560, 1.474)	1.048 (0.623, 1.765)
If you were diagnosed with a mental illness, would you be interested in receiving treatment for this condition?	—a	—a
If you were diagnosed with a mental illness, would you be willing to receive help for this condition if others thought you would benefit from it?	—a	—a
Which bereavement interventions would you be receptive to:	—b	—b
Bereavement support group	2.364 (0.671, 8.330)	5.141 (1.108, 23.853)
Psychotherapy	—a	—a
Medication	0.362 (0.079, 1.661)	0.447 (0.090, 2.209)
Religious group/counselor	2.410 (0.858, 6.775)	2.477 (0.765, 8.018)
Total (all items combined)	0.699 (0.484, 0.923)	0.719 (0.498, 1.036)

^aCould not be computed due to cell size.

^bInitial part of question—see following question subparts.

^cAdjusted for age, gender, diagnosis of complicated grief, education level, and the presence of any psychiatric disorder (defined as one or more of the following disorders: agoraphobia, generalized anxiety disorder, major depressive disorder, obsessive-compulsive disorder, panic disorder, panic disorder with agoraphobia, posttraumatic stress disorder, simple phobia, and social phobia).

The dependent variable was a yes or no answer to the following question: “During the past 60 days, have you gone to any hospitals, or clinics, or talked with a doctor, nurse, counselor, or other health professional for help with a psychological or emotional problem?”

We used logistic regression to analyze whether the entire SRS measure, each of the three subscales, and each of the 12 individual items predicted access to mental health services. Then we repeated each of these analyses, adjusting for age, CG diagnosis, education level, gender, and the presence of any psychiatric disorder. We conducted each analysis separately in participants with and without CG. Because there were no significant differences in outcomes between the participants with and without CG, we present only the findings from analyses of the full sample.

Results

A total of 135 subjects completed the SRS. The average age of study participants was 62 (13), and the mean number of years of education was 14 (3). A total of 107 (80%) participants were women, and 129 (96%) were white. Of the participants, 105 (78%) lost a spouse, seven (5%) lost a child, 14 (10%) lost a parent, five (4%) lost a sibling, and four (3%) had an unknown relationship to the deceased. At the wave 3 interview, 16 (12%) had any psychiatric disorder, and 16 (12%) had had CG at some point within the study observation period. Six of 16 people had both CG and any psychiatric disorder, 10 had only a psychiatric disorder, and another 10 had CG only. Any psychiatric diagnosis and CG were each independent predictors of any recent mental health services use (p = 0.02 and p = 0.05, respectively); age, education, and gender were not significant predictors.

Two individual SRS items significantly predicted recent use of mental health services among participants with and without CG. First, receptivity to a bereavement support group significantly increased the odds of any mental health services in the past 60 days (adjusted OR = 5.14; 95% CI, 1.11, 23.85). Second, individuals who were concerned about meeting criteria for a mental illness were significantly less likely to have received any mental health treatment (adjusted OR = 0.07; 95% CI, 0.01, 0.58). Of the three SRS subscales, subscale 1, attitudes towards a CG diagnosis, predicted that negative attitudes towards a CG diagnosis significantly decreased likelihood of recent treatment (adjusted OR = 0.34; 95% CI, 0.15, 0.75). The SRS as a whole was a significant predictor of service use in unadjusted analyses only (OR = 0.70; 95% CI, 0.48, 0.93).

Discussion

Our findings highlight several points. First, receptivity to a bereavement support group is a strong predictor of its use. Second, concerns about having a mental health diagnosis substantially decrease likeliness of service use. Third, receptivity to other psychological treatments such as medication and psychotherapy does not predict of use of mental health services. Bereaved older adults' receptivity to professional assistance for mental (and possibly physical) health impairments may not influence the rate of actually accessing these services because, while they accept the usefulness of professional help in general, their personal need for professional assistance may be perceived as a threat to their capacity to live independently. Supportive treatment may have been more appealing and receptivity may have heightened the likelihood of accessing support groups because this form of care is perceived as self-help rather than professional assistance.

Results of this study also indicated that knowledge of a mental health diagnosis and beliefs about others' perceptions and reactions toward a CG diagnosis does not increase the likelihood of service use. These findings highlight the need for both assessing receptivity to supportive services for the bereaved and working with bereaved individuals to minimize their concerns about a mental health diagnosis and its treatment, potentially including education on how effective treatment may actually enhance their resilience and capacity for independence.

Because this study was a cross-sectional analysis, prospective examinations are needed of the effects of stigma and receptivity to mental health services on its use. In addition, SRS questions focused on attitudes and beliefs associated with CG. Further research should examine how participants would react to other psychiatric diagnoses and also, for comparison and generalizability, how they would react to physical illness diagnoses. How well a measure such as SRS would perform in a younger population or among non-bereaved participants should also be explored.

Conclusion

This study provides a first step in quantifying how attitudes toward mental health disorders can influence use of services. Allaying fears and concern about a mental health diagnosis and exploring receptivity to different types of services are tangible and achievable goals for providers of care for bereaved individuals.