Manifestations of Stigma and Discrimination

Roundtable participants identified three types of stigma: self, public, and institutional. The causes and consequences of stigma and discrimination are different for older adults with mental illnesses than for others with mental illnesses. In addition, mental illness in an older adult is viewed differently than it would be in a younger person.

Self-Stigma

Older adults may be fearful of seeking treatment or acknowledging that they have a mental illness for a number of reasons. They worry that if they identify themselves as in need of mental health services, they may jeopardize their health care and their insurance. They also fear loss of financial security and independence, embarrassment, isolation, or being declared incompetent. At worst, they fear institutionalization, being sent away somewhere and never being heard from again.

“The stigma that is attached with mental illness is so tough. My generation was taught you don’t look to anyone else to take care of your problems. You take care of your own. It’s diffcult to get past that but we’re working on it.”

—George Kotwitz, Older Adult Consumer Mental Health Alliance

Public Stigma

The public view of mental illnesses in older adults is intertwined with ageism. Stigma against older adults who suffer mental illnesses is exacerbated by the “double jeopardy” of society’s negative views of aging and mental illnesses. Roundtable participants felt that, as a general population, older adults experience discrimination because of the stereotypes that they are childish, resistant to change, stubborn, and needy. Older adults with mental illnesses are further isolated by society, because they are viewed as untreatable or as not worth being treated.

“Society by and large believes that when you’re old …you’re going to get crazy. They think it’s OK.”

—Hikmah Gardiner, Aging Advocacy Group

Mental Health Association of Southeastern Pennsylvania

For example, depression among older adults is subject to misconceptions. The assumption is that depression is “normal” to the aging process. Often, it is not recognized as a treatable disease, and some may view it as not worth treating in older adults. Society often devalues the mind of the older adult.

“Whenever I mention that I have recovered from schizophrenia, with paranoid tendencies and depression, I am surprised to find there is stigma from many folks. Recently our family physician retired and we found a good internist who said to me,‘You couldn’t have had schizophrenia, those folks never get better and we were taught this in medical school.’ ”

—Janet Stiles, Founder and President, A New Way to Better Living

Institutional Stigma

Structural barriers based on assumptions about older adults can cause discrimination. Although these assumptions are not intended to discriminate against older adults, the public policies based on

Forms of Discrimination Poor quality treatment and care Marginalization within care systems “Warehousing” outside the health care system Low status of professionals, services providing care Staff recruitment and retention problems Inadequate funding at national and local levels Inequity in reimbursement for treatment Negative impact on family Victimization, abuse, neglect Unnecessary institutionalization Avoidance Poor quality of life Exclusion from research Adverse economic effects Discriminatory legislation Unemployment Material and financial inequity Government neglect and lack of legislative protections Derogatory language (WHO, WPA Report—Graham et al., 2003)

these assumptions have a deleterious impact nevertheless.

Examples of these discriminatory policies are the lack of mental health parity under Medicare, exclusion or elimination from insurance coverage, loss of driving privileges, and reduced funding for mental health services for older adults with mental illnesses. Not integrating mental health services with other health care can result in older adults receiving poorer quality mental health care. Policy decisions that result in a bias in funding priorities against older adults are another manifestation of discrimination.

“If you [as a policymaker] don’t believe change is possible, why in the world would you want to fund or begin funding treatment programs?”

—Larry Dupree, Chair Department of Aging and Mental Health

Florida Mental Health Institute

The Consequences

The identified manifestations of stigma and discrimination lead to the following consequences for older adults with mental illnesses:

• Poor outcomes and poor quality of life

• Family disintegration

• Lack of contribution to society

• Lack of trust in the health care system by ethnically diverse populations.

On a societal level the consequences include the following:

• Public ignorance of the issue

• Fewer health professionals specializing in mental illnesses in older adults

• Systematic marginalization of older adults with mental illnesses by society

• The absence of a national health policy on mental illnesses in older adults.

It Is Time to Act

Mental illnesses and Aging: Double Jeopardy • Culture traditionally has stigmatized mental illnesses AND advanced age. • Older adults are less likely than younger persons to self-identify mental health problems and are less likely to seek specialty mental health services. • Family members and professionals share the misperception that mental disorders are a “normal” part of aging.

The Indiana Consortium for Mental Health Services Research has found that anti-stigma and anti-discrimination efforts are needed now. Americans have a more sophisticated view of mental illnesses than they did 40 years ago, the last time a major study of Americans’ attitudes towards mental illnesses was undertaken.

“The good news is that people get it,” said Bernice Pescosolido, a researcher with Indiana University. Seventy percent of Americans, when given a story about a person with depression, can recognize the illness. In addition, 88 percent of Americans can recognize and correctly label a person with schizophrenia. Americans also believe that psychiatric medications work to help people with mental illnesses (Pescosolido et al., 2000).

However, Pescosolido said, perceptions of danger associated with people with mental illnesses are extremely prevalent. More than 60 percent of Americans believe that a person with schizophrenia is likely to do something violent to others; more than 85 percent believe such a person is likely to harm himself or herself. In addition, when you ask Americans what mental illnesses are, the spontaneous mention of dangerousness or violence has dramatically increased. In 1950, 7.2 percent of Americans mentioned violent symptoms when describing mental illnesses. That number jumped to more than 12 percent of Americans in 1996 (Pescosolido et al., 2000).

Although the public’s understanding of both mental illnesses and their treatment has increased, perceptions and experiences of stigma still exert a toll on individuals, caregivers, and social policy (Pescosolido et al., 2000).