An Investigation of Factors that Influence Older Adults to Use Mental Health Services for Depression and Anxiety Symptomatology

Background. Depression and anxiety are common in older adulthood, yet they are not a normal part of growing old and prevalence rates are generally lower than in cohorts of younger adults. However, late life depression and anxiety are associated with increased morbidity and mortality. Although older adults with depression and anxiety can be effectively treated with psychosocial interventions, they consistently underuse mental health services.
   
   Aims. Guided by an adapted version of Andersen and Davidson’s (2007) behavioural model of health services use, the current study aimed to investigate how need factors (perceived need, depression and anxiety), quality of life enabling factors (optimism and perceived control), and predisposing factors (social support, help-seeking attitudes and help-seeking intentions) influence older adults’ use of mental health services for depression and/or anxiety symptomatology. An additional aim was to investigate whether these factors varied across gender, age and residential setting.
   
   Design. A cross-sectional, within and between groups, mixed methods design was employed.
   
   Study 1. Study 1 was quantitative. Participants (N = 214, 60.7% female, age range 60-96 years, M = 75.15 years, SD = 8.40 years) lived in Australia and completed a self-report questionnaire containing measures of lifetime mental health service use (MHSU), need, enabling and predisposing factors. Need factors included perceived current need for mental health care, the Geriatric Depression Scale (GDS) and Geriatric Anxiety Inventory (GAI); enabling factors included the Life Orientation Test – Revised (LOT-R), Perceived Control of Internal States Scale (PCOISS), Coping Competence Questionnaire (CCQ) and the World Health Organisation Quality of Life (Old) (WHOQOL-OLD); and predisposing factors included the Duke Social Support Index (DSSI), Inventory of Attitudes Toward Seeking Mental Health Services (IASMHS), and help-seeking intentions. Results indicated that in the total sample, 40 participants (18.7%) scored at or above the clinical cut-off score on the GDS, and 30 participants (14%) scored at or above the clinical cut-off score on the GAI. Of these, 29.9% (n = 64, 65.5% female) reported having used a mental health service for depression and/or anxiety in their lifetime. This subsample was aged between 62 and 90 years (M = 72.39 years, SD = 7.63 years).
   
   Some differences were found for gender, age and residential setting across study variables in the total sample. Women reported higher levels of the need factors. PCOISS differed significantly between the young-old and old-old age groups with those in the young-old age group reporting the lowest PCOISS scores and those in the old-old age group reporting the highest PCOISS scores. DSSI differed significantly between the young-old and middle-old age groups with those in the middle-old age group reporting higher levels of social support. Psychological openness (IASMHS subscale) significantly decreased across age groups as did lifetime MHSU. Elders living in a residential aged care facility (RACF) reported higher levels of depressive symptoms than those in the community and higher levels of social network (DSSI subscale) were reported by older adults living in a retirement village than in a RACF. Of the enabling factors, only the two perceived control measures (PCOISS and CCQ) significantly predicted older adults’ quality of life measured with the WHOQOL-OLD.
   
   Two help-seeking pathways were identified. Firstly, higher levels of the need factors (perceived need, depression and anxiety) were significantly related to lifetime MHSU for depression and anxiety symptomatology and the enabling factors (PCOISS and CCQ) significantly mediated this relationship. Secondly, higher levels of social support (DSSI) were significantly related to non-use of mental health services and this relationship was serially mediated by help-seeking attitudes (IASMHS) and help-seeking intentions. A suppression effect was indicated in this analysis. Older adults with higher levels of social support used lower levels of mental health services for depression and/or anxiety unless social support led to higher levels of help-seeking attitudes, which led to greater intentions to seek help, which led to the use of mental health services.
   
   Study 2. Study 2 was qualitative. Selected participants (N = 13, age range 67-93 years, M = 81.77 years, SD = 8.69 years) who had exceeded the clinical cut-off score on the GDS and/or the GAI in study 1 and lived in Melbourne, Australia, completed a semi-structured face-to-face interview regarding their decision to seek help or not for depression and/or anxiety symptomatology. The qualitative study identified a further potential help-seeking pathway via the predisposing factors. Positive and negative subjective prior experiences with a mental health service for depression and/or anxiety led to the formation of outcome expectancies regarding future MHSU and this distinguished between those who intended to seek help again in the future (positive prior experiences) and those who did not (negative prior experiences).
   
   Conclusions. Findings suggest that interventions aimed at increasing older adults’ self-awareness of internal states may facilitate mental health service use for depression and anxiety symptomatology. Additionally, interventions aimed at building the capacity of the aged care workforce and family carers to recognise depression and anxiety symptomatology in elderly people and encourage help-seeking, may facilitate MHSU. It is suggested that future research focus on the development and validation of a scale to measure outcome expectancies based on past use of mental health services to measure this potential help-seeking pathway and provide further insight into the help-seeking behaviours of older adults.