Perceptions of Overall Mental Health and Barriers to Mental Health Treatment Among U.S. Older Adults

Abstract

Objectives:

We surveyed older adults about their perceived mental health and their comfort discussing and engaging in mental health treatment.

Methods:

A nationally representative survey of community-dwelling older adults aged 50–80 (N=2,021), with respondents asked to rate their current mental health as compared to 20 years ago, comfort discussing their mental health, and potential hesitations to seeking treatment in the future.

Results:

79.6% reported their mental health as the same or better than 20 years ago; 18.6% reported their mental health to be worse. Most respondents reported that they were comfortable (87.3%) discussing their mental health, preferring to discuss such concerns with their primary care provider (30.6%). 28.5% of respondents did endorse some hesitation seeking mental health care in the future.

Conclusions:

Most older adults reported that their mental health was as good if not better than it was 20 years ago and felt comfortable discussing mental health concerns.

OBJECTIVES:

Two commonly held beliefs about mental health are that older adults are more likely to experience worse mental health with aging and have less comfort discussing and engaging in mental health treatment.¹ Aging is associated with unique challenges that can negatively impact mental health including loss of social support, increased illness burden, and functional decline. Older adults are often perceived as having less comfort in discussing mental health as compared to younger generations due to stigma, and may be more likely to prioritize physical over mental health concerns.

Yet studies from nearly 20 years ago demonstrate that the rates of depression among community-dwelling older adults are significantly lower than among younger and middle aged adults.^1,2 In addition to having lower rates of depression, older adults report greater life satisfaction than younger cohorts.³ However, the COVID-19 pandemic continues to be a substantial source of stress, with increased rates of depression, anxiety, and insomnia reported.⁴ We sought to evaluate how older adults perceive their mental health relative to earlier in their lives and also examine potential barriers to engaging in treatment in a nationally representative sample.

METHODS:

Sample

The University of Michigan National Poll on Health Aging is a survey of adults ages 50–80 years. The poll uses KnowledgePanel (Ipsos Public Affairs LLC), a probability-based web panel of the civilian, noninstitutionalized U.S. population to generate a nationally representative sample. Demographic information collected among panel members is used to generate and adjust design weights to ensure respondents reflect the U.S. Census population.⁵ The internet survey was fielded between January 14, 2021 to January 28, 2021. Panel members were notified of the survey by email and additional reminder emails were sent to non-responders; free internet service and a web-enabled device was provided to households without internet access.⁵ The overall response rate was 78%. This study was approved by the University of Michigan institutional review board.

Mental Health Questions and Respondent Characteristics

Respondents were asked “Compared to 20 years ago, how would you rate your overall mental health now?”. Next, respondents were asked “How comfortable are you talking about your mental health?”. Respondents were also asked “If you had a mental health concern, who would you most want to talk with about it?”. Next, respondents were asked “Do you have any hesitations about seeing a mental health professional in the future?”. Finally, among respondents who did report potential hesitation, they were asked about specific reasons they were concerned about receiving treatment.

Respondents provided basic demographic information including age, sex, race/ethnicity, education level, income, employment status, and self-reported physical health.

Analysis

We used logistic regression to evaluate current perceived mental health as compared to 20 years ago (1 = worse; 0 = better or same) to determine if there was an association with respondent characteristics. Similar analyses were completed to evaluate respondent comfort with discussing mental health and potential hesitations about engaging in treatment. Models were adjusted for age, sex, race/ethnicity, education, total annual household income, current employment status, and perceived physical health status. Among those who reported potential hesitations in seeing a mental health professional in the future, reported concerns were examined by demographic characteristics using chi square tests. Analyses used survey weights to draw national inferences and performed using Stata Version 15.1.

RESULTS:

Overall Mental Health and Comfort Discussing Mental Health

Among 2,021 respondents (50–80 years), the mean age was 62.8 years, 52.7% were female, and 70.9% were non-Hispanic white. 79.6% reported their mental health as the same or better as compared to 20 years ago; 18.6% reported their mental health to be worse. Being female was associated with greater odds of worse mental health (22.0% vs. 14.2% male; adjusted odds ratio [AOR] 1.75, 95% CI 1.36–2.26), as was lower rated physical health (24.4% vs. 17.2% excellent, very good, or good physical health; AOR 1.61, 95% CI 1.14–2.28; Table 1). In contrast, older respondents were less likely to report perceiving their mental health as worse compared to younger respondents (e.g., 12.9% 70–80 vs. 23.3% 50–59 years; AOR 0.37, 95% CI 0.26–0.52).

Table 1.

Respondent characteristics associated with perception of overall mental health and comfort receiving mental health care^a

		Overall mental health compared to 20 years agob			Comfort in talking about mental healthc			Hesitations about seeing a mental health professional in the futured
Characteristics, %	Overall (n=2021)	Better/Same	Worse	AOR (95% CI)e	Very/Somewhat Comfortable	Not Very/Not at All Comfortable	AOR (95% CI)e	No	Yes/Unsure	AOR (95% CI)e
Age range, y
50–59	32.1	76.7	23.3	Ref	85.2	14.8	Ref	70.8	29.2	Ref
60–69	39.1	83.6	16.4	0.55 (0.41, 0.74)	86.7	13.4	0.79 (0.56, 1.13)	71.3	28.7	0.95 (0.68, 1.34)
70–80	28.7	87.1	12.9	0.37 (0.26, 0.52)	91.5	8.5	0.41 (0.26, 0.65)	70.7	29.3	0.91 (0.62, 1.33)
Sex
Female	52.7	78.0	22.0	1.75 (1.36, 2.26)	87.9	12.1	0.83 (0.61, 1.12)	70.1	30.0	1.00 (0.76, 1.32)
Male	47.3	85.8	14.2	Ref	86.6	13.4	Ref	71.7	28.3	Ref
Race/ethnicity
White, non-Hispanic	70.9	80.5	19.5	Ref	87.4	12.6	Ref	71.2	28.8	Ref
Black, non-Hispanic	10.7	84.9	15.1	0.65 (0.41, 1.04)	92.3	7.7	0.50 (0.26, 0.96)	76.8	23.3	0.71 (0.43, 1.18)
Hispanic	11.5	82.6	17.4	0.82 (0.53, 1.28)	86.0	14.0	1.02 (0.61, 1.71)	71.4	28.6	0.88 (0.55, 1.41)
Other, non-Hispanic	6.9	87.7	12.3	0.51 (0.27, 0.98)	80.0	20.0	1.53 (0.84, 2.78)	58.1	41.9	1.77 (0.99, 3.17)
Education
High school	40.3	84.5	15.5	Ref	86.2	13.8	Ref	65.5	34.5	Ref
Some college	29.0	82.1	17.9	1.33 (0.96, 1.86)	89.3	10.7	0.80 (0.55, 1.16)	80.3	19.7	0.49 (0.35, 0.69)
Bachelor’s degree	30.8	77.6	22.4	2.05 (1.46, 2.88)	86.7	13.3	1.09 (0.74, 1.58)	70.9	29.1	0.86 (0.60, 1.22)
Total annual household income
Less than $30,000	17.5	83.4	16.6	Ref	83.4	16.6	Ref	67.0	33.0	Ref
$30,000–$59,999	21.7	79.9	20.1	1.31 (0.85, 2.02)	90.0	10.0	0.64 (0.37, 1.10)	66.0	34.0	1.13 (0.70, 1.82)
$60,000 or more	60.9	81.9	18.1	1.00 (0.65, 1.53)	87.4	12.6	0.84 (0.52, 1.35)	73.6	26.4	0.84 (0.54, 1.32)
Current employment status
Employed	40.2	82.6	17.4	Ref	88.5	11.5	Ref	72.5	27.5	Ref
Retired/not working	59.8	81.1	19.0	1.48 (1.10, 1.98)	86.5	13.5	1.46 (1.03, 2.06)	69.9	30.1	1.06 (0.77, 1.44)
Physical health
Excellent, very good, or good	84.4	82.8	17.2	Ref	88.6	11.4	Ref	71.9	28.1	Ref
Fair or poor	15.7	75.6	24.4	1.61 (1.14, 2.28)	79.8	20.2	2.96 (1.31, 2.93)	63.2	36.8	1.48 (0.97, 2.25)

^aAdjusted models included the characteristics presented in the Table rows.

^bPoll respondents were asked: “Compared to 20 years ago, how would you rate your overall mental health now?” with possible responses “better”, “about the same”, or “worse”.

^cPoll respondents were asked: “How comfortable are you talking about your mental health?” with possible responses “very”, “somewhat”, “not very”, and “not at all comfortable”.

^dPoll respondents were asked: “Do you have any hesitations about seeing a mental health professional in the future?” with possible responses “yes”, “unsure”, and “no”.

^eAdjusted odds ratios (AOR) reflect odds of worse mental health symptoms (e.g., overall mental health worse = 1, overall mental health better or same = 0), being uncomfortable talking about mental health (e.g., not very/not at all comfortable = 1, very/somewhat comfortable = 0), and having hesitations about seeing a mental health professional (e.g., yes/unsure = 1, no hesitations = 0).

Most respondents reported that they were comfortable (87.3%) discussing their mental health. They preferred to discuss such concerns with their primary care provider (30.6%), followed by mental health professional (25.0%), spouse/partner (24.7%), or other family or friends (11.3%). Older (8.5% 70–80 vs. 14.8% 50–59 years; AOR 0.41, 95% CI 0.26–0.65) and non-Hispanic Black respondents (7.7% vs. 12.6% non-Hispanic white; AOR 0.50, 95% CI 0.26–0.96) were less likely to have discomfort discussing mental health concerns. Respondents with lower rated physical health (20.2% vs. 11.4% excellent, very good, or good physical health; AOR 1.96, 95% CI 1.31–2.93) were more likely to report discomfort with discussing mental health concerns.

Hesitation in Seeking Mental Health Treatment Services

While most respondents (71.5%) stated they would not have hesitations about engaging in mental health treatment in the future, 28.5% reported they would have some hesitation. Comfort engaging in treatment did not vary significantly with respondent age; male and female respondents were also similarly comfortable (Table 1).

Among those reporting potential hesitations to engaging in mental health treatment, respondents most cited concerns that treatment would not be needed (54.5%), would not help (21.4%), embarrassment (15.9%), and cost (13.9%) as barriers. Concerns about affording treatment was endorsed more frequently by Hispanic and other race and ethnicities respondents (24.8% and 28.4% vs. 11.5% non-Hispanic white; χ²=16.6, df=348, p=0.02) as well as female respondents (19.7% vs. 8.1% male; χ²=9.8, df=348,p=0.008; Figure 1).

Figure 1.

Reasons respondents would be hesitant to see a mental health professional by age (A), sex (B), and race/ethnicity (C)

The percentage of poll respondents who endorsed specific concerns about seeing a mental health professional in response to the following questions “Why would you be hesitant to see a mental health professional?” with possible responses of: “I don’t think I would need to” (54.4%), “I don’t think it would help” (21.4%), “I could not afford it” (13.9%), “I would feel embarrassed” (15.9%), “too hard to find a provider” (3.8%), and “other” (15.2%). Respondents we asked to select all that applied. Responses are grouped by age, sex, and race/ethnicity. Chi square tests were used to compare concerns endorsed by age, sex, and race/ethnicity. Significant differences are noted with an asterisk and detailed in the manuscript text.

CONCLUSIONS:

In this nationally representative survey of U.S. adults aged 50–80, nearly 80% reported their mental health was the same or better than it was 20 years ago. Among these older adults, the oldest respondents were significantly less likely to perceive their mental health as worse compared to those 50–69 years of age. While a previous national survey demonstrated that older adults reported greater life satisfaction than younger cohorts, such studies have not asked older adults to reflect on their past mental health.³ Resilience, wisdom, and life experience may help contribute to perceived improved mental health in the face of stressors with age.^1,3 Over 85% of respondents were comfortable talking about their mental health, again highest among the oldest respondents.

Older respondents reported being more open to discussing and seeking mental health help than prior research suggests,⁶ with 87% reporting that they were comfortable discussing their mental health—however, the majority prefers to discuss such concerns with their primary care provider. Less than 3% of older adults receive mental health care with a psychiatrist with the majority of patients receiving mental health treatment within primary care.⁷ While this may be related to difficulty accessing mental health care, the low rates of specialty care use also reflect where the majority of these older adults prefer to receive care. Health systems and insurers should continue to support screening and integration of primary and behavioral health services which have been proven effective in reducing mental health symptoms among older adults within primary care settings.⁸

While public attitudes have grown more favorable toward psychotropic medications, and older adults have become more open to mental health treatment,⁹ the results of the survey suggest barriers and stigma to engaging in treatment still remain. Of respondents, 29% endorsed some hesitation in potentially seeking mental health care in the future, citing concerns that treatment would not be needed, would not help, embarrassment, and cost. Perceived stigma related to receipt of mental health care among older adults can lead to less engagement in care and early discontinuation of treatment.¹⁰ These survey findings demonstrate that, for at least a subset of older adults, stigma may still be a barrier limiting treatment engagement among some older adults in need.

Limitations of this study include reliance on self-reported perception of overall mental health rather than use of validated questionaries and the potential for non-response bias, though our analyses applied survey weights to account for this. Additionally, the study panel does not include adults older than 80 years, so our results to do not include the perspectives of the oldest old. Lastly, this study is unable to examine whether results reflect cohort differences or aging-related changes without longitudinal follow up.

This study found that most older adults reported that their mental health was as good if not better than it was 20 years ago, and they felt comfortable discussing mental health concerns. However, nearly 30% of respondents reported hesitations about engaging in treatment. Clinicians can play an important role in debunking common misperceptions about mental health treatment—such as concerns that treatment is not effective—to help address this stigma. Given the association between poor physical health with both worse mental health and discomfort discussing mental health concerns, it may be useful for clinicians to anchor discussions about mental health in its potential to improve quality of life and comorbid medical conditions. Lastly, given the preference of older adults to discuss mental health concerns with their primary care provider, it is important for health systems to continue to support mental health treatment services within primary care, such as through collaborative care programs.