Shena Wadian, M.A. A dissertation. In Counseling Psychology

Transcription

1 The Impact of Stigma and Etiological Beliefs on Willingness to Seek Treatment for Depression: A Comparison of Undergraduate and Behavioral Sciences Graduate Students by Shena Wadian, M.A. A dissertation In Counseling Psychology Submitted to the Graduate Faculty of Texas Tech University in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF PHILOSOPHY Approved C. Steven Richards, Ph.D. Chair of Committee Clyde Hendrick, Ph.D. Susan S. Hendrick, Ph.D. Darcy A. Reich, Ph.D. Dominick Casadonte Interim Dean of the Graduate School August, 2013

2 Copyright 2013, Shena Wadian

3 Acknowledgements I am grateful for the support, encouragement, advice, and assistance of many who have helped me with this project. I am incredibly appreciative of my dissertation chair, Dr. Steve Richards, for his support, guidance, and thoughtful suggestions. I have valued not only his consistently thorough and expeditious feedback but his genuine support and enthusiasm. I would like to thank Dr. Darcy Reich and Dr. Clyde Hendrick for their thoughtful comments that stimulated rich discussion and further strengthened this project. I am truly honored to have had the insight and suggestions by Dr. Stephanie Harter. I am saddened that she could not be a part of the final product; however, I feel fortunate to have had the opportunity to work with her. Her knowledge and insights were invaluable in shaping this study. I cannot express enough my extreme gratitude for Dr. Susan Hendrick and her willingness to serve on my committee on short notice. I would also like to thank Dr. Lisa Witcher. Her support and encouragement over the last year was instrumental in helping me stay focused and complete this project. Additionally, the advice, input, and support of my internship colleagues, particularly Heather Kruse, helped me maintain perspective and keep me motivated. I am thankful for the statistical advice of Taylor Wadian; his knowledge and enthusiasm for statistical analyses was a tremendous help. I am also appreciative for the love and support of my partner, Chad Smith. His ability to make me laugh when I became stressed, his encouragement, and his confidence in me helped keep me centered. And finally, I would like to extend my gratitude to my family and friends. Without their continued support and encouragement I would not be where I am today. ii

4 Table of Contents Acknowledgements... ii Abstract... v List of Tables... vii I. Introduction... 1 Depression Treatment... 4 Stigma... 5 Types of Stigma... 6 Predictors of Depression Stigma... 7 Impact of Depression Stigma... 9 Etiological Beliefs Purpose II. Hypotheses and Research Questions III. Method Participants Measures Procedures IV. Results Preliminary Analyses Hypotheses and Results V. Discussion iii

5 Limitations Recommendations for Future Research Conclusions References Appendices Appendix A: Extended Literature Review Appendix B: Depression Stigma Scale Personal Subscale Appendix C: Depression Stigma Scale Perceived Subscale Appendix D: Etiological Beliefs Questionnaire Appendix E: Treatment Seeking Questionnaire Appendix F: Center for Epidemiologic Studies Depression Scale Appendix G: Open-Ended Questionnaire Appendix H: Demographic Questionnaire iii

6 Abstract Depression is often a recurrent disorder that causes significant financial, social, and psychological problems. Despite the costs of depression, many people delay treatment, if they seek treatment at all. Those who do seek professional help are often treated solely by medication or minimally acceptable interventions. Research suggests higher depression stigma is one factor related to a decrease in willingness to seek treatment. Men, people with lower education, and people with less knowledge about depression report greater stigma. Research suggests etiological beliefs influence what people view as the most helpful treatment for depression, but there is a lack of research emphasizing etiological beliefs specifically in depression stigma and willingness to seek treatment. Further, although predictors of stigma may lead to the assumption that people with graduate training in applied behavioral sciences will report less stigma, this had not been empirically tested. The current study expanded upon prior research by including a sample of graduate students with a background in applied behavioral sciences, in addition to an undergraduate student sample. Participants were assessed on measures of stigma, etiological beliefs, depressive symptoms, and willingness to seek treatment. Findings from the current study were consistent with prior research suggesting higher education is related to lowered personal stigma and greater willingness to seek therapy. Undergraduate students reported greater willingness to seek help from friends or family than any other source, which is consistent with prior research suggesting that people are hesitant to seek professional mental health services. Higher stigma predicted a decreased vi

7 willingness to seek treatment for graduate students, but was not predictive for undergraduates. Beliefs about the causes of depression were related to levels of stigma in both graduate and undergraduate samples. Specifically, a belief that depression has a religiously-based influence was related to increased levels of personal stigma for graduate and undergraduate students. Moreover, beliefs that depression is linked to ineffective coping or an underlying biological influence were related to higher perceived stigma among undergraduate students. Beliefs about the cause of depression do not seem to influence willingness to seek any specific form of professional mental health treatment. Rather, willingness to seek treatment appeared to be more heavily influenced by stigma. vi i

8 List of Tables 1. Factor Loadings for Etiological Beliefs Descriptive Statistics for Graduate Student Sample Descriptive Statistics for Undergraduate Sample Hierarchical Regressions of Graduate Willingness to Seek Therapy or Medication Hierarchical Regressions of Undergraduate Willingness to Seek Therapy or Medication Hierarchical Regressions of Graduate Willingness to Seek Treatment Exploratory Variables Hierarchical Regressions of Undergraduate Willingness to Seek Treatment Exploratory Variables Correlations among Education Level, Stigma Scores, Etiological Beliefs, Depression, and Treatment Willingness Analysis of Variance Comparing Gender and Participant Group Willingness to Seek Help for Depression Analysis of Variance Comparing Gender and Participant Group Scores on Personal and Perceived Stigma Measures Analysis of Variance Comparing Gender and Participant Group Endorsement of Etiological Beliefs Graduate Correlations among Stigma Scores, Etiological Beliefs, Depression, and Treatment Willingness Undergraduate Correlations among Stigma Scores, Etiological Beliefs, Depression, and Treatment Willingness vii

9 Chapter I Introduction Regardless of the nature of services needed, seeking help can be associated with disapproval, shame, or loss of social standing (DePaulo & Fisher, 1980; Lee, 2002). However, seeking help for medical problems, such as diabetes, cancer, and broken bones, is often viewed less negatively than seeking help mental health issues (Ben-Porath, 2002). Not seeking such medical attention can be viewed as dangerous, unwise, or unhealthy. Mental health issues traditionally present a much different story. Seeking treatment for mental health can be seen as a weakness (Ben-Porath, 2002) and such treatment is often delayed, if sought at all (Wang et al., 2007). According to Kessler (2002) and Wang et al. (2007), depression is one of the most burdensome illnesses. The estimated economic burden of depression in 2000 was $83.1 billion, including $26.1 billion as a result of medical costs and $5.4 billion in mortality costs as a result of suicide (Greenberg et al., 2003). Birnbaum et al. (2010) found depression was related to decreased work performance, unemployment, and disability. It is estimated that depression-related costs in the workplace accrued to nearly $51.1 billion in 2000 (Greenberg et al., 2003). Depression is one of the most common mental health disorders (Craighead, Sheets, Brosse, & Ilardi, 2007). Recent epidemiological research on prevalence rates of depression suggests that one out of six adults experience a major depressive episode during their life (Kessler, 2002). Further, the prevalence of major depression appears to 1

10 be increasing for younger generations (Craighead et al., 2007), which suggests even more people will experience at least one major depressive episode in their lifetime. Depression onset typically occurs in lower to mid-20 age range, placing many at risk during important transitions in life (Kessler, 2002). College attrition rates may in part be due to the onset and subsequent effects of depression. The mid-20 s age range is also when many people typically get married and start careers. Despite the clear seriousness of depression, people hesitate to seek treatment, and often delay treatment until their symptoms are particularly severe (Wang et al., 2007). This delay is especially seen in younger people. Michael, Huelsman, Gerard, Gilligan, and Gustafson (2006) found less than 30% of a college sample meeting criteria for depression reported seeking treatment. Because previous episodes of depression are a significant predictor for subsequent episodes (Richards & Perri, 2010; Sjoholm, Lavebratt, & Forsell, 2009), the delaying of treatment is particularly concerning for younger people. If young adults seek treatment earlier, the number and severity of recurrent episodes may decrease, thus lessening the social, psychological, and economic costs related to depression (Hollon, Stewart, & Strunk, 2006; Richards & Perri, 2010). Kessler (2002) reported many people with symptoms of depression receive minimally acceptable treatment. Many often seek treatment from general medical practitioners, while others are beginning to use complementary and alternative therapies, such as St. John s Wort and energy healers. Although treatment for mental health is at higher rates than 10 years ago (Olfson et al., 2002), people still report delaying treatment at least 4 years after first onset (Wang et al., 2007). Further, according 2

11 to Wang et al. (2007), treatment often consists of medication only or seeking general practitioners rather than receiving psychosocial therapy. As noted by Richards and Perri (2010), although medication-only treatment is effective for treatment of depression in the short term, it does not facilitate development of effective coping skills, problem-solving skills, and increased insight. Psychosocial therapy promotes development of such skills, thus reducing risk of relapse. Given that depression often begins in young adulthood, is likely to reoccur, and is related to substantial financial, social, psychological, and daily living disturbances, it seems logical that early treatment is important. Yet people hesitate to seek treatment in a timely manner and often seek treatment from sources other than mental health professionals. There are many factors as to why this might be, including financial limitations or other logistical limitations such as transportation or availability of resources (Ward, Clark, & Heidrich, 2009). An area of particular interest includes stigma related to depression. Although nursing and medical literature has considered the concept of stigma for some time (e.g., Elliott, Yoder, & Umlauf, 1990), it was not until more recently that researchers have considered stigma of depression and treatment for depression specifically. The paucity of research is concerning, particularly because adequate treatment cannot happen if people are not willing to seek treatment. One way to reach more clients is to better understand what is preventing them from seeking treatment for depression. The aim of the present study was to examine the impact of stigma and etiological beliefs on willingness to seek treatment for depression. To expand upon prior research, the current study included graduate students in applied behavioral sciences 3

12 programs in addition to an undergraduate sample. Prior research has not considered the behavioral sciences graduate student sample. Depression Treatment Wang et al. (2007) performed an international survey regarding issues related to seeking mental health treatment. In the United States, earlier age of onset was related to lower likelihood of seeking treatment. Approximately 35% of people in the United States reported seeking treatment in the year of onset of their depression. The median amount of time between year of onset and year of seeking help was 4 years. Although length of treatment delay for depression was better than the average treatment delay for anxiety and substance abuse (23 years and 13 years respectively), the delay remains concerning because of the recurring nature of depression. Early treatment may prevent later relapse and associated problems (Richards & Perri, 2010). Mental health treatment for depression is effective. Pharmacological drugs and psychotherapy are the most common forms of treatment, with more extreme measures involving electro-convulsive therapy (Nermeroff & Schatzberg, 2007). Behavioral therapy, cognitive-behavioral therapy, and interpersonal therapy are particularly effective in the treatment of depression (Craighead et al., 2007). Although medication and psychotherapy alone are both efficacious, the combination of medication and psychosocial therapy is superior for severe and chronic depression (Hollon et al., 2006; Richards & Perri, 2010). Olfson et al. (2002) considered changes in depression treatments over a 10 year span. The number of people treated with antidepressants almost doubled in percentage, 4

13 while the proportion of people receiving psychotherapy dropped. Moreover, a larger number of people were treated for depression by physicians. Michael et al. (2006) similarly found that over 80% of college participants seeking treatment for depression were treated solely with medication. Although it is promising that Olfson et al. found more people were being treated for depression, the decrease in psychotherapy use could be cause for concern. Psychotherapy for depression has shown to provide life-long skills that are more cost effective and longer lasting than that of psychoactive medication alone (Craighead et al., 2007; Hollon et al., 2006). Stigma Stigma, or negative beliefs, related to depression is demonstrated in a variety of ways. People with mental health issues are viewed by the general public as dangerous, unpredictable, and unreliable (Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999). Moreover, people may be less willing to employ someone with depression, hire someone with depression to babysit, or rent an apartment to someone with depression (Schomerus, Matschinger, & Angermeyer, 2009). Depression is often viewed as controllable, and as a result, people with depression may be blamed for their mental health issues. Instances of failures are frequently considered as a consistent and permanent character-logical flaw in a person with depression (Sacco & Dunn, 1990), whereas successes are attributed to being a fluke. Further, people with depression are seen more negatively than those with medical issues, such as back pain (Ben-Porath, 2002). Specifically, when compared to someone with back pain, Ben-Porath (2002) found that people with depression were rated 5

14 as more emotionally unstable, less interpersonally interesting, less competent, and less confident. Types of stigma. Previous researchers have found conflicting results about depression stigma and treatment seeking. Some researchers have failed to find any influence of stigma (e.g., Blumenthol & Endicott, 1996/1997), while others have found stigma significantly affects willingness to seek treatment (e.g., Golberstein, Eisenberg, & Gollust, 2008). One possible reason for these contradictory findings may be how the phenomenon of stigma is defined. Griffiths, Christensen, Jorm, Evans, and Groves (2004) argue stigma is not a singular construct; rather it can be conceptualized into perceived and personal stigma. Personal stigma relates to beliefs that people hold personally (e.g., I think people with depression are weak ), whereas perceived stigma involves perceptions of what others think about people with depression (e.g., Others think that people with depression are weak ). That is, personal stigma is the individual s beliefs, and perceived stigma is what that individual thinks others believe about depression. This distinction is small but significant. Researchers who have used the personal and perceived stigma constructs have more consistently found significant effects on treatment seeking compared to using stigma as a singular construct (e.g., Barney, Griffiths, Jorm, & Christensen, 2006; Brown et al., 2010; Griffiths, Christensen, & Jorm, 2008). In Griffiths et al. s (2008) research, personal stigma accounted for greater amount of variance compared to perceived stigma. Other researchers (e.g., Barney et al., 2006; Brown et al., 2010) have also found support for internalized (i.e., personal) stigma as more influential in treatment seeking. Based 6

15 upon findings by previous researchers, stigma in the current study was conceptualized as a multi-dimensional construct and included both personal and perceived components. Although prior research has suggested that personal stigma is more influential in treatment seeking, perceived stigma was included in the current study. Because less research is available on stigma beliefs and treatment seeking in the graduate student sample, it was unclear if personal stigma would be more influential for graduate students as well. Predictors of depression stigma. Research has suggested some people are more likely to report depression stigma. Specifically, persons over the age of 65 (e.g., Connery & Davidson, 2006; Roger & Johnson-Greene, 2008), men (e.g., Corrigan & Watson, 2007), and those with less education (e.g., Griffiths et al., 2008) report higher levels of stigma. Further, greater stigma is also related to less knowledge about mental illness (Roh et al., 2009) as well as less personal experience with mental illness. Personal experience includes either a personal history of depression or treatment (Golberstein et al., 2008; Pyne et al., 2004) or experience of a family member with mental illness or depression (Wang & Lai, 2008). Griffiths et al. (2008) considered predictors of personal and perceived stigma in a national sample of Australian adults. Participants were asked to respond to various questions after given a vignette describing someone with depression. Personal stigma was higher for older, less educated, and male participants. Further, less exposure to depression (e.g., no prior personal depression, no prior treatment, and no family members with depression) and lack of knowledge about depression were also related to higher levels of 7

16 personal stigma. Knowledge was operationally defined as whether or not participants recognized that the person in the vignette had depression. Whereas older participants scored higher on personal stigma, they scored lower on measures of perceived stigma (Griffiths et al., 2008). That is to say, older participants viewed depression negatively but believed that others do not hold negative beliefs about depression. Griffiths et al. also found that greater exposure to depression predicted higher scores on measures of perceived stigma, which suggests that a person with greater exposure to depression views depression in a less negative way but thinks others hold negative attitudes towards depression. Unlike personal stigma, no gender differences were found in perceived stigma nor were there differences in perceived stigma level based upon knowledge of depression. Participants who reported depression were more likely to personally think negatively about depression if they lacked knowledge, were in greater distress, and had less education (Griffiths et al., 2008). Moreover, less education and greater distress appeared to be a predictor of higher perceived stigma for those with depression. Current psychological distress was a predictor for both personal and perceived stigma. Griffiths et al. suggested common cognitive distortions (e.g., Nobody likes me and Everyone thinks I m stupid ) might explain this latter finding. These stigma-like beliefs, which may also be held in the absence of depression, appear to be heightened during an episode. Further, it is likely that such cognitive distortions also exacerbate stigma related to treatment, experiences, and secrecy (Kanter, Rusch, & Brondino, 2008). However, cognitive distortions do not entirely account for increased personal and perceived stigma. 8

17 Marcus and Davis (2001) and Schomerus et al. (2009) have found that people do tend to distance themselves from those with depression. Pyne et al. (2004) suggest that people who are depressed are more socially isolated than non-depressed persons. Cognitive distortions, therefore, may play some role in self-stigma but do not explain it as much as Griffiths et al. seem to suggest. Impact of depression stigma. Stigma can potentially be damaging for someone at risk for depression or who is suffering from depression. Stigma is related to loss of self-esteem and self-efficacy (Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001; Watson, Corrigan, Larson, & Sells, 2007) and discrimination (Link & Phelan, 2010). Additionally, treatment delay (Schomerus et al., 2009) and noncompliance (Sirey et al., 2001) may be affected by stigma. As mentioned previously, seeking treatment for depression is often delayed (Wang et al., 2007). The stigma of mental health issues is one factor in this delay (Kushner, & Sher, 1989; Schomerus et al., 2009) and research suggests that negative perceptions exist towards those who seek treatment (e.g., Ben-Porath, 2002). Ben-Porath (2002) compared undergraduate students responses to vignettes portraying a person with depression or a person with back pain. Vignette conditions included seeking help for depression, not seeking help for depression, seeking help for back pain, or not seeking help for back pain. The person seeking help for depression was viewed as more unstable than the person who sought treatment for back pain. Moreover, seeking help for depression was viewed more negatively than not seeking treatment for depression. This finding suggests that not only is seeking mental health treatment viewed more negatively 9

18 compared to seeking medical treatment, but seeking any help for mental health issues may be seen more negatively than not seeking help. If people view seeking help more negatively, they may not be willing to seek treatment at all. Stigma also appears to impact the acceptability of various treatment options. Psychosocial treatments are viewed more negatively than alternatives (Givens, Katz, Bellamy, & Holmes, 2007). Givens et al. considered people s perceptions of prescription medication, mental health counseling, herbal remedy, and spiritual counseling. The researchers also considered personal stigma and stigma related to telling friends and family, community, and coworkers (i.e., perceived stigma) about seeking each treatment. Herbal remedies appeared to have the least amount of associated stigma. For Caucasian participants, prescription medication was deemed most acceptable; this was significantly lower for African American participants. Spiritual counseling was significantly higher in acceptability for African American participants compared to Caucasian participants. Mental health counseling was more negatively impacted by stigma than prescription medication. It is suggested that perhaps it is easier to conceal usage of prescription medications over counseling. Therefore, the ability to keep it secret allows one to avoid negative views from others. This appeal of medication is consistent with Olfson et al. s (2002) findings of increase in medication use over counseling. Barney et al. (2006) also found participants reported greater preferences for nonpsychosocial treatments. The researchers asked participants to consider a vignette of a depressed individual. Participants were then asked to rate the likelihood they would seek treatment from a general practitioner, counselor, psychologist, psychiatrist, or 10

19 complementary practitioner if they were experiencing something similar to the vignette. Participants were further asked to consider for each professional, how embarrassed they would be, what others may think of them if they pursued help from each professional, and the anticipated reaction from each professional. There appeared to be a distinction between general practitioner and other mental health professionals. Specifically, participants stated they would be least embarrassed to see a general practitioner and would experience the least amount of stigma from others if they saw a general practitioner for mental health concerns. Seeing a psychiatrist and, to a lesser degree, a psychologist were rated as most embarrassing (Barney et al., 2006). Similarly, psychiatrists and psychologists were associated with higher risks of negative views from others. Interestingly, although participants reported being more likely to go to a general practitioner for treatment, they also reported they would feel more negative responses from general practitioners than psychologists and counselors. This finding seems to suggest that although seeking treatment from a general practitioner is viewed as less stigmatizing, people feel more comfortable talking with a psychologist or counselor about problems. Seeking treatment from general practitioners likely makes it easier to hide mental health issues. However, it may also make it more difficult to openly discuss mental health issues, thus heightening the risk of inaccurate diagnosis and less effective treatment options. Although Givens et al. s (2007) research suggests prescription medications may be more acceptable, medications are still associated with stigma. Sirey et al. (2001) found that noncompliance with medication was associated with higher perceived stigma, after 11

20 controlling for age and interpersonal problems. Although medication may be more acceptable (Givens et al., 2007), it appears greater perception of public stigma significantly impacts how likely one is to adhere to the required medication. This finding is important to note because Olfson et al. (2002) indicate a rise in the reliance upon medication in depression treatment. If medication is the primary means of treatment, it is important that people are using the medication correctly and as prescribed for maximum benefit. If stigma interferes with compliance, people may not experience the full benefit of medication. Etiological Beliefs Research suggests a variety of psychological, social, and biological factors contribute to onset of depression (Feliciano & Arean, 2007). Current understanding of the etiology of depression suggests that multiple factors interact with one another. The general public holds a variety of beliefs about the etiology of depression (Link et al., 1999). These explanations range from personal blame and personal weakness (Schomerus et al., 2009) to chemical imbalance and daily stress (Lauber, Falcato, Nordt, & Rossler, 2003; Samouilhan & Seabi, 2010). Although the general public endorses many etiological factors supported by research (Goldstein & Rosselli, 2003) the public also endorses many factors (e.g., personal weakness, blame, and religious punishment) that are not supported by research (Link et al., 1999). Link et al. (1999) used a nationwide sample to assess the general public s views on various mental illnesses, including major depression. Link et al. asked participants to read vignettes depicting various mental disorders. Participants then selected all causes 12

21 they believed played a factor in the disorder. Participants endorsed multiple factors for depression, suggesting the general public has some awareness of the complexities involved in depression. Generally, participants endorsed factors supported by research (e.g., stressful circumstances, chemical imbalance, and genetics). These causes were endorsed more often than those not supported by research (e.g., bad character and God s will). Although it is encouraging that empirically supported factors were more often endorsed, it is somewhat troubling that nearly 40% of participants endorsed bad character as a cause of depression along with empirically supported causes. Etiological beliefs can affect how depressed persons are perceived. Goldstein and Rosselli (2003) found that various etiological beliefs were associated with varying degrees of stigma. More specifically, biologically related etiological beliefs were associated with less negative attitudes about depression. Psychological beliefs (e.g., lack of will power and lack of social support) predicted greater stigma and greater desire for social distancing. Goldstein and Rosselli further found that endorsement of environmental beliefs (e.g., stress and life events) were associated with beliefs that people with depression are more violent than people without depression. The researchers posit that perceived controllability may account for variation in negative attitudes. If depression is due to a genetic predisposition, for example, depression is less likely to be seen as the person s fault and therefore more likely to be out of the person s control. People may report less negative beliefs because the depression is not in the depressed person s control. Similarly, viewing depression as lack of will power or social support 13

22 may be related to increased negative beliefs because of the perceived controllability of the depression. In addition to impacting views about persons with depression, etiological beliefs have also been found to influence views of appropriate treatment options (Goldstein & Rosselli, 2003; Samouilhan & Seabi, 2010). In a study of South African university students, Samouilhan and Seabi (2010) considered specifically what participants thought would be the best treatment based on etiological beliefs. Endorsement of social factors as the primary cause of depression was positively related to beliefs that help from clergy or prayer would be most helpful as well as dealing with symptoms by oneself. Seeking help from clergy was additionally noted as the most useful treatment for those who believed depression was a result of a personal weakness. Samouilhan and Seabi (2010) further found that viewing chemical imbalance as a cause of depression was related to greater endorsement of medication as the best treatment and lower endorsement of psychotherapy or a support group. Participants were more likely to endorse dealing with depression by oneself if they perceived depression to be a result of genetics. It may be that people do not understand that psychosocial treatment may be helpful even if there are biological influences in the onset of depression. Additionally, Samouilhan and Seabi (2010) found a strong negative relationship between seeing depression as caused by the way one is raised and dealing with it by oneself. That is, participants reported it would be less helpful to deal with depression by oneself if depression was considered to be a result of one s upbringing. The same was not 14

23 found for stressful life events. Rather, endorsement of stressful life events was related to an increased likelihood to view talking to family and friends as helpful and medication as less helpful. It is clear, then, that differing views of the cause of depression were related to differing views of what type of treatment is most helpful. It is further interesting to note that few etiological beliefs were related to believing in the merits of pursuing psychosocial treatment. Although etiological beliefs are found to influence beliefs about what treatment is effective, it is less clear if they impact willingness to seek treatment. Samouilhan and Seabi (2010) found that although not against seeking treatment entirely, participants were not particularly likely to seek treatment. The researchers did not investigate whether etiological beliefs would have any influence on willingness to seek a particular form of treatment. For example, if a person believes depression is a result of weak will, is he or she less likely to seek professional services? Therefore it is unclear which, if any, specific treatment people would be more or less likely to seek based upon beliefs. Purpose Depression is a potentially debilitating disorder that can create substantial social, psychological, financial, and daily living disturbances. Although often a recurrent condition, depression is treatable and can be managed with psychotherapy and/or medication. However, many people either delay treatment or fail to seek treatment. One possible factor in treatment delay or failure to seek treatment is stigma. Stigmatizing beliefs about depression are found worldwide and across a variety of demographics. Men, less educated persons, and less knowledgeable persons tend to report greater levels of 15

24 stigma. It is unclear based on prior research how etiological beliefs are related to personal and perceived stigma. It is also unclear how etiological beliefs influence willingness to seek psychosocial treatments. Moreover, prior research has included nationwide samples, university students, and medical professionals. There is a lack of research in this area using participants with a background specifically in behavioral sciences and psychological disorders. The aim of the current study was to advance the current understanding of stigma in mental health issues by examining beliefs about depression among persons with training in applied behavioral sciences. The focus included the role of stigma and etiological beliefs in willingness to seek mental health treatment. The current study included an undergraduate comparison group. Although prior research leads to the assumption that those with psychological training would report less stigma and greater willingness to seek treatment, this has not been empirically tested. With greater understanding of stigma and treatment willingness, mental health professionals may be more knowledgeable about how to provide the general public with resources or specific education to increase treatment utilization. Further, greater understanding may guide how behavioral sciences graduate programs address stigma and treatment willingness within their training system. 16

25 Chapter II Research Questions and Hypotheses General Research Question: How are stigma and etiological beliefs related to willingness to seek psychosocial treatment for depression and how do these beliefs differ between undergraduate students and behavioral sciences graduate students? By better understanding the relationship among these factors, it is hoped that mental health professionals are more effectively able to address delays in treatment seeking and promote mental health treatment. Additionally, greater understanding of how depression is viewed will help practitioners deal with concerns upon initial contact with clients. Much research has been performed outside the United States (e.g., Griffiths et al., 2008; Samouilhan & Seabi, 2010; Yen et al., 2005) and in nursing and medicine (e.g., Elliot et al., 1990), but there is little research on the stigma of depression as well as willingness to seek treatment among persons training for employment in applied behavioral sciences fields. Examining this group will fill a gap in current research. H1: Stigma will significantly predict willingness to seek treatment. This hypothesis is consistent with prior research suggesting higher stigma is related to treatment seeking (e.g., Brown et al., 2010). It is believed that people will be less willing to acknowledge depression by seeking treatment if they have more negative beliefs about depression. H2: Type of etiological belief will significantly predict type of treatment one is willing to seek (e.g., medication, psychosocial treatment). More specifically, it is hypothesized that a belief that depression results from biological factors will predict 17

26 greater willingness to use medication. Beliefs related to coping will predict greater willingness to seek therapy. Beliefs related to personal blameworthiness or punishment will predict less willingness to seek treatment. This hypothesis is consistent with prior research implicating the role of etiological beliefs in treatment seeking (e.g., Roh et al., 2009; Samouilhan & Seabi, 2010). H3: Higher education will be significantly correlated with lower levels of stigma and greater willingness to seek treatment. This hypothesis is consistent with prior research suggesting higher education is related to lower levels of stigma (e.g., Corrigan & Watson, 2007; Golberstein et al., 2008; Highet, Luscombe, Davenport, Burns, & Hickie, 2006). Previous research has not used students pursuing education in applied behavioral sciences fields specifically; however, it is believed that education level and specific training will be related to significantly lower levels of stigma and increased willingness to seek treatment for depression. Research Question 1: How do men and women differ on willingness to seek treatment, etiological beliefs, and level of personal stigma? Based on prior research (e.g., Corrigan & Watson, 2007; Griffiths et al., 2008), it is believed that men will report higher levels of stigma and be less willing to seek treatment. This gender difference, however, is not as clear for the behavioral sciences graduate student sample. Higher education level, as discussed in Hypothesis 3, is related to lower stigma and greater willingness to seek treatment. The behavioral sciences graduate student sample also has more training in mental health issues. Previous research suggests that greater knowledge about depression is related to lower stigma and greater willingness to seek treatment (e.g., 18

27 Griffiths et al., 2008). Therefore, it is possible that gender differences will not exist among graduate students. It is also unclear if men and women will endorse different etiological beliefs. Research Question 2: How is depression level related to willingness to seek treatment, etiological beliefs, and level of personal stigma? Previous research has found somewhat conflicting results about the impact of depression level. Some research suggests greater distress is related to an increased willingness to seek treatment (e.g., Blumenthal & Endicott, 1996/1997), whereas other research has indicated greater distress is related to less willingness to seek treatment (e.g., Schomerus et al., 2009). It is further unclear whether greater severity of depressive symptoms will impact stigma or treatment seeking in the graduate student sample. Research Question 3: How are etiological beliefs related to level of stigma? This question will address whether certain etiological beliefs are more strongly related to higher levels of stigma compared to other beliefs. Previous research suggests blameworthiness is more strongly related to negative stigma (Teachman, Wilson, & Komarovskaya, 2006), but the relationship between other etiological beliefs is less clear. 19

28 Chapter III Method Participants Participants of primary interest for this study included graduate students (n = 89, 23 male, 66 female) recruited from the Marriage and Family Therapy (n = 3), Clinical Psychology (n = 17), Counseling Psychology (n = 23), and Educational Psychology (n = 45) departments from a large southwestern university. Average age was 27, with a range between 22 and 64 (s.d. = 14). Ethnicity included Caucasian (n = 74), Latino/a (n = 6), African-American (n = 1), Asian-American (n = 1), and Other/multi-racial (n = 6). The comparison group included undergraduate students (n = 88, 47 male, 41 female) from the same southwestern university; participants were recruited through the general psychology participant pool. Undergraduate students were given partial course credit for participation in research. Average age was 20, with a range between 17 and 38 (s.d. = 3.7). Ethnicity included Caucasian (n = 46), Latino/a (n = 22), African-American (n = 16), Asian-American (n = 3), and Other/multi-racial (n = 1). Methods of the current study were in alignment and compliance with the American Psychological Association (APA) ethics code and approved by the university Institutional Review Board. Participants responses were not tied to their identities to protect participant confidentiality. Measures All measures were self-report. Because of a lack of well-established instruments currently available for measuring variables of interest, items from various less-known 20

29 assessments were adapted for use in the current study. Further, because measures were adapted for use in the current study, questionnaires were piloted first to ensure ease of completion, utility, and to identify potential concerns. Concurrent and predictive validity were not calculated and assessed due to the limitations of the current study. The research design of the current study is a two-group design, with one assessment of each participant. The one-time-only assessment did not allow for corroborative data of selfreported depression and treatment seeking. Stigma. The Depression Stigma Scale (DSS; Griffiths et al., 2004) was used to assess stigma related beliefs. Both the DSS-Personal and DSS-Perceived subscales were used. The DSS-Personal subscale comprises nine items that assess personal attitudes towards depression (e.g., Depression is a sign of personal weakness; I would not employ someone if I knew they had been depressed), with the following major themes: depression as an illness, personal control of depression, depression as a character flaw, dangerousness and unpredictability of someone with depression, shame of depression, and avoidance and discrimination of those with depression (see Appendix B). Item responses are scored on a Likert-scale (1 = strongly disagree, 5 = strongly agree). For the current study, strongly disagree responses were scored as a 0, whereas strongly agree responses was scored as a 4, for a total possible score ranging from 0 to 36, with a higher score being indicative of greater personal stigma. The DSS-Personal subscale has demonstrated acceptable reliability, with a Cronbach s α of 0.76 and test-retest reliability between 0.66 and 0.79 (Griffiths et al., 2004). No validity information is available for the 21

30 DSS-Personal subscale. Cronbach s α for the current study was similar to previous research (Cronbach s α = 0.80). The DSS-Perceived subscale (Griffiths et al., 2004) consists of nine items that assess what participants think most other people believe about depression (e.g., Most people believe that people with depression are unpredictable, Most people would not vote for a politician they knew had been depressed). Similar to the DSS-Personal subscale, the DSS-Perceived subscale measures perceptions across the following major themes: depression as an illness, personal control of depression, depression as a character flaw, dangerousness and unpredictability of someone with depression, shame of depression, and avoidance and discrimination of those with depression (see Appendix C). Item responses are scored on a Likert-scale (1 = strongly disagree, 5 = strongly agree). For the current study, strongly disagree responses were scored as a 0, whereas strongly agree responses were scored as a 4, for a total possible score ranging from 0 to 36, with greater stigma related to higher scores. The DSS-Perceived subscale has demonstrated acceptable reliability, with a Cronbach s α of 0.82 and test-retest reliability between 0.67 and 0.73 (Griffiths et al., 2004). No validity information is available for the DSS-Perceived subscale. Cronbach s α for the current study was Etiological beliefs. To assess etiological beliefs about depression, participants were asked to rate on a Likert-scale (1 = strongly disagree, 5 = strongly agree) how strongly they agree with the following etiological options: weak will or lack of personal strength, chemical imbalance, the way the person was raised, stressful events in the person s life, social factors such as negative peer influence, a genetic or inherited 22

31 problem, spiritual forces, inadequate coping skills and problem-solving skills, and other (see Appendix D). The etiological beliefs questionnaire for the current study was similar to the items used by Samouilhan and Seabi (2010), but was adapted in the current study to maintain continuity within the set of questionnaires. Items were modified for the current study to include response options on a 5-point Likert-scale of agreement (1 = strongly disagree, 5 = strongly agree). Cronbach s α for etiological beliefs factors in the current study was After further exploration of etiological variables, it did not appear that removing any of the etiological variables significantly increased alpha. The low alpha may be related to the variation in etiological variables. Treatment seeking. As done by Barney et al. (2006), participants likelihood to seek treatment was assessed by nine items rated on a 5-point Likert-scale (1 = not at all likely, 5 = very likely). As shown in Appendix E, items include: If I had depression I would seek help from a (counselor, psychologist, psychiatrist, general practitioner, clergy, other) and If I had depression, I would not seek treatment from a professional. Additionally, similar items assessed one s willingness to take medication or participate in therapy for depression (e.g., If I had depression, I would be willing to take medication; If I had depression, I would be willing to seek therapy). No validity or reliability information was provided by Barney et al. Cronbach s α for willingness to seek treatment in the current study was.74. Depression symptoms. Current depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977). The CES-D is a frequently used self-report depression screening measure, asking participants 20 23

32 questions about intensity of common depression symptoms over the past week (e.g., I was bothered by things that don t usually bother me and I did not feel like eating; my appetite was poor). Items are rated on a 4-point Likert-scale (1 = Rarely or none of the time, 4 = Most or all of the time). Rarely or none of the time responses are scored as a 0 and Most or all of the time responses are scored as a 3, for total score range between 0 and 60, and higher scores indicate more severe symptomology. Items particularly emphasize affective aspects of depression over cognitive or physical symptoms (see Appendix F). Used in numerous studies, the CES-D was developed for non-clinical samples, which made it ideal for use in the current study. The CES-D has demonstrated acceptable validity and reliability. Fischer and Corcoran (2007) report internal consistency alphas of.85 for the general public and Spearman-Brown reliability coefficients between.77 and.92. Further, the CES-D is reported to have excellent concurrent validity with other well established measures of depression, including the Beck Depression Inventory (BDI). Research also indicates the CES-D is effective in discriminating between those in the general public who report needing help and those who do not (Fischer & Corcoran, 2007). Cronbach s α for the current study was 0.93, which is consistent with prior research. Open-ended section. To further assess participants attitudes and beliefs about stigma, etiology, and treatment of depression not otherwise identified on close-ended questionnaire items, an open-ended short answer question (see Appendix G) was included at the end of the questionnaire (i.e., What other comments do you have about the causes 24

33 of depression, the stigma of depression and those with depression, and seeking treatment from a professional for depression?). Demographic questionnaire. A short demographic questionnaire was administered (see Appendix H) that consisted of items about age, gender, ethnicity, education level (year in major), program or department, and major course of study (or undecided). Procedures All procedures were reviewed and approved by the Texas Tech University Institutional Review Board prior to data collection. Participants were informed that the researcher was interested in better understanding views and beliefs about depression and depression treatment. Participants were told that all responses would be kept confidential, anonymity preserved, and that there should be minimal risks from participation in the study. They were also informed participation was entirely voluntary and they were free to withdraw at any time. All undergraduate students completed measures in person. Graduate students completed the same questionnaire either in person or online. An online option was included and approved by the Institutional Review Board to increase sample size. All participants first completed a set of demographic questions. Next, they completed selfreport measures. The DSS-Personal subtest, DSS-Perceived subtest, and etiological beliefs items were interspersed. Participants then completed items regarding treatment willingness and beliefs about effective treatments for depression followed by CES-D items. The open-ended item was completed at the end of the questionnaire. All measures 25