Graduate Student Journal of Psychology Copyright 2 Graduate Student Journal of Psychology Copyright 2006 by the Department of Counseling & Clinical Psychology 2006, Vol. 8 Teachers College, Columbia University ISSN 1088-4661 The Effects of Patient Age and Diagnosis on Perceived Necessity of Psychological and Medical Treatment by Young Adults Julie Blundon, Jessica Neubauer, Kristin Candan, Jacqueline Mesnik, and Janet A. Sigal Fairleigh Dickinson University Perceptions of and attitudes towards the elderly as related to the perceived necessity of treatment for physical and psychological symptoms were examined. Eighty participants from undergraduate classes at a medium-sized university in the northeastern United States were randomly assigned to read one of four vignettes, which were identical with the exception of the age (30 and 80) and diag- nosis (Major Depressive Episode and arthritis) of the vignette character. Contrary to original hy- potheses, participants reported that it was more important for an 80-year-old to obtain medical treatment than a 30-year-old. When analyzing the importance of obtaining psychological treatment, no statistically significant differences were found based on the age of the character. Medical treat- ment was universally rated as more important regardless of the age of the character in the scenario. Ageism has been defined as the deliberate or subcon- scious discrimination based on age (Lachs & Boyer, 2003). Discrimination can manifest itself as a lack of available services as well as overall negative attitudes towards the elderly. A review of the literature suggests that this discrep- ancy, especially its relationship to the delivery of mental health services and its impact upon this population, has not been adequately measured. However, it is apparent that negative stereotypes of the elderly exist in both the general population as well as in the professional world (e.g., doctors and psychologists). “Ageism is so firmly embedded within the social fabric of U.S. culture that few people even ques- tion the fact that age is considered a legitimate reason for limiting access to health care and productive employment” (Pasupathi, Carstensen, & Tsai, 1995, p. 160). Negative perceptions of the elderly vary depending on the population surveyed. However, in general, these percep- tions are that the elderly are not open-minded or flexible, not sexually active, not useful members of the community, and not bright or alert (Praseedom, Tube, Vourdas, Rafnar, & Woodfield, 1999). It has also been suggested that ageism is so ingrained in our society that psychological research is biased against elderly subjects in their under-representation and in the assumption of their homogeneity as a group (Schaie, 1993). A meta-analysis by Kite and Johnson (1988) revealed that attitudes towards older people were more negative than attitudes towards younger people across all rating dimensions. The most extreme negative results were found in ratings of physical attractiveness and compe- tence. Results from more recent studies, however, indicate Correspondence concerning this article should be addressed to Julie Blundon, T-WH01-1, Psychology Department, Fairleigh Dickinson University, 1000 River Road, Teaneck, NJ 07601; e-mail: julieblundon@hotmail.com. that differences between evaluations of older and younger people were smaller than past research would suggest. In fact, it appears that younger people hold a variety of posi- tive, negative and neutral beliefs about older people (Slot- terback & Sarnio, 1996). Attitudes of College Students Towards the Elderly Schmidt and Boland (1986) examined the multitude of stereotypes college students report towards the elderly. They found that the term “old person” elicits both positive and negative stereotypes depending on the type of elderly person the student is referencing. For example, a student may think of his beloved grandparent, and consequently describe an “old person” as warm, caring and generous. On the other hand, the phrase “older person” may bring to mind thoughts of a sick, elderly neighbor who could be seen as miserly, incompetent and needy. The study found that stereotyping of the elderly is likely to occur at a more spe- cific level (e.g., grandparent vs. elderly neighbor) because “the elderly” is not a homogeneous group and thus draws many different descriptions. Therefore, ageism may be more directed at the elderly who are perceived to represent negative stereotypes than towards those who represent posi- tive ones (Schmidt & Boland, 1986). With the exception of the previous study, the attitudes of college students towards the elderly have been found to be consistently negative over time (Schwalb & Sedlacek, 1990). Slotterback (1996) has argued that negative percep- tions of the elderly are the result of generational influences. For example, younger adults view those from a previous generation as different from themselves, not only because they are older, but because of the historical context in which they developed. Operating under a generational in- fluence, young people would likely find it difficult to relate 33 BLUNDON ET AL. 34 to the wartime mentality of elderly adults who grew up with few material possessions. Slotterback and Sarnio (1996) investigated whether the assessment of negative attitudes towards the elderly was affected by the type of instrument used (a rating task vs. an open-ended task) and the type of attributes assessed (cogni- tive, personal-expressive, and physical). They found that negativity was most apparent in open-ended tasks and when rating physical characteristics of the elderly. McConatha, Schnell, Volkwein, Riley, and Leach (2003) examined undergraduates’ discrimination towards older adults using the Anxiety About Aging Scale, which highlights four dimensions of ageism: fear of old people, psychological concerns, changing physical appearance, and fear of losses. Cultural differences in attitudes toward aging also were investigated, as the study included participants from both the United States and Germany. Results indicated significant differences between the American and German samples in three of the anxiety subscales, as well as gender differences in the raters. German participants reported greater fear of old people, more psychological concerns about aging, and more fear of losses associated with aging than did American participants. Additionally, both Ameri- can and German women scored significantly higher than male participants on items regarding concerns about physi- cal appearance. Ageism in Health and Mental Health Service Providers The underutilization of mental health services in the elderly population may be a function of ageism on the part of mental health providers (Gatz, Karel, & Wolkenstein, 1991). Many service providers lack training with the geriat- ric population and have negative expectations concerning treatment effectiveness with this group (Gatz & Pearson, 1988). James and Haley (1996) found some evidence of age bias in a sample of 371 psychologists who responded to detailed vignettes of a client presenting with symptoms of depression. However, they found stronger evidence of health bias regardless of client age, meaning that healthier clients were viewed more positively. This suggests that mental health service providers, psychologists in particular, have more negative attitudes towards physically ill indi- viduals as opposed to healthier individuals, regardless of age. Such a bias may have implications for service delivery, considering the common presentation of depression and other psychological disorders with concomitant health prob- lems in the elderly. The negative attitude concerning treatment outcome of elderly patients is not confined to the mental health com- munity. Uncapher and Arean (1999) found that physicians are less likely to treat suicidal ideation in older patients. These findings were based on a study in which 215 primary care providers rated a vignette of a suicidal, depressed pa- tient. The only difference between the vignettes was the age of the patient and employment status. The physicians rec- ognized depression and suicidal risk in both the adult and geriatric vignette, but reported less willingness to treat the older patient. Physicians reported that the suicidal ideation on the part of the older patient was both normal and ra- tional. Therefore, doctors were less willing to use therapeu- tic strategies to treat older patients and did not believe that psychiatrists or psychologists should be consulted. Grant (1996) discussed specific biases that may be pre- sent in health care workers, which can be partly explained by both a lack of education concerning geriatric health is- sues and a lack of exposure to elderly patient populations. These biases include providing disabling support (as op- posed to enabling support) as well as managing symptoms (as opposed to promoting health) when working with geriat- ric populations. These biases on the part of health care workers have led to increased dependence and less aggres- sive treatment plans. Cultural Differences in Perceptions of the Elderly Studies of family relationships in Asian American cul- tures have found that the majority of adolescents and col- lege-age students espouse the values of deference and re- spect towards their family elders. White American teenag- ers and college students do not display the same level of reverence for the elderly as their Asian American counter- parts (Ying, Coombs, & Lee, 1999). White American ado- lescents instead tend to separate and individuate, and to focus primarily on their own goals as opposed to those set forth by their families. Ying and colleagues (1999) also found that Asian American adolescents (Chinese, Japanese and Korean) tend to maintain the Eastern orientation of valuing the opinion of the elderly despite the American cultural emphasis on autonomy and independence. This positive perception of the elderly seems to be an integral part of the Asian American cultures and provides a signifi- cant contrast to White Americans’ mixed perceptions of the older population. Young, Jeong, Knight, and Benton (1999) examined the differences in familism values (in which the family takes precedence over individual interests) and attitudes toward caregiving among Korean, Korean American, and White American dementia caregivers. They found that Ko- reans reported the highest level of distress associated with caregiving, followed by Korean Americans and White Americans. A possible explanation for these results may be related to the correlation between familism and distress; higher ratings of the importance of family were correlated with higher levels of anxiety and depression concerning the caretaking of demented elders. It can be postulated that the more interdependent a family, the more distressing it is for one of the family members to fall ill and require care. The Present Study The research reviewed clearly demonstrates the pres- ence and impact of ageist attitudes in our society. There is EFFECT OF PATIENT AGE AND DIAGNOSIS ON TREATMENT 35 some evidence suggesting that ageism plays a role in the perceptions of symptom severity, decisions regarding whether or not to treat geriatric patients, and the quality of care that is received. However, there is a need for further research in order to better understand those areas in which ageist attitudes most severely influence treatment decisions, particularly in terms of the perceived necessity of clinical services. This line of study could have direct implications for the training of health care professionals working with older adults and general treatment planning for geriatric patients. The present study explores not only the attitudes of a college student population towards the elderly, but how such attitudes impact upon the perceived necessity of psy- chological and mental health treatment for elderly individu- als. Three hypotheses were tested. The first is that subjects will rate treatment necessity higher for the younger charac- ters presented in the vignettes, regardless of the type of condition (medical vs. psychological). Second, psychologi- cal treatment will be rated as less important than medical treatment, regardless of the age. Third, the perceived social value of the elderly will be influenced by the country of origin and culture of the respondent. The overarching pur- pose of this study was not to examine how malleable ageist attitudes may be in response to an intervention, but rather how such attitudes are expressed in terms of perceived need for treatment. Method Participants Participants were 92 undergraduate students enrolled in classes from a variety of disciplines at a medium sized uni- versity in the northeastern United States. A manipulation check was conducted to test participants’ recall of the age and possible diagnosis of the individual in the vignette, and the 12 participants who failed the check were not included in the final analyses. Participants ranged in age from 17 to 33, with a median age of 18. Twenty-nine (36.3%) of par- ticipants were male; 51 (63.8%) were female. The majority of participants were Caucasian (36.3%), followed by Afri- can American (20%), Asian (17.5%), Latino (12.5%), and Caribbean American (5%). Materials Two vignettes featured an individual presenting with symptoms indicative of a Major Depressive Episode as classified by the Diagnostic and Statistical Manual of Men- tal Disorders, Fourth Edition (DSM-IV, 1994). These symp- toms included sleep disturbances, lack of interest in usual activities, lack of energy, trouble with concentration, and lack of appetite. The other two vignettes portrayed an indi- vidual experiencing the symptoms of arthritis. Symptoms included severe joint pain, fatigue, lack of agility, and lack of concentration. In each of these two conditions, the vi- gnettes were identical with the exception of the age of the person being portrayed; the individual described in the vi- gnette was either 30 or 80 years old. The sex of the vignette character was not specified so as to eliminate gender of the vignette character as a confounding variable. Participants were randomly assigned to one of four conditions: a 30 year-old individual experiencing symptoms of arthritis; a 30 year-old individual experiencing symptoms consistent with a major depressive episode; an 80 year-old individual experiencing symptoms of arthritis; and an 80 year-old individual experiencing symptoms consistent with a major depressive episode. All participants completed four Likert-type questionnaire items created for this study that focused on the importance of seeking medical and psycho- logical treatment, as well as symptom severity for the indi- vidual described in the vignette. The four questions were: 1) “How likely is it that Pat will receive medical treatment?”; 2) “How important is it that Pat receive medical treat- ment?”; 3) “How likely is it that Pat will receive psycho- logical treatment?”; and 4) “How important is it that Pat will receive psychological treatment? For the two items addressing the likelihood that the vignette character will seek medical or psychological treatment (questions 1 and 3), the Likert scale ranged from 1 (completely unlikely) to 7 (completely likely). The Likert scale for the two questions regarding the importance of seeking medical or psychologi- cal treatment (questions 2 and 4) ranged from 1 (not at all important) to 5 (extremely important). Finally, the Social Value of the Elderly Scale of the Aging Opinion Survey, developed by Kafer, Rakowski, Lachman, and Hickey (1980), was used as an additional measure to assess participants’ perceptions of elderly indi- viduals. This measure is comprised of fifteen Likert-type questionnaire items covering several content areas, includ- ing the contribution of elderly individuals to the community (e.g., “After retirement one should not have much influence in public policy making”) and general perceptions of eld- erly individuals (e.g., “Old people usually interfere with their adult-children’s child-rearing practices”). The Likert scale for each item ranged from 1 (completely disagree) to 5 (agree completely). Design and Procedure The study used a 2 (age of character in vignette: 30 years old vs. 80 years old) X 2 (diagnosis: major depressive episode vs. arthritis) design. Participants were told that they would be participating in a study regarding perceptions of people. The age and diagnostic condition of the character were not identified as significant variables. After providing informed consent, participants were randomly assigned to one of four vignette conditions (see Table 1). Participants in all conditions were asked to read a short vignette and an- swer four Likert-type questionnaire items. Next, partici- pants were asked to complete the Social Value of the Elder- BLUNDON ET AL. 36 Table 1 Number of Participants Per Condition Age of Diagnosis of Number of participants character character (n) per condition 30 Depression 24 30 Arthritis 20 80 Depression 21 80 Arthritis 15 ly Scale of the Aging Opinion Survey and three short ma- nipulation check items. Finally, participants were asked for demographic information and debriefed. Results Univariate analyses of variance (ANOVA) revealed a statistically significant difference regarding the perceived importance of medical treatment across the four groups. Specifically, the respondents believed that it was more im- portant for an 80 year-old individual to obtain medical treatment than a 30-year-old regardless of the presenting symptoms (F = 6.877, p = 0.011). No statistically signifi- cant differences were found between the ages of the vi- gnette character and the perceived importance of obtaining psychological treatment. On average, the importance of obtaining medical treatment, regardless of whether a Major Depressive Episode or arthritis was depicted in the vignette, was rated as a 4.11 on a five-point Likert scale (1 = not at all important, 5 = extremely important). On the same scale, the importance of obtaining psychological treatment was rated, on average, as 3.08. These results were seen regard- less of the age of the character. Given symptomatology consistent with a diagnosis of a major depressive episode, the average ratings of the impor- tance of obtaining medical and psychological treatment were examined as a function of the age of the individual portrayed in the vignette (see Table 2). The average rating of the importance of obtaining medical treatment was 3.54 for the 30-year-old character, and 4.17 for the 80-year-old character. The average rating of the importance of obtaining psychological treatment was 3.38 for the 30-year-old char- acter, and 3.33 for the 80-year-old character. No statisti- cally significant differences were found between these rat- ings (see Figure 1). Table 2 Perceived Importance of Treatment, Symptoms of Major Depressive Episode Age 30 Age 80 Medical treatment 3.54 4.17 Psychological treatment 3.38 3.33 0 1 2 3 4 5 Medical Psych Age 30 Age 80 Figure 1. Perceived importance of treatment for vignettes with symptoms of Major Depression For those vignettes in which arthritic symptoms were depicted, the average rating of the importance of obtaining medical treatment as a function of vignette character’s age was 4.35 for the 30-year-old character, and 4.60 for the 80- year-old character (see Table 3). The average rating of the importance of obtaining psychological treatment was 2.60 for the 30-year-old character, and 2.87 for the 80-year-old character. No statistically significant differences were found between these ratings (see Figure 2). Table 3 Perceived Importance of Treatment, Symptoms of Arthritis Age 30 Age 80 Medical treatment 4.35 4.60 Psychological treatment 2.60 3.33 0 1 2 3 4 5 Medical Psych Age 30 Age 80 Figure 2. Perceived importance of treatment for vignettes with symptoms of arthritis Expecting some difference by ethnicity of respondent in terms of social value of the elderly, total scores on the Social Value of the Elderly Scale were tabulated and aver- aged across the ethnic backgrounds of the respondents. Caucasians had a mean score of 43.41; African Americans, 41.69; Caribbean Americans, 9.50; Latinos, 42.00; and Asians, 42.43. An ANOVA revealed no statistically signifi- cant differences among the ethnic groups in terms of the averaged total scores on this measure of ageist attitudes. EFFECT OF PATIENT AGE AND DIAGNOSIS ON TREATMENT 37 Discussion Contrary to our hypotheses, no evidence of ageist atti- tudes were found in this sample, as seen by the lack of dif- ference in perceived need for psychological treatment across age groups. In regard to medical treatment, respon- dents rated importance of obtaining care as more important for elderly individuals, which is suggestive of non-ageist attitudes in this population. As predicted, the overall per- ceived need for psychological treatment was less than the perceived need for medical treatment when controlling for diagnosis. In fact, looking specifically at those participants who received psychological disorder vignettes, medical treatment was seen as more important than psychological treatment. It is possible that participants did not fully under- stand the psychological treatment options available, or per- ceived the somatic complaints associated with the major depressive episode to necessitate medical interventions. No overall differences were found on total score of the Social Value of the Elderly Scale based on ethnic back- ground of the respondents. Because the current study did not investigate why respondents answered in terms of ne- cessity of treatment, future research focused on positive or negative reasons for treatment would be warranted. For example, examining whether viewing the elderly as being in greater need of medical care is based on something posi- tive (such as honoring elders) or something negative (such as the elderly as being frail) would further clarify ageist or non-ageist attitudes. The current findings are important, as they suggest an absence of ageist attitudes in this sample. They may indi- cate that the trend, noted earlier, of college-aged people viewing the elderly in a negative light, may be changing. However, it may be more likely that the heterogeneity of this sample is indicative of the heterogeneity of the envi- ronment from which the participants were drawn, and that the immersion in such an environment fosters an overall, general attitude of acceptance and tolerance. Should this be the case, our subjects would be less prone, as compared to individuals from a more homogeneous environment, to en- gage in discriminatory actions and beliefs, and might be less inclined to exhibit ageist attitudes. Certainly more re- search is needed to explore whether being a member of a heterogeneous population disinclines one to prejudice and discriminatory tendencies. Additionally, while medical and psychological treat- ment were both rated as important, medical treatment was universally rated as more important regardless of diagnosis. This finding suggests the need for the education of caregiv- ers and the community at large regarding the efficacy of psychological treatment for various psychological disor- ders. It is possible that this finding reflects a general ten- dency to treat various psychological conditions with medi- cation, which is often obtained from a medical professional. The abundance of advertisements for psychotropic medica- tions in the general media may be contributing to this trend. Future research should be focused on exploring the impact of such advertisements on the perceived usefulness of psy- chological interventions for treating psychological condi- tions given a medically-based alternative. The current study has several limitations that may have impacted the results and that should be addressed in future research. Specifically, the small sample size and small number of participants per group limits the conclusions that can be drawn from the data, as there was low statistical power. Also, the gender of the subject in the vignette was ambiguous, and it would be interesting to see how including the gender of the patient would influence results. As our respondents were generally in the age range of 18 to 20, and age of respondent could influence perceptions of the need for treatment, a follow-up study should not only replicate the current research, but seek to incorporate respondents of a more diverse age range. Future research should also ex- plore the idea that students in different fields (specifically those intending to work with elderly populations, such as psychology, social work, pre-medicine, nutrition) may be less likely to view symptoms of a Major Depressive Epi- sode as needing medical rather than psychological attention. Ultimately, this research can serve as a starting point for future research impacting the care that the elderly popula- tion receives. References Gatz, M., Karel, M. J., & Wolkenstein, B. (1991). 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Table 1 Number of Participants Per Condition Results Table 2 Perceived Importance of Treatment, Symptoms of Major Depressive Episode Table 3 Perceived Importance of Treatment, Symptoms of Arthritis Discussion Gatz, M., & Pearson, C. G. (1988). Ageism revised and the provision of psychological services. American Psychologist, 43, 184-188.