Age plays a very important role in mental health and mental health care utilization. In fact, older people are statistically less likely to utilize mental health services (Mackenzie et al., 2008). Moreover, “[a]dolescents and young adults frequently experience mental disorders, yet tend not to seek help” (Gulliver et al., 2010, p. 1). This is especially significant because 1 in 5 U.S. adults and 1 in 6 U.S. youth have experienced mental illness at some point in their life (NAMI, 2019). We as the research team wanted to better understand the relationship between age and mental health/mental health care, and in particular the reasons that older adults tend to underutilize mental health. Thus, we formed a research question: how do younger and older people’s experiences and understandings of mental health differ? While literature has established certain themes regarding understandings of mental health among different ages by means of quantitative analysis, there is little qualitative data supporting these findings. Existing research has also provided limited insight into why older individuals do not seek out mental health care. This study intends to fill this gap in the literature, providing rich qualitative data regarding perspectives and experiences of mental health across age groups.

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Literature Review

As mentioned previously, this is not a topic that has gone unstudied. In fact, many researchers have examined the relationship between mental health and age. One article by Mackenzie et al. (2008) intended to find out if the underutilization of mental health care by older adults is due to negative attitudes and beliefs regarding help-seeking and mental health treatment. This was accomplished by taking a cross-sectional sample of both younger and older U.S. adults who were administered the NCS-R. The NCS-R gauges the prevalence and comorbidities of psychiatric disorders, particularly “attitudes toward professional mental health services use” (p. 6). Ultimately, it was found that adults aged 55+ were actually far more likely than younger adults to report positive health-seeking attitudes. These findings mirror those of another study conducted by Mackenzie et al. (2006), which also examined help-seeking attitudes across age groups. Researchers sampled Canadian adults aged 18-89, and had them fill out a questionnaire-style packet surveying attitudes toward seeking mental health care. Similar to the previous study, they found that older people actually have more positive attitudes toward mental health than younger people. They also found that individuals are most likely to seek help for a mental health issue from a mental health professional, and least likely to manage the issue themselves. 

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Robb et. al (2003) investigated further into this area of inquiry, assessing the breadth of perspectives held by different age groups on mental health. In their sample of U.S. adults aged 18-65 and 65+, researchers found that “older adults have less experience, less knowledge, and less likelihood of seeking help for most mental disorders and problems in living…[yet, c]ontrary to common perception, older persons believe that mental health issues are important and value access to this care” (p. 150). This finding is important to consider, because it seems to refute the presumption that older people tend not to seek mental health care because they view it negatively. 

While the methods utilized by these studies differ from ours, they nonetheless provide valuable insight into the attitudes and beliefs of different age groups regarding mental health. Overall, the research on this topic suggests that the underutilization of mental health care among older people is not due to a negative perception of mental health treatment, as the view of mental health issues and access to mental health care appears to be predominately positive in older individuals. As such, these results may indicate the existence of an alternative variable, which should be pursued further in psychological research. This knowledge informs our research topic and measures, and provides us with a quantitative framework to expand upon with qualitative data. We as the research team want to begin to uncover what this alternative variable may be in our study by obtaining a qualitative sample of interview data and analyzing it for any common themes across or between age groups. 

 

Method

This study was completed under a constructivist scientific paradigm utilizing a qualitative approach. Due to this, we as the research team recognized the inevitability, and even usefulness, of a relationship between researchers and participants. This relationship is especially beneficial when discussing sensitive or controversial topics, as participants may feel more comfortable disclosing information when they trust the researcher (Guillemin et al., 2018, p. 1). In particular, qualitative interviews entail more of this relationship and thus are “ideal for [examining] sensitive issues” (Braun & Clarke, 2009, p. 210). As our research question deals with mental health, a topic that can be sensitive or controversial for some individuals, we chose interviews as the sole source of data collection for this study. Due to the time constraints of this project, the research team decided not to employ any additional data collection techniques.

 

Researcher Description

Two researchers worked on this study, Daesoleil and Arabella. Arabella (Bella) is an intensive psychology student with a long history of experience with mental illness. She has a lot of friends and family who have experienced mental illness and has undergone treatment for mental health conditions in the past. Her upbringing stressed the relevance of mental health care and acknowledged the existence of mental health issues among all types of individuals. Arabella works with youth as a nanny and swim instructor, and thus has considerable professional insight into the lives of younger individuals. Daesoleil is also an intensive psychology student who works with youth. She currently works in the mental healthcare field, interning at a short-term residential therapeutic facility for youth aged 13-16. Daesoleil has received mental health treatment in the past, and has friends and family who have struggled with mental illness as well. She had a similar upbringing to Arabella, in that her family emphasized the significance of seeking mental health care regardless of the severity of the issues one is experiencing. 

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Due to the personal connections we held with the subject matter, we remained very focused on maintaining critical reflexivity when conducting interviews and analyzing data for this study. This was especially pertinent considering the close relationship researchers had with participants. This process entailed full disclosure of our background in the beginning stages of the project, and necessitated strong self-awareness during data collection, analysis, and interpretation. We also made sure to share our own experiences with the participants either before or during the interview, to build trust and help them feel comfortable discussing such a sensitive topic. As both researchers are caucasian and middle class, it is also important to recognize our position within societal and cultural power structures. To mitigate the influences of these factors, we did our best to display critical reflexivity by keeping thorough notes from the research process and frequently discussing and acknowledging our positionality.  

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Materials

Interview questions were created using broad categories adapted from previous literature examining mental health beliefs. These categories included: understanding of mental health, attitudes regarding mental health care, and views on age’s relationship with mental health. We then created nine questions corresponding to these three categories, with each category being assigned between 1-5 questions. The number of questions each category received was decided dependent on the breadth of the category, as broader categories required more specific questions for a comprehensive view. Interview questions were then edited and reviewed to ensure quality. All nine interview questions asked of participants can be found in Appendix G. 

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Procedure

Before interviews occurred, participants were informed of the research topic, what their data would be used for, and what the interview would entail. All participants gave verbal informed consent. Interviews were conducted either by phone or in-person and lasted on average 30 minutes. With the permission of participants, audio from interviews was recorded and later transcribed. We then analyzed interview transcripts using thematic analysis. As we intended to find themes and commonalities among data, thematic analysis was the ideal analysis method. We utilized the six-phase thematic analysis process, first coding interview transcripts and then discerning themes and subthemes. Lastly, we discussed and refined themes and subthemes among the research team and with other professionals to ensure quality and rigor.

 

Participants

Participants were recruited via opportunity sampling, meaning the research team utilized individuals who were available and convenient to interview. Thus, all participants had some previous relationship with us (e.g. a friend, family member, family member of a friend, etc.). This sampling method was chosen because it was the most feasible given the time constraints of the study and the significant time commitment interviews and transcription requires. Moreover, it was thought by the research team that people who know and trust us already would be more willing to share on this sensitive topic. We specifically recruited participants from two age groups (16-21 and 65+) because our research question pertains to understanding of mental health among young adults and the elderly only. In total we recruited five participants: two family members, one friend, one family member of a friend, and one landlord. Two of these participants (Sid and Rose) are/were psychology majors, which may be important to note considering the topic of research. Moreover, one participant (Beth) is an immigrant from the UK. Exact sample demographics (age, gender, ethnicity, location) are displayed on the chart below. 

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Participant Demographics

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Member Check

 

We also completed a member check with various participants after we had some idea of our themes and subthemes. These were completed both in person and electronically and lasted on average 10 minutes. Member checks included showing participants the theme maps created with interview data and asking them for feedback. Participants were told that not all of the displayed data came specifically from their interview, as the theme maps were a result of analysis across all interviews. Ultimately, we received positive feedback regarding our analysis. Participants expressed agreement with the interpretation of the interview data and appreciation for the inclusion of their perspective in the research process. While we were not able to reach every participant in the short time between analysis completion and finalizing this paper, a majority of participants were able to complete the member check.

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Results

Ultimately, a lot of our results appeared to mirror those found in the literature, with some unexpected and surprising results. As discovered through thematic analysis, there were an abundance of similarities and differences among participants of different age groups. In fact, both younger and older participants discussed having their lives affected by mental illness. This was demonstrated in the quote below where participant Beth talks about her close friend: 

I have a friend here who is very depressed and erm, I told you about my student who is a psychiatrist for 12 years in Santa Cruz, and I sent my friend to her and I was so thrilled because she came out and said... I mean... I took her there... I drove her, I was still driving [laughs] I drove her there and I picked her up a couple of hours later and she said 'I feel like a whole load has been lifted off my shoulders' and I was so proud of my student that... well she wasn't my student… but I just was so impressed that [it worked out]. (p. 31)

Younger participant Sid also discussed experiencing anxiety, though she is not officially diagnosed. This is reflected in her statement, “yeah, I would really like a generalized anxiety diagnosis. I know I have it, everyone knows I have it but like I could actually get resources and stuff if someone told me that I had it” (p. 22). Another participant Rose had specifically sought out and received treatment for her anxiety, and she discusses her experience trying to find a therapist that fit her religious views by saying, “that wasn’t my top priority, my top priority was anxiety, someone that deals with anxiety, and it’d be great if they were Christian” (p. 26). While not every participant had experienced mental illness themselves, every participant expressed the fact that mental illness had impacted their lives in some way, regardless of age. 

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In addition to having personal experience with mental health problems, all participants discussed believing mental health problems could be triggered by or attributed to a wide variety of causes. Participant Beth said, “Yeah, you have to not eat sugar and stuff like that so that you can keep your marbles!” (p. 30), implying that diet is partially responsible for maintaining mental health. Participant Dan, while slightly an outlier, discussed both trauma and cell phones as causes for mental health, quoted in his interview as saying: 

[laughs and picks up my cell phone off the table] This is a microwave generator, like microwave oven, you put this next to your brain, like my brother did this for ten years he had uh melanoma on his brain on the side he used it and held his cellphone. So, you're gonna see a lot of people having mental issues because of that, putting that next to their brain. (p. 46)

Participant Rose said directly that there are "unlimited reasons” mental health issues can occur (p. 28). Sid expressed a similar sentiment when she said she thinks mental health issues occur for “all different reasons, I’m very nature and nurture together” (p. 23). 

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Additionally, younger participants cited more reasons for seeking mental health treatment and acknowledged more barriers to receiving that treatment. Younger participant Sherry discusses these barriers in the quote below, saying:

 I know people my age are more inclined at the very least to take mental health seriously. And they sometimes struggle to actually obtain it though due to legal guardians. I have a friend whose parents don't believe that therapy does anything and so since that is an issue it's harder for them to get the help that they need. (p. 51)

It appears that younger participants face more barriers because they have to rely on others, particularly parents, to provide them with resources and support. Relying on someone else, especially financially, adds an extra step to receiving treatment and thus can make it more difficult for the individual. Participant Sid expressed this when she said, “it’s just that I could totally ask my parents, but it makes me feel bad spending their money if I think I can handle myself” (p. 22). Earlier in the interview she also talked about the social barriers she feels younger people experience, saying:

I wish it [mental health care] was more talked about. Like I wish there was somebody being like “hey come here for a free screening” or “here is where you can go and pay a student price for therapy”, cause no one talks about it like that...I just, I wouldn’t even know where to start, and there’s a community social block, rather than a financial or physical block. (p. 20)

Younger people in this study appeared to recognize that while the culture around mental health is changing, seemingly for the positive, there are still barriers to receiving the treatment they feel they should have access to. 

On another note, it appeared that older participants felt as though personal choices played a larger role in mental health, and were more likely to address how mental health changes throughout people's lifetimes. In fact, Rose stated in her interview how growing up it was felt that, “If a person is anxious or depressed, isn’t capable of leading a productive life, it’s their fault. Mental illness growing up was someone's fault” (p. 29). When Participant Beth said, “Yeah, you have to not eat sugar and stuff like that so that you can keep your marbles!” she also implied that personal choices play an important role in mental health (p. 30). Rose also discussed how mental health changes throughout your life when she said:

The older you get, your body, physically and emotionally changes, and wears out. As older people, our bodies are wearing out and that causes emotional stress, emotional issues. So, yes. There’s also some behaviors that can be considered appropriate when you’re younger but not as you grow up, so that’s age related as well. Also, sometimes kids, young or teenagers, experience trauma or extra stress, so they either grow up too fast, miss out on a part of childhood, or they have to resort to certain behavior to just get by, so that again would be an age affecting something. (p. 28)

Somewhat of an outlier, older participant Dan expressed that with age he became increasingly dissatisfied with conventional mental health care. He is stated in his interview as saying:

One of the really scary things I think, i'm not sure what the initials are I think it's MDA it's like this group of, I think it's a group of psychologists or psychiatrists they get together every once in a while and they make up all these new diseases and they write it and then they prescribe uh drugs for them. So like it's a perfect business model for big pharma and for these guys, and they're writing all these prescriptions and putting all these people on drugs and it's just and there's like no science-backed on any of the you know, they come up with this disease, there's no science about it, there's no like studies or clinical nothing it's all they just get together in the meeting and they just decide a new disease. (p. 41)

This is an example of older participants’ responses being more varied, possibly due to the formation of niche schemas regarding mental health over time. While it may be an extreme case, it does indicate the existence of some negative sentiment toward mental health care by older adults, though more particularly toward services offered by conventional care systems. 

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Younger participants’ comments about age’s relationship with mental health seemed more to reflect that with age comes additional experience and understanding of mental health. Sherry is quoted as saying:

Yeah, I think the only thing that's changed [with age] is my awareness of it because when you're like 8 years old you don't have many thoughts towards people. And I think the older I get the more I have met people that suffered through mental health issues, like I [sigh] I have one friend that tried to commit suicide and ended up in a- the hospital for that and I have one friend that suffers through auditory hallucinations and I have one friend who suffered through childhood trauma and now suffers through PTSD symptoms they're trying to get stuff for. (p. 52)

Essentially, Sherry suggests that the older you are the more people you encounter who experience issues with mental health/mental illness. This quote reveals that youth actually have far more extensive histories with mental health and mental illness than people may assume. 

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Pictured in Appendix A are the theme maps, which contain the detailed themes and subthemes found in interview data. Note that they are a culmination of data from interviews, and each subtheme was not necessarily held by every member in the age group. Interview transcripts, where these quotes are sourced, can be found in Appendix B through Appendix F. 

 

Discussion

We began this study with the assumption that younger participants would have more positive views regarding mental health treatment, and possibly more understanding of mental health in general. While this was partially confirmed, there were several aspects of the results we found exceptionally interesting. Specifically, the fact that both younger and older participants all had similar amounts of personal experience with mental illness and mental health problems was surprising to find. With the exception of Dan who only worked with adults who have been through trauma, all participants described having a lot of experience with mental health problems. Prior to the study, we had assumed older participants would have more experience with mental health problems simply because they have more life experience, but that was incorrect.  

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The finding that youth may experience more barriers to treatment because they are financially reliant on others is interesting as well. This reflects what has been found in previous literature on youth and mental health/mental health care, and may suggest that the concern is more widespread than some may have previously recognized (Gulliver et al., 2010). Moreover, it implicates that increasing open discussions between young people and their guardians regarding mental health treatment may be beneficial in reducing their perceived barriers to treatment. 

Though studies have found that in the United States older adults statistically underutilize mental health care, we found that in our sample, this is likely not due to individual’s holding negative attitudes or beliefs regarding mental health or mental health care (Mackenzie et al., 2008). However, this study did little to reveal a commonality as to why that might be. Our sample of older participants cited such a wide variety of personal reasons to either seeking or not seeking mental health care, it was difficult to discern a single common theme. This may suggest a larger variance in perspectives among older people than younger people regarding mental health/mental health care. However, our sample size is too small and too local to make any definitive claims on that matter. Readers should keep this limitation in mind when trying to apply findings to different settings.  

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The main ethical dilemma experienced during this study was that two of the participants had or were in the process of earning bachelor's degrees in psychology. This could have possibly skewed our data, because most psychology majors can be assumed to have higher level of baseline interest in mental health, though not always. Participants may also represent a biased sample, as researchers had signfiicant experience with mental health issues and recruited individuals they were familiar with. Future research should find a way to control for this, if at all possible. Future research should also attempt to find more marked commonalities among perspectives of older adults, as that may provide insight as to why they are less likely to utilize mental health care (Mackenzie et al., 2008). This would require a much larger study than the one we conducted, and ideally would involve a more unbiased sampling method to achieve a more representative sample. 

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References

Braun, V., & Clarke, V. (2013). Successful qualitative research: A practical guide for beginners. London: SAGE.

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Guillemin, M., Barnard, E., Allen, A., Stewart, P., Walker, H., Rosenthal, D., & Gillam, L. (2018). Do research participants trust researchers or their institution? Journal of Empirical Research on Human Research Ethics, 13(3), 285–294. https://doi.org/10.1177/1556264618763253

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Gulliver, A., Griffiths, K.M. & Christensen, H. (2010). Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review. BMC Psychiatry, 10, 113. https://doi.org/10.1186/1471-244X-10-113

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Mackenzie, C. S., Gekoski, W. L. & Knox, V. J. (2006) Age, gender, and the underutilization of mental health services: The influence of help-seeking attitudes. Aging & Mental Health, 10(6), 574-582. 10.1080/13607860600641200

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Mackenzie, C. S., Scott, T., Mather, A., & Sareen, J. (2008). Older adults' help-seeking attitudes and treatment beliefs concerning mental health problems. The American Journal of Geriatric Psychiatry, 16(12), 1010–1019. https://doi.org/10.1097/JGP.0b013e31818cd3be

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NAMI. (2019, September). Retrieved from https://www.nami.org/learn-more/mental-health-by-the-numbers 

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Robb, C., Haley, W. E., Becker, M.A., Polivka, L. A., & Chwa, H. J. (2003). Attitudes towards mental health care in younger and older adults: Similarities and differences, Aging & Mental Health, 7(2), 142-152. https://doi.org/10.1080/136078603100007232