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Perceived Stigma and Depression among Black Adolescents in

Outpatient Treatment

Theda Rose, MSWDoctoral Candidate

National Catholic School of Social ServiceThe Catholic University of America, Washington, DC

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Acknowledgments Co-Authors Sean Joe, PhD, LMSW, Associate

Professor, School of Social Work, University of Michigan

Michael Lindsey, PhD, MSW, MPH, Assistant Professor, Schools of Social Work and Medicine, University of Maryland, Baltimore

Research Lab on Race and Self Destructive Behavior (Katie Taylor, Ajabeyeng Amin, Lili Deng)

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Depression in Adolescence Among adolescents, depression is widely studied due to its:

potential negative impact on future life choices and experiences (Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993)

proposed correlation to future depression (Canals, Domenech-Llaberia, Fernandez-Ballart, & Marti-Henneberg, 2002; Monroe, Rohde, Seeley, & Lewinsohn, 1999)

co-occurrence with other disorders such as anxiety and substance abuse (Hjemdal, Aune, Reinfjell, Stiles, & Friborg, 2007; Peterson et al., 1993; Substance Abuse and Mental Health Services Administration (SAMHSA), 2003)

connection to suicide attempts in adolescents (Joe et al., 2009; Peterson et al., 1993; SAMHSA, 2003) and

contribution to the global disease burden (Merry, McDowell, Wild, Bir, & Cunliffe, 2004).

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Depression in Adolescence

By the age of 18, up to 24% of youth will have experienced at least one incident of major depressive disorder (Kowalenko et al., 2002)

Approximately two million adolescents, aged 12-17, experienced a major depressive disorder during 2008 (SAMHSA, 2009b)

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Mental Health Service Use Numerous alternatives for the treatment of depression

exist, but service use remains low in an adolescent population (SAMHSA, 2009a)

Approximately 80% of young people that need mental health treatments are not accessing suitable treatments (National Advisory Mental Health Council, 1990; US Department of Health and Human Services (USDHHS), 1999)

Only 37.7% of adolescents, ages 12-17, diagnosed with major depressive disorder during the 2008 year received treatment (SAMHSA, 2009b)

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Mental Health Service Use According to the U.S. Surgeon General’s report on

mental health, ethnic minority children are less likely than white children to receive mental health services (USDHHS, 1999, 2001)

9.5% of Black and 9.7% of Hispanic adolescents as compared to 12.7% of white adolescents utilized outpatient mental health services in 2008 (SAMHSA, 2009b)

Emotionally distressed Black adolescents received mental health counseling significantly less that their white or Hispanic counterparts (Kodjo & Auinger, 2004)

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Stigma and Mental Health Service Use

Stigma is one of the major factors that serve as a deterrent to mental health service utilization:

The stigmatizing of people with mental disorders remains a key obstacle to the advancement of prevention, treatment, and illness recovery efforts (Corrigan, 2007; Mann & Himelein, 2004; Pescosolido, Perry, Martin, McLeod, & Jensen, 2007; USDHHS, 1999)

Depressed children and adolescents may be more susceptible to mental illness stigma than adults (Perry, Pescosolido, Martin, McLeod, & Jensen, 2007)

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Stigma and Mental Health Service Use

Generally, research has confirmed a relationship between stigma and seeking, initiating, maintaining, and discontinuing treatment. Stigma has been inversely related to positive attitudes

towards treatment and help seeking behaviors (Barney, Griffiths, Jorm, & Christensen, 2006; Mann & Himelein, 2004)

Stigma predicted treatment discontinuation among older patients (65+) with major depression (Sirey et al. (2001)

Negative influence of stigma on treatment seeking and adherence in population of adults with mental illness (Dinos, Stevens, Serfaty, Weich, & King, 2004)

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Mental Disorders and Stigma Clinical diagnoses labels and their associated criteria can

increase public stigma by prompting stereotypes about and promoting prejudice and discrimination against the mentally ill (Corrigan, 2007)

Dinos et al. (2004) reported that those with anxiety, depression, and personality disorders were more impacted by subjective feelings of stigma

Yen et al. (2005) reported that Taiwanese outpatients (aged 14-87) with more severe depression reported greater levels of self-stigma

Higher levels of depressive symptoms (Ragarum Weiss, Channabasavanna, & Devins, 1996) and greater depression severity (Pyne et al., 2004) in psychiatric outpatients were significantly related to greater perceived stigma

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Purpose of Study

Scant scientific attention has been given to exploring the relationship between specific stigma and mental health disorders, particularly the severity of depression among adolescents.

The purpose of this study was to explore the relationship between Black adolescents’ perceived stigma and their current level of depression severity in an outpatient sample.

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Research Question & Hypothesis

What is the relationship between perceived stigma and depression severity among Black adolescents in outpatient treatment?

We hypothesize that depression severity is positively associated with greater perceived stigma

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Methods - Participants

108 adolescents (aged 12-17) and parent dyads were recruited from a community mental health agency in Detroit, MI

Majority were African American (102), 2 mixed race, 2 Latinos and 2 American Indian

58 female and 50 male adolescent participants

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Methods - Measures

Reynolds Adolescent Depression Scale (RADS-2)(RADS-2; Reynolds, 1987)

Developed to evaluate the clinical severity of depressive symptoms in adolescents’ ages 12 through 18 years

Attitudes Toward Psychological Help (Stigma)(ATPH – Modified from Komiya, Good, & Sherrod, 2000; Pyne, 2004)

5-item scale developed to assess individuals’ awareness of social stigma associated with receiving psychological services

4 Likert-type responses (strongly disagree, disagree, agree, strongly agree) were given to questions reflecting attitudes toward mental health treatment

Perceived Need of Mental Health Service (In last 6 months) Have you needed an emotional counselor? Have you needed a psychiatrist?

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Methods – Data Analysis The Cronbach’s alpha for the adapted mental health stigma scale

(ATPH) was determined through assessing the mean, standard deviation, and the item to total correlation for items on the scale (α=.67)

Chi-square analyses were conducted to examine: perceived mental heatlh stigma (ATPH) by socio-demographic

characteristics such as age, gender, grade, time in treatment, perceived service need, and the RADS score

depression severity (RADS) by socio-demographic characteristics

Logistic Regression analyses were conducted to measure the effect of depression severity on perceived stigma

Results

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Results – Chi-Square Analyses

Normal (n=77)

Mild to Severe (n= 31)

pValueN (%) N (%)

AgeChild (0-12) 19 (90.48) 2 (9.52)Early Adolescence (13-14) 27 (65.85) 14 (34.15)Late Adolescence (15-17) 29(69.05) 13 (30.95)

0.14Gender

Male 43 (86.00) 7 (14.00)Female 34 (58.62) 24 (41.38)

0.002**Grade

Elementary (1-6) 10 (100.00) 0 (0.00)Intermediate (7-8) 26 (70.27) 11 (29.73)High School (9-12) 36(66.67) 18 (33.33)

0.08Time in Treatment

Low (0-110 days) 25 (75.76) 8 (24.24)Med (111-193 days) 19 (54.29) 16 (45.71)High (194- 337 days) 29 (80.56) 7 (19.44)

0.62Perceived Service Need

None 38 (84.44) 7 (15.56)Psychiatrist or Counselor 26 (76.47) 8 (23.53)Both 13 (44.83) 16 (55.17)

0.0004***

* p < .05; ** p < .01; *** p < .001

Depression (RADS Score)Table. Clinical and Sociodemographic Characteristics of Subjects

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Results – Chi-Square Analyses: Table 1

Evidence of a significant association between gender and depression severity (χ2 = 9.75; p <.01)

Evidence of a significant association between perceived need for treatment and depression severity (χ2 = 12.49; p <.001)

Depression severity was not significantly associated with other socio-demographic characteristics such as age, grade, and time in treatment

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Results – Chi-Square Analyses: Chart 1

Interaction Between Percieved Service Need and Depression Severity

0

10

20

30

40

50

60

70

80

90

Normal Mild to Severe

Depression Severity Score

Perc

enta

ge

None

Psychiatrist or Counselor

Both

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Low Medium HighTotal 0 to 3 4 to 6 7 to 15 pValue

N (%) N (%) N (%)Age

Child (0-12) 21 6 (28.57) 8 (38.10) 7 (33.33)Early Adolescence (13-14) 41 12 (29.27) 15 (36.59) 14 (34.15)Late Adolescence (15-17) 42 13 (30.95) 14 (33.33) 15 (35.71)

x22 0.0000; 1.00

GenderMale 50 15 (30.00) 21 (42.00) 14 (28.00)Female 58 17 (29.31) 18 (31.03) 23 (39.66)

x21 0.64; 0.42

GradeElementary (1-6) 10 3 (30.00) 5 (50.00) 2 (20.00)Intermediate (7-8) 37 10 (27.03) 12 (32.43) 15 (40.54)High School (9-12) 54 18(33.33) 20 (37.04) 16 (29.63)

x22 0.12; 0.73

Time in TreatmentLow (0-110 days) 33 12 (36.36) 10 (30.30) 11 (33.33)Med (111-193 days) 35 7 (20.00) 15 (42.86) 13 (37.14)High (194- 337 days) 36 12 (33.33) 14 (38.89) 10 (27.78)

x22 0.03; 0.87

Perceived Service NeedNone 45 16 (35.56) 12 (26.67) 17 (37.78)Psychiatrist or Counselor 34 12 (35.29) 16 (47.06) 6 (17.65)Both 29 4 (13.79) 11 (37.93) 14 (48.28)

x22 2.06; 0.15

RADS ScoreNormal (30-75) 77 29 (37.66) 26 (33.77) 22 (28.57)Mild to Severe (76-120) 31 3 (9.68) 13 (41.94) 15 (48.39)

x21 7.86; 0.005**

Table. Sociodemographic Characteristics and Their Association With Perceived Stigma

Percieved Stigma

* p < .05; ** p < .01; *** p < .001

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Results – Chi-Square Analyses: Table 2

Evidence of a significant association between perceived stigma and depression severity (χ2

= 7.86; p <.01)

Perceived stigma was not significantly associated with other socio-demographic characteristics such as gender, age, grade, time in treatment, and perceived service need

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Results – Chi-Square Analyses: Chart 2

Mental Health Stigma and Depression Severity

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10

20

30

40

50

60

Low (0-3) Mild (4 to 6) High (7 to 15)

Mental Health Stigma

Percent

Normal (30-75) Mild to Severe (76-120)

X2=7.86; 0.005**

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Results – Logistic Regression

Odds Ratio 95% CI P-valueAge

Child (0-12) 1.00Early Adolescence (13-14) 1.12 0.3 - 4.27 0.95Late Adolescence (15-17) 1.18 0.21 - 6.53 0.88

GenderMale 1.00 Female 1.02 0.36 - 2.9 0.97

GradeLess than highschool (1-8) 1.00High School (9-12) 0.45 0.12 - 1.75 0.25

Time in TreatmentLow (0-110 days) 1.00Med (111-193 days) 2.81 0.75 - 10.56 0.18High (194- 337 days) 1.52 0.50 - 4.62 0.85

Perceived Service NeedNone 1.00Psychiatrist or Counselor 0.87 0.31 - 2.41 0.24Both 2.6 0.63 - 10.76 0.14

RADS ScoreNormal (30-75) 1.00Mild to Severe (76-120) 0.29 0.06 - 1.34 0.11

Table. Logistic Regression of the Effect of Perceived Stigma on Mental Health Stigma

Mental Health Stigma

* p < .05; ** p < .01; *** p < .001

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Results – Logistic Regression: Table 3

Though the odds of being in the higher perceived stigma category was lower for adolescents considered in the normal group versus the mild to severe group, the results were not significant

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Discussion Significant association between mental health stigma and service

use: Almost 50% of the adolescents classified by RADS as mild to

severe experienced high perceived stigma associated with receiving mental health treatment.

However, in contrast with other research (i.e. Pyne, 2004) further analysis did not support depression severity as a predictor of perceived stigma.

May need to examine the direction of the relationship. Lindsey, Joe, and Nebbitt (in press) found that stigma influenced depression, albeit in an inverse relationship.

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Discussion Additional findings of interest:

Gender associated with depression severity – supports much of the literature. The study showed a greater number of females in the mild/severe range and a correspondingly lower number in the normal range

77% (24/31) of those characterized as mild or severe perceived a need for treatment from either psychiatrist or counselor or both –makes sense.

51% of those characterized as normal based on the RADS score perceived a need for treatment from one or both mental health service providers: May be that those adolescents considered below the cut-off for

clinical endorsement of depression may also have mental health service needs.

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Limitations

Cross sectional survey design; cannot infer causality

Small sample size and non-probability sample limits generalizability

Small sample size might also account for some non-significant relationships

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Implications Future research can explore the relationship between

the variables of interest, possibly through longitudinal study or with a larger sample

The responses to perceived service need shows that Black adolescents have a sense of their own mental health service needs - can be furthered explored

May need to explore interventions (i.e. prevention interventions) for adolescents categorized in the normal RAD range as they perceived a need for treatment