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 Table of Contents  
Year : 2020  |  Volume : 36  |  Issue : 3  |  Page : 184-190

Stigma for mental disorders among the elderly population in a rural setting

Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission11-Dec-2019
Date of Decision10-Jun-2020
Date of Acceptance30-Jun-2020
Date of Web Publication28-Sep-2020

Correspondence Address:
Dr. Aseem Mehra
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_124_19

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Aim: The primary objective of the study was to evaluate the extent of stigma for mental disorders among the older adults (aged ≥60 years) from a rural background visiting a general outpatient's clinic at the civil hospital as an attendant of patients. The secondary objective of the study was to assess the correlation of stigma with the sociodemographic profile and family history of mental illness. Methodology: One hundred and four older adults (aged ≥60 years) from a rural background visiting a general outpatient's clinic at the civil hospital as an attendant of patients with physical illnesses were evaluated on Community Attitudes toward the Mentally Ill (CAMI) Scale. Results: About three-fifths of the participants (59.6%) were females. About one-third (32.7%) of the study participants had a family history of mental illness. On CAMI Scale, the highest score was obtained in the domain of benevolence (BE), followed by authoritarian, community mental health ideology (CMHI), and social restrictiveness (SR). Those with a family history of mental illness and from middle socioeconomic status scored significantly higher on the SR domain of CAMI. Level of education had a significant positive correlation with the scores in the domains of BE, SR, and CMHI. Age had a significant negative correlation with the SR domain score. Conclusions: Elderly in a rural setting, in general, have a positive attitude toward mental illness and have a lower level of stigma associated with mental illnesses. Certain demographic and clinical variables such as middle socioeconomic status, low level of education, and presence of mental illness are associated with stigma.

Keywords: Attitude, elderly, mental illness, stigma

How to cite this article:
Mehra A, Singla H, Grover S, Avasthi A. Stigma for mental disorders among the elderly population in a rural setting. Indian J Soc Psychiatry 2020;36:184-90

How to cite this URL:
Mehra A, Singla H, Grover S, Avasthi A. Stigma for mental disorders among the elderly population in a rural setting. Indian J Soc Psychiatry [serial online] 2020 [cited 2023 Feb 6];36:184-90. Available from: https://www.indjsp.org/text.asp?2020/36/3/184/296256

  Introduction Top

Mental illnesses are a significant contributor to the global disease burden.[1] One in every four person in the world, while every sixth Indian, is affected by one or other mental disorder at some point of their lifetime.[2],[3] Despite the start of the District Mental Health Program in 1996,[4] the mental health and mental illnesses are largely ignored and neglected, with an extensive “treatment gap.”[5] Nearly two-thirds of the people suffering from mental disorders do not seek help from a mental health professional and prefer to hide their problems.[6] The major roadblock in the treatment is the discrimination or presence of stigma in the community.[7],[8]

Since a long time, mental illnesses are perceived as frightening, shameful, imaginary, feigned, and incurable. At the same time, the patients are characterized as dangerous, unpredictable, untrustworthy, unstable, lazy, weak, worthless, and/or helpless in the community.[9],[10],[11],[12],[13] There is conclusive evidence to suggest that mental illnesses are associated with more stigma than physical illnesses.[14],[15]

Stigma among general public is associated with belief that mental illness is an outcome of evil spirits and people with mental illness are violent and dangerous to the public.[16] Tracing the attitude of people toward mental illness, it is possible to predict the knowledge and awareness regarding mental illnesses among general public.[17]

A few studies have evaluated the relationship between demographic characteristics with the attitude of the public toward people with a mental disorder. However, the findings are, in general, inconclusive. For instance, some studies report that younger people can easily accept people with mental illnesses.[18] In contrast, other studies suggest that stigma decreases as people become older.[19],[20] and some studies have found no association with age.[21]

Mental illnesses are poorly understood by the general public, especially by those from the rural locality. People from rural area prefer to seek help from quacks and local faith-healers, which often leads to delay in starting of effective treatments.[22],[23]

A limited number of studies have evaluated the attitudes toward mental illness among rural populations.[23],[24],[25],[26] The existing literature is limited in certain ways; first, the studies are more from urban areas, and second, the studies have focused mainly on the adult population.

Younger and older people represent a distinct cohort with different life experiences, cultural values, and perception about mental health services. Finally, in terms of medical help seeking, elderly persons are the decisive authority in the families of rural area in India. A few studies have looked at the relationship between the knowledge, attitude, and mental illness in the elderly population.[27],[28] In general, the data are inconsistent with some of the studies, suggesting older adults often suffer from negative effects of stereotypes and exclusion. The stigma is more pronounced among older adults from minority ethnic communities due to additional access barriers stemming from their cultural and linguistic background.[29],[30] Older African-Americans have been found to have more stigma when compared to their White counterparts. Older African-Americans tended to hold more negative views of mental illness such as depression considered that pharmacological or psychological treatment as “socially embarrassing” and were less likely to accept pharmacotherapy and psychotherapeutic treatment.[31]

Other studies suggest that older people consider mental illness as a sign of personal failure and weakness.[32] However, the studies involving older Latinos have reported the elderly to be having more positive perceptions of mental health treatment.[33] Due to conflicting results, the available literature on public stigma among elderly is still inconclusive. No literature is available from India about the assessment of the attitude toward the mental illness among the elderly population. Hence, there is a need to assess the attitude and public stigma related to mental illnesses among the elderly, especially those residing in the rural locality, so that age-specific intervention programs can be designed to reduce the stigma among the elderly.

It is expected that reduction in stigma among elderly populations can help in improving the identification, management of mental illnesses, and proper utilization or mental health services in the rural area, as well as in other community settings. However, before addressing the extent of stigma among the elderly populations, it is essential to identify the extent of public stigma among older people in a rural area. Accordingly, the present study aimed to evaluate the public stigma in the form of attitude toward mental illness among the elderly population in a rural area.

  Methodology Top

This cross-sectional study was carried out among the older adults (aged ≥60 years) from a rural background visiting a general outpatient's clinic at the civil hospital as an attendant of patients. The study sample comprised 104 elderly from the rural background, residing in the northern part of Haryana state selected by convenient sampling. The institutional ethics committee approved the study, and all the elderly participants were recruited after obtaining written informed consent. To be included, the elderly were required to be residing in the rural locality and attending the general outpatient clinic as an attendant of other patients. The participants were required to be free from any diagnosed psychiatric illness in the past, significant cognitive decline (determined by subjective reporting of forgetfulness amounting to difficulty in activities of daily living), or any major physical illness at the time of the assessment. Those who were unwilling to participate were excluded.

The study participants were assessed on Community Attitudes toward the Mentally Ill (CAMI) Scale.[34] This scale was developed to measure community attitudes toward people with mental illness. The scale consists of 40 attitudinal statements about mental illness, with participants saying how much they agreed or disagreed with each statement on a 5-point Likert scale, i.e., 5 - strongly agree, 4 - agree, 3 - neutral, 2 - disagree, and 1 - strongly disagree. The 40 items are divided into four subscales, i.e., authoritarianism (AU), benevolence (BE), social restrictiveness (SR), and community mental health ideology (CMHI). AU is a “view of the mentally ill person as someone who is inferior and requires supervision and coercion.” BE corresponds to “a humanistic and sympathetic view toward mentally ill persons,” and higher BE score corresponds to a less humanistic and less sympathetic (malevolent) view toward a person with mental illness (PWMI). SR reflects the “the belief that mentally ill patients are a threat to society and should be avoided.” CMHI is “the acceptance of mental health services and the integration of mentally ill patients in the community” with a higher score on the CMHI subscale, indicating a rejection of mental health services and the integration of PWMI into the community.

BE and CMHI subscales are referred to as positive attitudes. The AU and SR are referred to as negative attitudes. There are 10 items for each subscale, and each consists of five positive statements and five negative statements. Respondents are required to rate how much they strongly disagree or strongly agree with each statement. Negative statements for each subscale are reversed coded. The total score is calculated to determine the attitudes toward mentally ill patients. A higher score indicates that the community has a high positive attitude. For instance, a high score for BE indicated that community have a benevolent attitude toward the mentally. The scale has been shown to have good test–retest reliability (Cronbach's alpha) and validity. The Cronbach's alpha is reported around 0.87. In the current study, the translated Hindi version of the scale has been used. The Hindi version has been used in a previous study from India.[35]

The sample size for the study was calculated using denial method, based on the prevalence figure of stigma ranging from 30% to 50%. Hence, considering the prevalence rate of 40% with a precision of 10% (confidence interval of 95%), the sample size came out to be 89. Considering a nonresponse rate of 15%, a sample size of 103 was estimated.

Statistical analysis

Statistical Package for the Social Sciences, Windows Version 14 (SPSS-14, SPSS Inc., Chicago, USA) was used for the analysis of data. The descriptive analysis involved the calculation of mean and standard deviation (SD) for continuous variables and calculation of frequencies and percentages for categorical variables. Comparisons were made using the Chi-square test and Student's t-tests. Correlation between attitude and other variables was evaluated using Pearson's correlation coefficient and Spearman's rank correlation.

  Results Top

As shown in [Table 1], the mean age of the study sample was 64.1 (range 60–75; SD - 6.9). About three-fifths of the participants were female (59.6%) and educated beyond primary schooling (43.2%). About one-third of the study participants had a family history of mental illness.
Table 1: Sociodemographic profile of the study participants

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Attitude toward mentally ill subjects

[Table 2] and [Table 3] show the results of the study participants on the CAMI Scale. The highest score was obtained for the subscale of BE, followed by authoritarian, CMHI, and SR.
Table 2: Attitude of elderly toward the mentally ill subjects

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Table 3: Correlation of various domain of community attitudes toward the mentally ill with each other, age, the income of participants, and level of education

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Association of attitude toward mental illness with other variables

When the scores on various subscales were compared for male and female participants, no significant difference emerged on any of the subscales. When those with and without a family history of mental illness were compared, the participants with a family history of mental illness scored significantly higher on the domain of SR (t-test - 2.205; P = 0.03).

When the relationship of attitude toward the mentally ill subject was evaluated with age, level of education, and the income of the participants as shown in [Table 3], level of education had a significant positive correlation with the subscales of BE, SR, and CMHI. Age had a significant negative relationship with SR.

Participants from the middle socioeconomic background had a significantly higher score (mean - 33.2, SD - 4.9) on the subscale of SR, as compared to the participants from the lower socioeconomic status (mean - 31.2, SD - 3.8; t-test - 2.279; P = 0.025). The internal consistency (Cronbach's alpha) of the scale for the studied group was 0.808.

  Discussion Top

The current study assessed the attitude toward the mental illness held by the elderly population from a rural community. The result shows that, in general, the elderly have a positive attitude towards mental illness. The results are consistent with the previous studies which have reported that younger and older people hold a positive attitude toward mental illness.[36],[37] Another study from India, conducted among the younger population from an urban community found the similar results as in the index study.[38]

A study, which compared the mental health attitude of urban and rural older adults from New York, reported that rural older adults hold a negative attitude toward mental illness. They were assessed on a variety of scales specifically designed to assess many dimensions of mental health care attitudes.[39] Webb et al.[40] assessed the attitude of 101 community-dwelling older adults by using three-hypothetical case-vignette of elderly women, i.e., depression, anxiety, and schizophrenia. The older adults viewed the person with schizophrenia as most dangerous and dependent, followed by depression and anxiety.[40] There are other studies which have reported that the elderly were more discriminators,[41] had negative attitude,[42] and considered depression as a sign of weakness, and mentally ill family members bring shame to the family.[43] The finding could be because of cultural differences, tolerance to the illness, and differences in the family setup, with good social support, which helps an individual with mental illness to perform their duties in a better way in a rural area. The other reason could be the use of different scales for the assessment of the attitude, different settings, and socially desirable response. Importantly, the demographic variables are not associated with the elderly attitude toward the mental illness. Of the various demographic variables examined (gender, a monthly income of patients, number of year of education), in the present study too, only socioeconomic status was found to be associated with the elderly attitude toward the mental illness. The people from the higher socioeconomic status reported that mentally ill patients are not threats to society and should be a part of society as compared to the people from lower socioeconomic status. This finding is consistent with the previous studies.[26],[43],[44],[45],[46],[47],[48] Previous studies also suggest that the rural Indian patients are working as a manual worker or from lower socioeconomic status report higher stigma.[49],[50] However, poverty is a multidimensional component and hence difficult to understand the phenomenon as other demographics were not associated with the stigma.

In the present study, people with a family history of mental illness considered that the patients with a mental illness are safe and should be a part of society. The previous studies also report the same that either direct contact with the patient or family history of mental illness is associated with a positive attitude.[37],[42],[51],[52],[53] The direct contact to, acquaintance with, and closeness to the mentally ill person typically contribute to be more tolerant behavior and understanding attitude.[7],[54] Chee et al.[55] also reported that the person visiting a state mental health had a higher negative attitude as compared to those attending to a general hospital. The current study sample was recruited from the general hospital of a rural community. However, there was no comparison group; hence, it is difficult to claim the same phenomenon.[55]

The current study also showed that older adults had a positive attitude toward mental illness. The reason could be due to contact with a patient of mental illness or experience from the community. However, the current study did not evaluate the information such as contact with a patient of mental illness, attending any mental health awareness program, or any other experience from the community.

Limitations of the study

The present study included a relatively smaller sample size, which was confined to hospital attending participants, and the sample was collected by convenient sampling. The present study also did not involve assessment of other associated factors, such as knowledge about mental health, belief in traditional system or religious cult, and contact with a person who has a mental illness other than family members. We did not assess the attitude toward the specific mental illness. There was a lack of comparison group. The translated Hindi version of CAMI has not been validated in the Indian cultural context. The cognitive assessment was based on a clinical interview. No objective information or instrument was used to assess the cognitive functions.

  Conclusions Top

The present study suggests that older people, in general, have a positive attitude toward mental illness. Although there is much work still to be done in the field, this study can serve as a springboard for further research. Future studies should explore how age influences the attitude and compare the attitude toward mental illness of younger and older people in the community. For future implications, some more variables can be added to the questionnaire such as beliefs and myths toward mental problems, religious views of subjects which give a better idea regarding attitudes.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]

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