Community Ment Health J (2011) 47:164–170
DOI 10.1007/s10597-009-9274-8
ORIGINAL PAPER
Attitudes Toward Mental Health Services in Hispanic Older
Adults: The Role of Misconceptions and Personal Beliefs
Yuri Jang • David A. Chiriboga • Julio R. Herrera •
Dinorah Martinez Tyson • Lawrence Schonfeld
Received: 17 February 2009 / Accepted: 8 December 2009 / Published online: 20 December 2009
Ó Springer Science+Business Media, LLC 2009
Abstract Focusing on misconceptions and personal
beliefs associated with depression, the present study
explored predictors of attitudes toward mental health ser-
vices in a sample of 297 Hispanic older adults living in
public housing (M age = 76.0 years, SD = 7.74). Results
from a hierarchical regression analysis showed that nega-
tive attitudes towards mental health services were predicted
by advanced age, belief that having depression would make
family members disappointed, and belief that counseling
brings too many bad feelings such as anger and sadness.
Findings suggest that interventions designed to promote
positive attitudes toward mental health services of older
Hispanics should address misconceptions and personal
beliefs.
Keywords Hispanics
Older adults

Attitudes toward mental health services
Introduction
Racial/ethnic minority elders often exhibit higher levels of
mental health problems than non-Hispanic Whites, but they
continue to be underrepresented among those receiving
mental health services (e.g., Alegrı́a et al. 2008; Blanco
et al. 2007; Cook et al. 2007; Smedley et al. 2002). Because
undetected and untreated mental health problems result in
Y. Jang (&)
D. A. Chiriboga
J. R. Herrera

D. Martinez Tyson
L. Schonfeld
Department of Aging and Mental Health Disparities,
Florida Mental Health Institute, University of
South Florida, 13301 Bruce B. Downs Blvd.,
MHC 1400, Tampa, FL 33612, USA
e-mail: yjang@fmhi.usf.edu
123
poorer quality of life, higher social costs for care, attenu-
ated effectiveness of treatment, and heightened premature
mortality (U.S. Department of Health and Human Services
2001), there is a compelling need for research that may
promote access to mental health services for racial/ethnic
minority older populations.
One area of access-related research that has received
comparatively little attention has to do with attitudes toward
mental health services, and particularly the correlates of
these attitudes among racial/ethnic minority older adults.
Assessment of factors contributing to the perceptions of
mental health services will help us identify facilitators and
barriers to the service utilization. Since attitudes have
shown to be a critical determinant of actual help-seeking
behaviors (Fischer and Farina 1995; Godin and Conner
2008), research on attitudes may provide valuable infor-
mation concerning how to design and implement effective
interventions to reduce disparities in mental health care.
In the present study, we focused on misconceptions and
personal beliefs associated with depression as determinants
of the attitudes toward mental health services. Miscon-
ceptions such as attributing depression to aging (e.g.,
Sarkisian et al. 2003) and perceiving depression as a sign of
personal weakness (e.g., National Mental Health Associa-
tion 1996; Ray et al. 1992) are quite common among
minority older adults, and such misconceptions are likely to
lead to negative attitudes toward mental health services
(Givens et al. 2007; Hines-Martin et al. 2004). Members of
racial/ethnic minorities have also shown to be misinformed
about psychological and pharmacological treatment for
depression (U.S. Department of Health and Human Ser-
vices 2001). Givens et al. (2007) report that compared to
Whites, racial and ethnic minorities were less likely to
perceive that depression is biologically based and more
likely to think that antidepressants are addictive and that
Community Ment Health J (2011) 47:164–170
counseling brings up too many bad feelings. In some cul-
tures, one’s mental illness is not perceived as a personal
matter but as a threat to the homeostasis and harmony of
the whole family, and having a family member with mental
illness is perceived as shame (Leong and Lau 2001; Lin
and Cheung 1999). Such personal beliefs linked to family
shame and disappointment have been identified as a major
cultural barrier to the use of mental health services (e.g.,
Leong and Lau 2001).
Given the trends of population aging and growth of
Hispanics in the United States, and the critical need for
mental health research on Hispanics (U.S. Department of
Health and Human Services 2001), the present study
assessed determinants of the attitudes toward mental health
services in Hispanic older adults. Although the present
study was exploratory in nature, we expected that mis-
conceptions and negative personal beliefs would contribute
to unfavorable attitudes toward mental health services.
Examples of such misconceptions are thinking that
depression is a normal part of aging, depression is a sign of
personal weakness, antidepressant medicines are addictive,
and counseling brings up too many bad feelings; examples
of personal beliefs include believing that having a mentally
ill family member brings shame to the whole family, or
would disappoint the family. Obtaining an understanding
of cultural perceptions associated with mental health issues
may help identify areas to focus when developing public
education and mental health promotion programs for His-
panic elderly populations.
Methods
Sample
The target population for the present study consisted of
Hispanic adults aged 60 or older who were living in public
housing and who had sufficient cognitive ability to
understand and complete the survey questionnaire. To
recruit participants, we first identified senior housing
facilities in the Tampa Bay area with high rates of Hispanic
residents. The next step was to establish contact through
telephone calls or actual visits with the manager and/or the
activities coordinator of facilities in order to request
approval for a survey. Of the 15 facilities contacted, 2 were
excluded because they were rehabilitation or assisted living
facilities. Approval was obtained from 9 facilities. After
obtaining approval, we posted an invitation flyer in the
facility and also sent one out to target residents. The flyer
announced the purpose of the study; eligibility criteria; and
the date, time, and location of the survey. The survey was
conducted in a community room or cafeteria in the facility.
The survey instrument was a standardized questionnaire
165
designed to be self-administered in a pen and paper format.
Participants were given a choice of using a questionnaire in
English or Spanish. The Spanish version was developed
using a back-translation method, and the final product was
reviewed and reconciled by bilingual individuals who did
not participate in the initial translation process (e.g., Brislin
1970; Hambleton and de Jong 2003). Survey question-
naires were printed using a large font, and trained bilingual
interviewers were available for assistance. All participants
received $10 for their time and effort. A total of 301
individuals were surveyed between April and June 2008.
After we excluded individuals who did not meet the eli-
gibility criteria (n = 4), the final sample size was 297.
None of the participants had more than 10% missing
information on their questionnaires. Details on the
recruitment process are available elsewhere (e.g., Jang
et al. 2009).
Measures
Demographic Variables
These variables included age, gender, ethnicity, marital
status, and educational attainment.
Background Variables
Acculturation and physical and mental health status were
included as background variables. Level of acculturation
was assessed with four items related to language: self-
reported English proficiency, language used in conversa-
tions with family, preferred language for TV or video, and
preferred language for book or newspaper. The items were
drawn from two indices of acculturation widely utilized in
research on Hispanic populations (i.e., Cuellar et al. 1995;
Hazuda et al. 1988). Each response was coded from 1 to 5,
with a higher score indicating a greater level of accultur-
ation. Internal consistency based on the four items was high
(a = .92).
Three items from the Older Americans Resources and
Services Questionnaire (Fillenbaum 1988) were used to
assess subjective perception of health. The items were
‘‘How would you rate your overall health at the present
time?’’ ‘‘How is your present health compared to five years
ago?’’ and ‘‘How much do your health troubles stand in the
way of your doing the things you want to do?’’ The rating
scale ranged from 0 (positive health perception) to 7
(negative health perception). Internal consistency based on
the three items was satisfactory (a = .73).
A short form of the Center for Epidemiologic Studies–
Depression scale (CES-D; Andresen et al. 1994; see also
Radloff 1977) was used to assess depressive symptoms.
The scale includes two positive items (‘‘I felt hopeful’’ and
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166
‘‘I was happy’’) and eight negative items (e.g., ‘‘I felt
depressed’’ and ‘‘I felt lonely’’). Participants rated on a 4-
point scale how often symptoms were experienced during
the past week. The positive items were reverse-coded, and
all items were summed into total scores that ranged from 0
(no depressive symptoms) to 30 (severe depressive symp-
toms). A score of 10 or higher on the short form of the
CES-D is typically suggested as a cutoff for probable
depression (Andresen et al. 1994). The CES-D has been
translated into Spanish, and its psychometric properties
have been validated in previous studies (e.g., Grzywacz
et al. 2006; Roberts 1980). Internal consistency in the
present sample was good (a = .75).
Misconceptions and Personal Beliefs Associated with
Depression
Six questions were asked about misconceptions and per-
sonal beliefs associated with depression. The items, adop-
ted from a National Mental Health Association (1996)
survey and a study by Cooper et al. (2003), questioned
whether participants (a) thought depression is a normal part
of aging, (b) thought depression is a sign of personal
weakness, (c) thought antidepressant medicines are addic-
tive, (d) thought counseling brings up too many bad feel-
ings such as anger and sadness, (e) thought having a
mentally ill family member brings shame to the whole
family, and (f) thought if he/she had depression, his/her
family would be disappointed with him/her. Responses
were coded as 1 (yes) or 0 (no).
Attitudes Toward Mental Health Services
As a measure of mental health treatment attitudes, we used
the Attitudes Toward Seeking Professional Psychological
Help Scale—Short Form (Fischer and Farina 1995). The
scale has been frequently used in mental health services
research, and acceptable psychometric properties have
been documented (e.g., Elhai et al. 2008). The scale
includes five positive statements (e.g., ‘‘If I believed I was
having a mental breakdown, my first inclination would be
to get professional attention,’’ ‘‘A person with an emotional
problem is not likely to solve it alone; he or she is likely to
solve it with professional help’’) and five negative state-
ments (e.g., ‘‘The idea of talking about problems with a
psychologist strikes me as a poor way to get rid of emo-
tional conflicts,’’ ‘‘A person should work out his or her own
problems; getting psychological counseling would be a last
resort’’). Individuals were asked to rate each statement on a
4-point scale: disagree (0), partly disagree (1), partly agree
(2), and agree (3). Responses to the negative statements
were reverse-coded, and all responses were summed for
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Community Ment Health J (2011) 47:164–170
total scores. Total scores could range from 0 to 30, with
higher scores indicating more positive attitudes toward
mental health services. An exploratory factor analysis with
varimax rotation yielded two factors (Positive and Nega-
tive Attitudes), that together accounted for 46.3% of the
variance. Internal consistency for the scale in the present
sample was acceptable (a = .67).
Results
Descriptive Information of the Sample and Study
Variables
As shown in Table 1, the sample consisted of 297 older
adults aged 60–105, with an average age of 76 years. As is
typical in studies of older adults, a substantial proportion of
the sample (73%) was female. In terms of the ethnic
composition of the sample, the majority were from a Cuban
background (64.3%), followed by Puerto Rican (18.2%),
other (14.5%), and Mexican (3.0%). Examples of the
country of origin specified for the ‘‘other’’ response
included Spain, Venezuela, the Dominican Republic, Peru,
Columbia, and El Salvador. Due to the relatively small
numbers of participants from non-Cuban backgrounds,
ethnicity was recoded as ‘Cuban’ and ‘all others’ for
bivariate and multivariate analyses. At 20%, the proportion
of the married individuals was relatively low, as was the
proportion (20%) who had gone beyond a high school
education.
The majority (86.2%) used the Spanish version of the
questionnaire for the survey. For this reason, it was not
surprising that the average total score for acculturation,
8.18 (SD = 4.24) out of a possible maximum of 20, was
relatively low. The mean score for self-perceived health
was 6.88 (SD = 1.72). Scores for depressive symptoms
averaged 9.76 (SD = 6.12); about 43% of the sample fell
within the category of probable depression when the sug-
gested cutoff score for the short-form CES-D (C10) was
applied.
More than half (51%) thought that becoming depressed
is a normal part of aging, and 35% thought that depression
is a sign of personal weakness. More than 62% of the
sample thought that antidepressant medicines are addictive,
and about 17% thought that counseling brings up too many
bad feelings. The percentages of the sample that associated
mental illness with shame (2.7%) and with family disap-
pointment (8.2%) were relatively low.
Finally, with an average score of 21.4 (SD = 5.29) out
of a maximum of 30, the participants appeared to hold
quite positive attitudes towards mental health services. The
scores of the attitudes toward mental health services were
reasonably normal in their distribution (skewness = -.50).
Community Ment Health J (2011) 47:164–170 167

Table 1 Descriptive
Variable % M/SD Range
information of the sample and
study variables (n = 297) Demographic variables
Age 76.0/7.74 60–105
Gender (female) 73.1
Ethnicity (Cubans) 64.3
Marital status (married) 2.2
Educational attainment (beyond high school) 2.2
Background variables
Acculturation 8.18/4.24 4–19
Self-perception of health 3.88/1.72 0–7
Depressive symptoms 9.76/6.12 0–30
Misconceptions and personal beliefs
Think depression is a normal part of aging 51.0
Think depression is a sign of personal weakness 35.0
Think antidepressant medicines are addictive 62.3
Think counseling brings up too many bad feelings 17.2
such as anger and sadness
Think having a mentally ill family member brings 2.7
shame to the whole family
Think if I had depression, my family would be 8.1
disappointed with me
Attitudes toward mental health services 21.4/5.29 0–30

Predictors of the Attitudes Toward Mental Health Discussion

Services
After ensuring the absence of multicollinearity by exam-
ining bivariate correlations (rs \ .52) and variance infla-
tion factor scores (VIFs \ 1.60), we estimated a predictive
model of the attitudes toward mental health services.
Hierarchical regression models were tested with the entry
order being (a) demographic variables (age, gender, eth-
nicity, marital status, and educational attainment), (b)
background variables (acculturation, self-perceived health,
and depressive symptoms), and (c) the items assessing
misconceptions and personal beliefs associated with
depression. The results are summarized in Table 2.
At the first step, demographic variables accounted for
3% of the variance, and only age was significant. Indi-
viduals of more advanced age were more likely to have
negative attitudes toward mental health services. The entry
of acculturation and health variables explained only a small
portion of the variance, and none of these variables were
significant. The final model included the measures of
misconception and personal beliefs, which together con-
tributed an additional 12% to the explained variance. The
total explained variance was 17%. The beliefs that coun-
seling brings up too many bad feelings and that having
depression would make family members disappointed were
found to be significant predictors of negative attitudes
toward mental health services.
The need for research on mental health among racial and
ethnic minority elders prompted the present study. The
particular focus was on the attitudes of Hispanic older
adults toward mental health services. We examined a
number of factors that might be associated with such atti-
tudes, especially those reflecting misconceptions and per-
sonal beliefs associated with depression, and tested a basic
predictive model that incorporated these factors.
Individuals’ propensity to use mental health services
was assessed with one of the most popular instruments in
mental health research, the Attitudes Toward Seeking
Professional Psychological Help Scale—Short Form
(Fischer and Farina 1995). Given that prior studies with
groups consisting primarily of college students report
average scores ranging from 15.9 to 17.4 (e.g., Elhai et al.
2008; Fischer and Farina 1995), the average in the present
sample (M = 21.4, SD = 5.29) seems to reflect a rela-
tively positive attitude. Previous studies that examined age
differences in attitudes have also reported that older adults
exhibit more positive perceptions of help seeking than their
younger counterparts (e.g., Mackenzie et al. 2006, 2008;
Robb et al. 2003; Sirey et al. 2001). Moreover, Cubans and
Cuban Americans, who constitute the bulk of the present
sample, generally are accepting of modern medical prac-
tices (e.g., Pan American Health Organization 2001).
Placing results from the present study of Hispanic older

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Table 2 Regression models of

Predictor Model 1 Model 2 Model 3
attitudes toward mental health
services b t b t b t

Age -.19 -3.12** -.19 -3.09** -.19 -3.17**

Gender -.03 -.42 -.00 -.05 .03 .46
Ethnicity .04 .61 -.00 -.12 .03 .50
Marital status -.04 -.70 -.07 -1.08 -.05 -.93
Educational attainment -.02 -.35 .00 .07 -.01 -.27
Acculturation -.12 -1.87 -.10 -1.50
Self-perception of health .03 .43 .01 .16
Depressive symptoms -.12 -1.60 -.05 -.78
Note: Gender (female = 1,
male = 0), ethnicity Normal part of aging .06 .98
(Cuban = 1, all others = 0), Sign of personal weakness -.08 -1.42
marital status (married = 1, Addictive .02 .32
not married = 0), educational
Bad feelings -.29 -4.98***
attainment (beyond high
school = 1, less than high Shame -.02 -.32
school or high school Family disappointment -.13 -2.15*
graduate = 0) DR2 .03* .02 .12***
* P \ .05, ** P \ .01, Overall R 2
.03* .05* .17***
*** P \ .001

adults in the context of the well-documented underutili-
zation of mental health services among minorities (e.g.,
U.S. Department of Health and Human Services 2001), the
present findings underscored the apparent paradox of
positive attitudes towards services being found in the same
group that has a long history of underutilization of these
services.
To explore the possible sources of this paradox, we
examined factors associated with attitudes towards ser-
vices. Several factors predicted. For example, those of
more advanced age were more likely to have unfavorable
attitudes toward mental health services. Such findings may
indicate cohort differences within the populations of His-
panics living in the United States. The younger cohorts
tend to be better informed of mental health issues and have
more exposure to mental health services than their older
counterparts. Such differences in experiences and expo-
sures may have led to the greater acceptance and willing-
ness to use mental health services among younger cohorts
of older adults. Considering that depressive symptoms are
more frequently experienced by older individuals with
advanced age, our findings call special attention to the
older cohorts of the elders in efforts to promote positive
attitudes toward mental health services. On the other hand,
it is also worth noting that ethnicity, in this case indicating
whether or not the respondent was of Cuban ancestry, did
not make a difference in attitudes.
The major focus of the present study was on the indi-
cators of misconceptions and personal beliefs associated
with depression. These indicators are of particular interest
because their existence has often been reported in studies
of minority populations including Hispanics (e.g., Gonz-
alez and Acevedo 2006; Leong and Lau 2001; Sirey et al.
2001). In the descriptive analysis, the sample was shown to
be quite prone to misconceptions and negative beliefs,
despite a generally positive attitude towards mental health
services. It is striking that more than half of the sample
thought that depression is a normal part of aging. More
than a third of the sample saw depression as a sign of
personal weakness, a figure that is considerably higher than
the 22% found in a recent national survey conducted by the
Mental Health America (2007). Substantial proportions of
the sample (62.3%) also showed a general apprehension
toward medications, and this finding is consistent with
those of other studies with Hispanics (e.g., Cabassa et al.
2007; Cooper et al. 2003).
More than 17% of the sample thought that counseling
brings up too many bad feelings (e.g., anger, sadness), and
such a belief was found to be significant in a multivariate
model predicting attitudes toward mental health services.
This finding underscores a need to increase public knowl-
edge and awareness about psychological treatments and
also suggests that counseling programs for Hispanic older
adults should target strength-based positive emotions rather
than problem-oriented negative emotions. A recent study
by D’Angelo et al. (2009) reports the effectiveness of
strength-based family-centered approach in treating
depression among Latinos with low income.
Although few individuals reported a concern about
family disappointment (8.1%), this concern was a signifi-
cant predictor to negative attitudes toward mental health
services in the multivariate analysis. This finding reflects

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cultural norms related to family expectations and inter-
personal communication among Hispanics that has previ-
ously been reported (e.g., Snowden 2007). Based on the
cultural values of ‘familismo,’ Hispanic older adults may
feel a greater sense of obligation and responsibility toward
their family; they may fear disappointing the family and
may not want to burden them. These cultural perceptions
associated with mental health and services should be taken
into consideration when developing intervention programs
for Hispanic older adults. For example, family involvement
in the process of mental health care seeking and treatment
is strongly encouraged.
In a supplementary analysis, the subgroup of individuals
who concerned about family disappointment (t = -2.18,
P \ .05) and the subgroup of individuals who thought
counseling would bring up too many bad feelings (t = -
2.64, P \ .01) were found to have significantly higher
levels of depressive symptoms than their counterparts. The
fact that those with a vulnerable mental health profile are
more prone to the negative beliefs about mental health care
underscores a need for intervention programs to promote
public knowledge and awareness of mental health services.
It is also possible that those individuals under distress are
more likely to have personal experiences of family disap-
pointment and negative encounters with counseling.
Some limitations of the present study should be noted.
Due to the study’s cross-sectional design and geographi-
cally defined, nonrepresentative nature of the sample,
causal inference and generalizability are not warranted.
Because the present sample was recruited from public
housing facilities, findings cannot be generalized to all
community-dwelling Hispanic older adults. The fact that
within-group variability across ethnic groups was not
addressed due to the limited sample size is also a limita-
tion. Despite these limitations, our findings identify sub-
groups and potential areas of focus for educational
interventions and campaigns to promote positive attitudes
toward mental health services in Hispanic older adults.
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