case study on help seeking

• Research article
• Open access
• Published: 11 June 2020

What are the barriers, facilitators and interventions targeting help-seeking behaviours for common mental health problems in adolescents? A systematic review

• Antonia Aguirre Velasco 1 ,
• Ignacio Silva Santa Cruz 2 ,
• Jo Billings 3 ,
• Magdalena Jimenez 4 &
• Sarah Rowe   ORCID: orcid.org/0000-0003-1072-6182 3  

BMC Psychiatry volume  20 , Article number:  293 ( 2020 ) Cite this article

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Increasing rates of mental health problems among adolescents are of concern. Teens who are most in need of mental health attention are reluctant to seek help. A better understanding of the help-seeking in this population is needed to overcome this gap.

Five databases were searched to identify the principal barriers, facilitators and interventions targeting help-seeking for common mental health problems in adolescents aged 10–19 years. The search was performed in June 2018 and updated in April 2019. Two independent screening processes were made using the eligibility criteria. Quality assessment of each study was performed, and findings summarised using a narrative synthesis.

Ninety studies meet the inclusion criteria for this review for barrier and facilitators ( n  = 54) and interventions ( n  = 36). Stigma and negative beliefs towards mental health services and professionals were the most cited barriers. Facilitators included previous positive experience with health services and mental health literacy. Most interventions were based on psychoeducation, which focused on general mental health knowledge, suicide and self-harm, stigma and depression. Other types of interventions included the use of multimedia and online tools, peer training and outreach initiatives. Overall, the quality of studies was low to medium and there was no general agreement regarding help-seeking definition and measurements.

Most of the interventions took place in an educational setting however, it is important to consider adolescents outside the educational system. Encouraging help-seeking should come with the increased availability of mental health support for all adolescents in need, but this is still a major challenge for Child and Adolescent Mental Health Services. There is also a need to develop shared definitions, theoretical frameworks and higher methodological standards in research regarding help-seeking behaviours in adolescents. This will allow more consistency and generalisability of findings, improving the development of help-seeking interventions and ensuring timely access to mental health treatments.

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Young people present with the highest prevalence of mental health disorders compared to individuals at any other stage of the lifecycle [ 1 ], with up to 20% of adolescents likely to experience mental health disorders [ 2 ]. Mental health has been defined as “a state of wellbeing in which and individual realizes of his/her abilities, can cope with normal stresses of life ( …) and is able to make a contribution to his/her community” [ 3 ]. Around 50% of mental health conditions start before the age of 14 [ 4 ] and the onset of 75% of cases is before the age of 18 [ 5 ]. The most common diagnoses are depression and anxiety [ 6 ] and around 25% of young people experience psychological distress [ 7 ]. Depression is one of the principal causes of illness and disability in teenagers, and suicide is the third most common cause of death among older adolescents [ 4 ]. Mental health problems can significantly affect the development of children and young people [ 4 ] having an enduring impact on their health and social functioning in adulthood [ 8 ]. Adolescents experiencing mental health conditions may face several challenges such as isolation, stigma, discrimination and difficulty in accessing health services [ 2 ]. However, 75% of adolescents with mental health problems are not in contact with mental health services [ 9 ], the primary reason being reluctance to seek help [ 1 , 10 , 11 ].

Help-seeking for mental health problems necessitates communicating the need for personal and psychological assistance to obtain advice and support. Rickwood and Thomas’ (2012) define help-seeking for mental health problems as “an adaptive coping process that is the attempt to obtain external assistance to deal with mental health concerns” [p.180, 12]. This includes both formal (e.g., health services) and informal (e.g., friends and family) sources of help. However, adolescents most in need of psychological help are those least likely to look for it [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. One of the biggest challenges in adolescent mental health is ensuring that at-risk individuals are linked with the appropriate support [ 14 ]. Understanding barriers and facilitators to help- seeking is fundamental for the development of interventions and programmes to support adolescents with mental health problems.

Rickwood et al., (2005), investigated the main barriers and facilitators of help-seeking for mental health problems in young people. They found that lack of emotional competence, negative beliefs about help-seeking and stigma were the most prominent barriers. Conversely, emotional competence, previous positive experiences with health professionals and mental health literacy, were the main facilitators [ 15 ]. Gulliver et al., (2010) performed a systematic review of the available literature at that time, finding similar results; however, they stated that stigma was the most prominent barrier for seeking for help in young people [ 1 ]. Another systematic review was made by Rowe et al., (2014), focused on in help-seeking for adolescent self-harm. They found that in addition to stigma, negative reactions from others related to confidentiality breaches and being seen as an “attention seeker” were the most relevant obstacles [ 10 ]. While interesting, these previous reviews do not address the help-seeking barriers and facilitators of most common mental health troubles among adolescents, nor include interventions targeting these. Rickwood, Deane et al., (2005) only included depressive symptoms, personal emotional problems and suicidal thoughts and Rowe et al. (2014), only focused on adolescent self-harm. The most complete review published by Gulliver and colleagues (2010) is almost 10 years old and need of updating.

Adequate and effective interventions that promote help-seeking are necessary for enhancing prevention, early detection, timely treatment and recovery from mental health problems [ 14 ]. Previous systematic reviews on interventions targeting help-seeking reveal some promising results in regard to enhancing mental health literacy [ 16 ] and a significant positive overall effect of these interventions in improving help-seeking for mental health problems [ 17 ]. Nonetheless, these reviews do not focus on adolescent populations and only one includes randomised controlled trials (RCT).

The primary aim of this review is therefore to provide an update of the literature on barriers and facilitators of adolescent mental health help-seeking including formal and informal sources of help, with the inclusion of interventions targeted at improving this. We will focus on common mental health problems, including depression, anxiety, suicidal thoughts, self-harm, emotional distress, among other personal-emotional symptoms. The secondary outcome is to examine any significant differences between age and sex. Understanding the difficulties around help-seeking behaviours and facilitating access to timely and effective treatment is essential for preventing the escalation of mental health problems among adolescents.

For the purpose of this review, help-seeking was defined as the action of actively searching for help for mental health problems, including informal (family, friends) or formal (GP, mental health professionals, etc.) sources, based on interpersonal and social abilities [ 11 ]. “Adolescents” were people aged 10 to 19 years, as defined by the World Health Organisation [ 4 ]. Despite the increasing debate regarding the age of adolescence [ 18 ], this definition was considered as appropriate for our study as it is accepted by international organisation such as OMS and UNICEF. Also, we considered this age range more homogenous and comparable in terms of lifecycle experiences and challenges that would be reflected in help-seeking behaviours and intentions. This review was prospectively registered on PROSPERO (CRD42018096917) and reported in accordance with the PRISMA guidelines [ 19 ]. The search terms were developed using the PICO structure, then expanded using MeSH terms and combined using Boolean operators. Four databases were selected including MEDLINE®, Embase, PsycINFO, and Web of Science, as well as the search engine Google scholar, identified as an optimal database combination [ 20 ]. Grey literature from the mentioned databases was also included and a search was carried in Open Grey. An initial version of the proposal for this study was reviewed by the McPin Foundation. The feedback was considered in the developmental stage, in order to evaluate the relevance and reception of the protocol by Patient and Public Involvement (PPI) organisations.

We included studies published in English, Spanish and French and focused on identifying barriers, facilitators and interventions targeting help-seeking behaviours for mental health problems in adolescents, specifically depression, anxiety, suicidal ideation, emotional distress and general symptoms of mental illness. Other mental health problems such as psychosis, anorexia, among others were excluded, because we decided to focus on most prevalent mental health problems which share a more similar help-seeking process. Regarding barriers and facilitators, we included studies published after 2010 since a previous systematic review on the topic was published then [ 1 ]. We did not include any limit regarding year of publication for help-seeking interventions. All study designs were considered, including feasibility studies and study protocols. We excluded studies that referred to young people over the age of 19 or children under 10 years old. When study populations included adolescents outside of the established age range, the paper was included if over 50% of the individuals in the sample were within the 10–19 years category or if separate outcome data was provided for the participants in this age range. Studies meeting the inclusion criteria and including parents in their sample were also considered. Finally, other exclusion criteria were articles written in other languages, or if the intervention did not explicitly target help-seeking behaviours or was not related to mental health conditions (Appendix S1 ) (Table  1 ).

The search was performed in June 2018 and updated in April 2019. The results were exported to EndNote X8 and duplicates were removed. Titles and abstracts were screened by one author (AA) at the first stage. At a second stage, two authors (AA and IS) checked the full articles using the pre-determined inclusion and exclusion criteria. A third member of the research team (MJ) was available to solve discrepancies. Disagreement on 12 studies was attributed mainly to differences concerning the definition and measurement of help-seeking and was resolved in a discussion with a third author (MJ) not involved in the process of screening. Authors were contacted when relevant information was missing or when we could not find the articles retrieved by the databases. Reference list of all included studies were screened in case we found other studies relevant to our review. Data were extracted using a predefined form, which allowed the research team to identify the main characteristics of each study. This process was executed by one author (AA) after a complete review of the included papers. For the first question, data extraction focused on identifying barriers and facilitators and for the second question, intervention and effect size when reported. We created an additional form to extract data regarding the secondary outcome (age and sex). For the quality assessment, we used the Joanna Briggs Institute Critical Appraisal Checklist [ 21 ] and the Mixed Methods Appraisal Tool (MMAT) [ 22 ], which were appropriate due to the variety of study designs included in this review; both have been previously validated [ 23 , 24 ]. The Joanna Briggs tool has a number of checklists to evaluate the main features of each study design. We used the checklist for cross-sectional studies, RCT, quasi-experimental studies and qualitative studies. Each checklist had a number of items to evaluate the most relevant aspect of the specific design (e.g: for RCT was allocation to treatment groups concealed? Were treatment groups similar at the baseline?). After completing the checklist an overall quality appraisal score was calculated to provide a measure (low, medium and high) of the quality of each study. The MMAT included a similar checklist but is specific to mixed method study reviews. Overall study quality was not used as an exclusion criterion because we opted to be overly inclusive and provide a thorough overview of help-seeking in adolescents. Results have been summarised using a narrative synthesis. We identified the most relevant features regarding help-seeking barriers, facilitators and interventions in our data. These features were grouped into themes that capture the essential aspects regarding the main outcome of this review. With this information we developed a preliminary synthesis of the results organizing the themes so that patterns regarding the main barriers, facilitators and interventions were identified. Finally, we explored previous evidence on the topic and explore the relationship between the included studies. This allowed us to explore the influence of heterogeneity and the robustness of the preliminary synthesis [ 25 ]. Due to the heterogeneous nature of the studies included, a meta-analysis was not conducted. The quality of each study was not used as an exclusion criterion or impacted the weight given to each study in the narrative synthesis. This over-inclusive criteria allowed us to have an overall picture not only regarding help-seeking barriers, facilitators and interventions, but also the methodological quality of the available evidence.

Two independent searches were carried out during June 2018 and then updated in April 2019. A total of 90 studies were included in this review, combining both barriers and facilitators ( n  = 54) and the intervention ( n  = 36) questions. PRISMA diagrams displaying the number of papers retrieved and the process of selection of the included studies is available in Figs.  1 and 2 . Regarding the inter-rater reliability for this review, the agreement between the researchers screening the papers was high, with a 85% accuracy and 95% precision (Kappa = 0.954). Adolescents identified a range of formal and informal help-seeking options across studies, such as GPS, psychologists, psychiatrists, teachers, social workers (formal), and friends, family, sporting coaches, and online communities (informal). Regarding question 1, most of studies focused on identifying barriers and facilitators towards formal sources of help, whereas intervention studies had a wider variety of sources of help, depending on help-seeking behavior attempted to promote.

Prisma 2009 Flow Diagram. Question 1: Help-seeking barriers and facilitators

Prisma 2009 Flow Diagram. Question 2: Help seeking interventions

Question 1: help-seeking barriers and facilitators

Fifty-four studies that reported barriers and/or facilitators including a total of 56,821 participants were considered in the narrative synthesis (Table  2 ). Most of the studies ( n  = 18) were conducted in Australia, followed by the United States ( n  = 12) and the United Kingdom ( n  = 5). The majority of the studies were cross sectional ( n  = 36) [ 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 ], thirteen studies were qualitative [ 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 ] and six used a mixed-method design [ 75 , 76 , 77 , 78 , 79 , 80 ]. Three PhD dissertations and one conference abstract were included in the grey literature. The age ranged from 8 to 26 years old. Three articles included adolescents and their parents, while one article included just adolescents’ mothers.

The majority of studies were conducted in educational settings, such as schools ( n  = 24) and tertiary education ( n  = 11) focusing in non-clinical samples. Sixteen studies included participants from other community settings and two studies were conducted in mental health care facilities. Among the studies that include actual help-seekers ( n  = 7), the most common reason for seeking help was suicidal ideation, self-harm, depressive symptoms, and general mental health concerns (e.g., anxiety/nervousness/fear). Therefore, the conclusions drawn by the majority of the articles were based on help-seeking intentions rather than actual behaviours, since the participants were not experiencing mental health problems and focused on hypothetical scenarios.

Help-seeking barriers

Stigma is defined as the fear of being socially sanctioned or disgraced leading to hiding or preventing certain actions or behaviours, including the misreporting of mental health problems [ 81 ]. More than half of the included studies ( n  = 30) made reference to this and other negative attitudes towards mental health problems as the main obstacle to help-seeking behaviours in adolescents. Of these, twenty-five studies referred to stigma as the primary obstacle, describing it through different concepts such as, “stigma”, “fear of stigmatisation”, “community stigma”, “perceived stigma” and “self-stigma”. Other negative attitudes towards mental health problems included shame, fear, and embarrassment.

Family beliefs

The second most mentioned barrier was associated to adolescents’ family beliefs toward mental health services and treatment ( n  = 15). Barriers related to problem with communication and distrust towards health professionals, negative past experiences with mental health services, and believing that the treatment is not going to be helpful. This was especially true for studies including immigrant and refugee populations, which referred to cultural barriers including mistrust of mental health diagnosis and practitioners, and lack of cultural sensitivity in services as a significant barrier.

Mental health literacy

Mental health literacy refers to the ability to use mental health information to recognise, manage and prevent mental health disorders and make informed decisions about help-seeking and professional support [ 82 ]. Almost one-third of the articles ( n  = 14) referred to problems related to mental health literacy as a significant barrier including poor recognition of mental health conditions (self and others) and lack of awareness of available sources of help.

Adolescents’ attitudes towards help-seeking revealed a perceived need of self-sufficiency and autonomy which were recognised as a relevant barrier in twelve studies, as well as fears of confidentiality breaches.

Other help-seeking barriers

To a lesser extent, problems regarding service and personnel availability and other structural factors (such as cost, transportation and waiting times) were mentioned as obstacles to help-seeking ( n  = 8). This was a significant barrier for studies including rural and immigrant populations, and in studies that included parents in their sample. Six studies focused on the relationship between symptomatology and help-seeking. These found that higher levels of psychological distress, suicidal ideation and depressive symptoms were linked to lower help-seeking behaviours.

Help-seeking facilitators

Of the 56 included studies, 19 also referred to facilitators of help-seeking behaviours. Mental health literacy and prior mental health care were the most cited facilitators for help-seeking for mental health problems ( n  = 10). Specifically, timely access to mental health was facilitated by having a previous positive experience with mental health services or help-seeking, being familiar with the sources of help, and good symptom and problem recognition. Higher engagement with the community and having a trusting and committed relationship with relevant adults such as parents, schoolteachers and counsellors also facilitated seeking help among adolescents. Further details of the included articles are available in Table 2 .

Secondary outcomes

Few studies identified a significant difference when comparing younger and older adolescents in relation to barriers and facilitators to help-seeking, with no conclusive findings being reached. Some findings suggested that older adolescents tended to establish to feel more comfortable with people with mental health issues [ 83 ] and had less help-seeking fears [ 40 ]. In contrast, younger adolescents had greater knowledge about professional sources of help [ 34 ]. Only one study found a significant difference between ages regarding help-seeking, with younger adolescents reporting higher intentions of seeking help [ 60 ].

Twenty-four studies examined possible gender differences in help-seeking barriers and facilitators. Seven studies did not find significant differences between genders [ 28 , 39 , 40 , 42 , 46 , 51 , 69 ]. One study reported higher help-seeking intentions in males experiencing suicidal intentions [ 60 ] and two studies found that females perceived more overall barriers [ 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 ]. However, this may be related to higher rates of females seeking help for mental health problems compared to males [ 31 , 33 , 37 , 42 , 48 , 53 , 58 , 61 , 76 ]. Studies reviewed did not evidence convincing differences between gender in relation to help-seeking.

Question 2: help-seeking interventions

Thirty-six studies on interventions targeting help-seeking behaviour, including a total of 28,608 participants, were summarised in the review (Table  3 ). Most of intervention studies were conducted in Australia (14) and the United States (14), followed by Canada (4) and United Kingdom (3). All studies were conducted in educational setting including high school ( n  = 35) and college ( n  = 1). The majority of studies developed interventions for non-clinical samples, and their focus was the prevention of mental health problems and the promotion of healthy coping strategies via help-seeking behaviours. Outcomes varied between help-seeking intentions, attitudes and behaviours. Almost half of the studies focused on the effectiveness of the interventions, while sixteen were feasibility or pilot trials and study protocols. Most of the studies used a quasi-experimental design ( n  = 21) followed by randomised controlled trials ( n  = 15). The age of participants ranged from 11 to 19 years old, although one study that included participants under 29 years old was incorporated as more than half of the sample were adolescents. Interventions were delivered using four main methods: psychoeducation, outreach interventions, multimedia tools and peer leader training.

Types of intervention

Psychoeducation.

Most of studies ( n  = 23) used psychoeducation and classroom-based interventions. Although all the interventions focused on encouraging help-seeking behaviours, the emphasis and content differed among them, including general mental health topics, suicide and depression awareness and stigma.

Five studies developed programmes based on the notion that promoting mental health awareness could enhance mental health literacy and promote help-seeking [ 84 , 85 , 86 , 87 , 88 ]. Four interventions targeting help-seeking for suicide were identified within five studies [ 89 , 90 , 91 , 92 , 93 ]. Five interventions explicitly targeted help-seeking for depression in school-based settings their focus being to educate the school population about adolescent depression and thereby encourage help-seeking [ 94 , 95 , 96 , 97 , 98 ]. Two studies evaluated the effectiveness of an intervention combining depression awareness and a suicide prevention programme promoting early identification and self-referral [ 99 , 100 ]. Six classroom-based interventions addressing stigma were identified, two of which used psychoeducation to overcome myths regarding mental illness [ 101 , 102 ] and four focused on providing interpersonal contact with people with mental health conditions in order to improve acceptance and increase help-seeking intentions [ 103 , 104 , 105 , 106 ].

Outreach interventions

Three studies used outreach interventions to target mental health help-seeking [ 107 , 108 , 109 ]. These aim to establish contact with adolescents who may be experiencing psychological and emotional distress in order to help them get the attention they need and increase their access to health services. They were based on the Building the Bridges to General Practice (BBGP) programme, developed by Wilson et al. (2005), a programme that aims to target help-seeking obstacles for physical and psychological problems by promoting contact between high school students and general practitioners [ 110 ].

Multimedia interventions

Six types of multimedia interventions have been developed to address some of the difficulties of reaching an adolescent population, such as fear of confidentiality breaches, stigma and self-reliance [ 111 , 112 , 113 , 114 , 115 ]. The interventions included interactive films to engage students with mental health related topic and online platforms providing personalised information regarding the decision-aids process.

Peer training interventions

Peer training interventions are focused on the training of peers who act as active agents of change and social interactions incorporated into the daily activities within the school environment [ 116 ]. All three programmes followed similar principles concerning improving the climate around mental health problems, promoting social connectedness, and challenging norms and behaviours associated with help-seeking [ 117 , 118 , 119 , 120 ]. “Peer leaders” acted as a link between the student population and mental health literacy, promoting the acceptability of seeking for help for mental health problems.

Further details of the included articles are available in Table 3 .

No studies referred to significant differences concerning the effectiveness of help-seeking interventions when comparing ages. No significant gender differences were identified regarding the effectiveness of the help-seeking interventions [ 89 , 101 , 103 , 111 ]. However, before the intervention¸ females tended to have higher mental health literacy and more adaptive attitudes regarding mental health problems [ 90 , 111 ], including greater help-seeking knowledge and intentions [ 107 , 112 , 113 ].

Effectiveness

The main goal of this review was to describe the interventions targeting help-seeking in adolescents and therefore did not include an analysis of their effectiveness. Almost half of the included studies were study protocols and feasibility studies, so effect sizes were not reported. However, some findings are worth mentioning.

Four studies which looked at effectiveness of the interventions focused on psychoeducation about depression found a significant effect in increasing help-seeking. King et al., [ 99 ] identified that there was an increase in future help-seeking behaviours after the interventions and that this was maintained at 3 months’ follow-up ( t  = 4.634/ p  < .001). Strunk et al., [ 100 ] found a significant increase of help-seeking ( p  < 0.0005); however, this was not sustained at follow-up ( p  = 0.014). Robinson et al., [ 95 ] found that the intervention group was more likely to seek help at post-test (Odds ratio (95% C.I) =3.48 (1.93, 6.29), p  < 0.0001) and Ruble et al., [ 96 ] found increased intention of help-seeking from others after the intervention ( t  = 13.658/ p  < 0.0001.).

The three studies that looked at the effectiveness of stigma reduction identified positive effects of the intervention on help-seeking. Two studies [ 101 , 104 ] found a significant reduction in self-stigma surrounding seeking help after the intervention ( p  < 0.05) and one study [ 103 ] found a significant effect of the intervention in help-seeking intentions (Wilks’ Λ = .942, F (4,417) = 6.428, p  < 0.001).

Finally, all the studies that focused on outreach found a significant effect of the intervention in help-seeking intentions. One detected an increase in intentions at 3 months follow-up ( F (2,217) = 3.04/ p  < 0.05) [ 108 ], Rughani [ 107 ] found short terms improvements in help-seeking intentions (F (14,225) =1.87 p  < .03) and Wilson [ 109 ] found a significant effect in the intention of seeking help for psychological problems after the intervention (F (2,598) = 4.31 p  < 0.01).

Quality assessment

The majority of the studies were low to medium quality with moderate to high risk of bias. Most of the cross-sectional studies did not state a clear inclusion and exclusion criteria and did not consider possible confounders affecting the interpretation of the outcome. Regarding qualitative research, the most common problem was linked to sample size and the difficulty of providing a clear strategy to address the subjectivity of the authors in the interpretations of the data. Mixed method studies presented some inconsistencies in addressing specific components of both quantitative and qualitative traditions, and in the process of integrating both approaches. Regarding intervention studies, it was difficult to identify to what extent the groups were similar at baseline. Although some studies included baseline measures of demographic information, most of them did not consider confounders or other factors influencing effectiveness, and some studies did not have any baseline measures. Also, few studies included follow-up and the ones that did, had high attrition rates and short follow-up periods (up to 6 months); therefore, it is not possible to attribute a long-lasting effect to the interventions. Quasi-experimental studies acknowledge possible selection and sample bias. Randomised controlled trials presented difficulties in terms of the blinding of the research team and participants at different stages of the process.

Overall there was inconsistency regarding the measurements of help-seeking, with most of the studies focusing on help-seeking intentions, which is not necessarily related to future behaviours. Moreover, many studies did not use valid and reliable instruments for measuring help-seeking. This is especially true for the experimental studies since most of them developed tools focused on their intervention rather than standardised help-seeking measures. Finally, most of the studies only used self-report measures, increasing the risk of bias of the findings. We did not assess the quality of study protocol, feasibility studies and pilot studies.

Question 1: barriers and facilitators

This review focused on identifying barriers, facilitators and interventions targeting help-seeking behaviours in adolescents. Consistent with previous findings [ 1 ], the most prominent barrier identified was stigma. Negative attitudes and beliefs about mental health services and professionals was the second most prominent barrier. Trusted and strong relationships with possible gatekeepers (teachers, parents, GPs, health professionals, etc.) and prior positive help-seeking experience were the most cited facilitators.

Few studies related symptom severity with help-seeking. Of those that did, higher symptomatology was associated with lower help-seeking intentions and behaviours. This is in line with previous studies suggesting that teens who are most in need are less likely to seek help [ 1 , 11 , 15 ]. It is possible that the nature of mental health symptoms such as self-blame, emotional distress, difficulty in speaking to others and diminished cognitive ability contribute to lower help-seeking behaviours. Adolescents with higher symptom severity may be even more vulnerable experiencing difficulties with the help-seeking process in areas such as identifying the need for professional assistance or fear of stigmatisation. This could be due to higher rates of isolation and exclusion from their peers. Increasing mental health literacy among this population may provide a way of improving social support between peers [ 121 ].

There are structural barriers affecting the help-seeking process that go beyond attitudes, for example, costs, waiting times and transportation. These barriers were not among the most prominent reasons cited in the research review; however, this may be related to the limited amount of studies that included parents’ perceptions. A previous review, which focused on the parents of children and adolescents, concluded that structural barriers were the most relevant [ 122 ]. This suggests that adolescents are less worried about the practical implications of accessing help for mental health problems and are more affected by being attitudinal barriers, but that structural barriers may be more relevant to parents.

Key facilitators to help-seeking should be considered when creating new interventions such as trusted relationships with gatekeepers, and familiarisation with the help-seeking process. However, the lack of studies focusing on facilitators precludes many conclusions being drawn. The majority of studies used sub-clinical samples and/or hypothetical help-seeking scenarios rather than asking genuine help-seeker with mental health problems who could refer to the real circumstances leading them to ask for help. More research including young people who have sought help from services would be useful in understanding the idiosyncrasies of this process.

These findings provide a useful overall picture of the relevant factors influencing the help-seeking process in adolescents. However, the included studies did not share a clear definition and framework regarding help-seeking. A wide range of tools were used to measure help-seeking, varying in their validity and reliability, and also in the constructs they measured. This limits the generalisability of the findings and our understanding of the help-seeking process. Rickwood & Thomas (2012) have proposed a framework regarding help-seeking, identifying the different parts of the process, sources of help, types of help and main concerns [ 15 ]. In the future, sharing such a framework could be a useful means to reach a general agreement regarding the definition of help-seeking and its components.

Question 2: interventions

The types of interventions varied considerably and included classroom-based psychoeducation, outreach interventions, multimedia and online-based interventions and peer training. Among classroom-based psychoeducation interventions, the most effective ones were those focused on prompting help-seeking through addressing depression and stigma. All peer outreach interventions had a significant effect in improving help-seeking intentions, thus showing promising results. In sum, addressing stigma, mental health literacy, and attitudes towards mental health services could be beneficial in terms of promoting help-seeking.

Most of the intervention studies included in this review did not investigate mechanisms of change with regards to help-seeking behaviour. The relevance of studying underlying mechanisms and practical requirements related to the functionality of interventions has been previously discussed [ 123 ], and most of the interventions included in this review did not refer to these processes. Identifying such mechanisms could help understand how interventions work, enlightening and optimising the process of decision-making and design [ 93 ]. Adolescence is a period essentially characterised by emotional, behavioural, hormonal, and neuronal changes [ 124 , 125 ]. Interventions congruent with the developmental stages may be useful to target age-appropriate factors.

It is important to mention that few intervention studies referred in detail to the implementation process and the main issues they encountered; however, the studies which did refer to this, found significant barriers. School administration issues, the difficulty of obtaining parental consent and attrition rates for the follow-up measures were one of the main difficulties regarding the implementation [ 93 , 97 , 102 , 115 ]. Teacher’s support and engagement with the intervention were also described as a barrier in the implementation process for some studies [ 85 , 93 , 114 ]. Most of studies concluded that implementation strategies should consider the reality and challenges of each school. For this the theme of contextualization is fundamental and the specificities of the process of implementation (planning, engaging, executing, reflecting and evaluating) [ 126 , 127 ].

All interventions were conducted within an educational setting. Special attention should also be paid to young people outside of the educational system, who are particularly vulnerable in terms of economic and social deprivation [ 128 ]. Around one in five children and adolescents are out of school according to the UNESCO [ 129 ], with psychosocial factors appearing to obstruct traditional educational trajectories [ 130 ]. Health and mental health conditions have a relevant role in terms of absenteeism and truancy [ 131 ]. Adolescents experiencing symptoms of depression and anxiety or in charge of a chronically sick relative can be more prone to avoid school and stay at home. These children can be even more vulnerable and harder to reach, and there is a lack of collaborative effort attempting to overcome this situation. Encouraging partnerships between the health and educational systems, community settings, youth detention centres, among other institutions providing social care, should be promoted with the purpose of supporting mental healthcare and provision for young people [ 132 ].

Encouraging adolescents to seek help for mental health problems is a key priority however, this does not resolve the discrepancy between needs and resources worldwide [ 132 , 133 ]. “Mental health services for children and adolescents have internationally been poorly understood, underfunded and even neglected by governments” [p.92, 134]. This may be associated with the lack of a general understanding of this population’s needs (including developmental issues), and the “implementation gap”, referring to the challenges of translating evidence to health service development and practice [ 134 ]. Simultaneously, focusing on increasing help-seeking and service availability for children and adolescents is necessary to reduce the global burden of disease and protect the future health of this population [ 125 , 135 ].

Limitations

This review has a number of limitations. First, only one author performed the data extraction and critical appraisal of papers therefore the data analysis is at risk of some subjectivity. Second, there is an increasing debate regarding the age that adolescence comprises, with some suggesting the age should be extended to 10 to 24 years old [ 17 ]. However, we decided to follow the definition of ´adolescent´ established by international organisations including the OMS and UNICEF. A significant number of papers were excluded considering our age range ( n  = 104). Defining adolescence as a period between 10 to 19 years old could be a limitation to our study. Thirdly, this review focused on common mental health problems such as depression, anxiety and emotional distress and excluded psychiatric conditions such as anorexia, schizophrenia and substance misuse, mainly due to the particular nature of the help-seeking processes. However, the exclusion of substance misuse problems could be seen as a limitation of this study due to its high prevalence in adolescence, making it a particularly sensitive issue during this period of life [ 136 ]. Finally, this review prioritised the overinclusion of studies to have an overall picture of the existing evidence regarding help-seeking for mental health problems in adolescents. As a result, low quality studies were included in the analysis and may affect the interpretation of the findings. There were some notable strengths in this review. This is the first systematic review studying help-seeking barriers, facilitators and interventions in order to give a comprehensive review of the topic. The search strategy developed was over-inclusive, using an optimal database combination, including multiple languages and PPI involvement in the development of the topic.

In conclusion, stigma and negative beliefs about mental health services appear as the most significant barriers to help-seeking for adolescents, whereas previous positive experiences with services and good mental health literacy are the most relevant facilitators. There are a number of interventions being developed to promote help-seeking for mental health problems in adolescents, and most of them take place in high education settings. They include a range of delivery methods including psychoeducation, stigma and depression awareness campaigns, online tools and peer training. Since such initiatives are relatively new, there is a need for more trials, with longer follow-up periods and the use of reliable and validated tools focused in future help-seeking behaviour. Despite school seeming to be the ideal setting for deploying these interventions, it is important to consider adolescents outside the school system who may be in more need of attention for psychosocial and mental health problems.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Abbreviations

Mixed Methods Appraisal Tool

Randomised Controlled Trial

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Acknowledgements

The completion of this systematic review would not have been possible without the support of The National Commission of Scientific and Technological Research (CONICYT-Beca Chile) under the Ministry of Education of the Chilean Government.

N/A. This review was conducted as a dissertation in the context of the MSc Clinical Mental Health Sciences at UCL.

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The contributions of the authors are as follows: AA developed the review protocol, was the first screener and drafted the paper; IS was the second screener for this review; JB commented on the draft of the paper; MJ was the third contributor available to discuss any discrepancies between the two screeners; SR was the senior author, and was involved the design of the review questions, the protocol and commented on the draft of the paper. The author(s) read and approved the final manuscript.

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Aguirre Velasco, A., Cruz, I.S.S., Billings, J. et al. What are the barriers, facilitators and interventions targeting help-seeking behaviours for common mental health problems in adolescents? A systematic review. BMC Psychiatry 20 , 293 (2020). https://doi.org/10.1186/s12888-020-02659-0

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The Seeking Mental Health Care model: prediction of help-seeking for depressive symptoms by stigma and mental illness representations

• Thomas McLaren   ORCID: orcid.org/0000-0001-8899-5476 1   na1 ,
• Lina-Jolien Peter   ORCID: orcid.org/0000-0002-0635-6687 2   na1 ,
• Samuel Tomczyk   ORCID: orcid.org/0000-0002-2846-5489 1 ,
• Holger Muehlan   ORCID: orcid.org/0000-0001-8048-5682 1 ,
• Georg Schomerus   ORCID: orcid.org/0000-0002-6752-463X 2 , 3 &
• Silke Schmidt   ORCID: orcid.org/0000-0002-4194-1937 1  

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Only about half the people with depression seek professional health care services. To constitute the different predictors and associating variables of health care utilisation, we model the process and aim to test our hypothesised Seeking Mental Health Care Model . The model includes empirical influences on the help-seeking process to predict actual behaviour and incorporates superordinate (stigma, treatment experiences) as well as intermediate attitudinal variables (continuum and causal beliefs, depression literacy and self-efficacy).

All variables are examined in an online study (baseline, three- and six-month follow-up). The sample consisted of adults with depressive symptoms (PHQ-9 sum score ≥ 8), currently not receiving mental health care treatment. To examine the prediction of variables explaining help-seeking behaviour, a path model analysis was carried out ( lavaan package , software R ).

Altogether, 1368 participants ( M age  = 42.38, SD age  = 15.22, 65.6% female) were included, 983 participating in at least one follow-up. Model fit was excellent (i.e., RMSEA  = 0.059, CFI  = 0.989), and the model confirmed most of the hypothesised predictions. Intermediary variables were significantly associated with stigma and experiences. Depression literacy ( ß  = .28), continuum beliefs ( ß  = .11) and openness to a balanced biopsychosocial causal model ( ß  = .21) significantly influenced self-identification ( R 2  = .35), which among the causal beliefs and self-efficacy influenced help-seeking intention ( R 2  = .10). Intention ( ß  = .40) prospectively predicted help-seeking behaviour ( R 2  = .16).

The Seeking Mental Health Care Model provides an empirically validated conceptualisation of the help-seeking process of people with untreated depressive symptoms as a comprehensive approach considering internal influences. Implications and open questions are discussed, e.g., regarding differentiated assessment of self-efficacy, usefulness of continuum beliefs and causal beliefs in anti-stigma work, and replication of the model for other mental illnesses.

Trial registration

German Clinical Trials Register: DRKS00023557. Registered 11 December 2020. World Health Organization, Universal Trial Number: U1111–1264-9954. Registered 16 February 2021.

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Introduction

Only around one in two people contact professional support services for their depressive symptoms, despite considering a broad range of services, including psychiatric or psychotherapeutic help, general practitioners, and counselling [ 1 ]. Even in regions with high healthcare density, there is a substantial proportion of people who do not seek professional help for their depressive symptoms [ 2 ]. The pathway to treatment is influenced by various individual, system, and disease factors [ 3 ], including availability and accessibility of services and structural stigma [ 4 ]. Even though all these factors are relevant, this work is focused on investigating personal attitudinal and cognitive variables to identify and overcome potential barriers for seeking mental healthcare [ 5 ] due to the importance of attitudinal barriers to mental health treatment for mild and moderate symptoms [ 6 ]. We provide a comprehensive Seeking Mental Health Care Model explaining the help-seeking process, as well as influences of superordinate and intermediate variables (see Fig.  1 ). In the following paragraphs, we will summarise key empirical findings on attitudinal and cognitive variables influencing professional help-seeking. We refer to the illness representations of the Common Sense Model of Self-Regulation (CSM, [ 7 ]) as the underlying theoretical framework, which Scott et al. [ 3 ] also used in their model.

Seeking Mental Health Care Model.

(Note: Superordinate and intermediary variables and their direct or indirect influences on the help-seeking process for mental health problems. In brackets: Illness representations from the Common-Sense Model of Illness Regulation assigned to the respective variables. Hypothesis on self-efficacy to seek help on behaviour was not postulated in the study protocol, but incorporated retrospectively due to previous findings and with the aim of analysing a comprehensive model)

Help-seeking for mental illness is understood as a process of experiencing symptoms, identifying them as such, forming an intention, and lastly actual help-seeking [ 7 , 8 , 9 ]. The identification of symptoms of mental illness is a crucial starting point to forming intention [ 10 , 11 , 12 , 13 ]. However, a symptom is subjectively not necessarily conceptualised as illness because subjective experience and perceived functional changes influence symptom identification [ 14 ]. Therefore, the help-seeking process must start with becoming aware of one’s complaints as a symptom of mental health issues (i.e., self-identification).

Moreover, previous treatment experience influences the help-seeking process, including self-identification and intention [ 15 ] by reducing stigmatising attitudes [ 16 ]. Stigma in turn has been identified as a major barrier, hindering both self-identification and help-seeking initiation [ 13 ]. The types of stigma [ 17 ] differ in their influence towards help-seeking [ 18 ]. While evidence of the impact on perceived public and anticipated stigma on help-seeking is mixed [ 19 , 20 ], internalized stigma has consistent negative influences on help-seeking attitudes and intention [ 13 , 20 , 21 , 22 , 23 , 24 ]. In order to explain help-seeking for mental health problems, it is important to consider these outlined superordinate variables originating from the public and social reactions as well as personal experiences [ 3 ]. They might influence present internal beliefs and attitudes (i.e., intermediary variables ) with direct influences on the help-seeking process . Figure  1 presents our Seeking Mental Health Care Model [ 7 ], which includes hypotheses most interesting for the total model whilst controlling for others. This is especially relevant for the multiple empirical associations between treatment experience and intermediary variables that are mentioned in the following sections. Therefore, instead of formulating every single correlational hypotheses to replicate each empirical finding, we see treatment experiences as superordinate influence that correlates with several model variables, but only formulate specific hypotheses of interest. In the next section we will present the intermediary variables (Fig. 1 ).

Continuum beliefs of mental health and illness are associated with lower stigmatising attitudes towards people with mental illness [ 25 ]. Concerning, for example, drinking behaviour, the understanding of drinking along a continuum is currently discussed as a way to promote self-identification as part of a broad operationalisation of problem recognition [ 26 , 27 ]. Evidence is sparse for continuum beliefs of people with depression [ 25 ], however there are indications that a continuum model increases perceived similarities with a depression vignette [ 28 ].

Mental health literacy , the capacity to access, process, and apply information about mental illness and treatment [ 29 ], is recognised as an intermediary variable. It is associated with lower stigma and higher self-identification as well as being positively influenced by treatment experience [ 13 , 15 ]. However, self-stigma seems to act as a barrier between mental health literacy and help-seeking, therefore these associations need further reassurance [ 30 ].

Causal beliefs concerning one’s mental health problems are associated with higher self-identification and are influenced by treatment experience [ 15 ]. However, there is conflicting evidence on various causal beliefs (e.g., biomedical, childhood related) and their relation to stigma (e.g., [ 31 , 32 ]). A balanced biopsychosocial model based on biopsychosocial model of health [ 33 ] might reflect a realistic and effective causal belief model which influences help-seeking behaviour while balancing possible adverse effects of stigma [ 34 , 35 ].

Self-efficacy [ 36 ] for engaging in health behaviours has mainly been investigated for physical health [ 37 , 38 ]. For mental health help-seeking, it might be important to differentially consider task-specific self-efficacy. On the one hand, seeking professional help self-efficacy has been shown to be beneficial for help-seeking [ 9 ]. On the other hand, self-help self-efficacy might decrease professional help-seeking in favour of tendencies to help oneself [ 39 , 40 ], however this has rarely been investigated. Concerning the association between treatment experience and self-efficacy we assume that they are positively associated, because treatment is shown to reduce self-stigma which is in turn negatively associated with self-efficacy [ 41 , 42 , 43 ].

Expanding the view to general health-related decision making, the Common-Sense Model of Self-Regulation (CSM; [ 7 ]) is applied. CSM has been investigated extensively in the context of physical health [ 44 ], but has also been replicated for the mental health context [ 45 ]. It assumes a dynamic process from becoming aware of health threats, their emotional processing to treatment use through an interplay of illness representations [ 14 ]. These include representations of the identity (labelling) and timeline expectations of symptom development, their causes, perceived controllability, coherence with internal concepts of illness, and consequences of past and present illnesses [ 14 , 46 ]. In a recent meta-analysis, Cannon et al. [ 45 ] found large effects of illness representations on treatment use, however, only a few studies investigate treatment use for mental illness resulting in a need for further research in this field [ 45 ]. Therefore, we theoretically match the CSM illness representations to the above mentioned empirical variables influencing professional help-seeking behaviour (see Fig. 1 ). The subjective sense of illness is matched with the consequence representation and self-identification of having a mental illness with the identity representations. Especially the intermediary variables can roughly be assigned: The extent towards a person’s belief in a continuum of mental health and illness can be understood as the representation coherence . Depression literacy includes people’s concept of illness timeline, causal beliefs refer to causes representation, and self-efficacy represents the aspect of perceived controllability . These illness representations develop and change throughout the process of the illness, they interact with illness perceptions, subjective complaints, and experienced emotions. As a consequence, they respectively influence future processing of health threats and an integration of new experiences. Stigma negatively influences the CSM representations, as found for most of the described variables [ 47 ].

Our aim is to test the Seeking Mental Health Care Model , with the novel approach of incorporating superordinate stigma and experiences and five intermediary internal processes of illness perception that empirically influence help-seeking. Therefore, we use a prospective study on help-seeking in a population sample with currently untreated depressive symptoms [ 7 ].

This study is part of a project funded by the German Research Foundation, with a published study protocol [ 7 ] and preregistration in the German Clinical Trial Register (DRKS00023557). Data was collected by the online panel respondi AG via their online platform Mingle between January and September 2021. If screened eligible for study participation the panellists were informed about study content and procedure after which they could give electronic informed consent. The study included a quasi-experimental intervention design manipulating the intermediary variables. For the analyses, pre-intervention data is used, except for the behaviour variable which could only be assessed three to six months post intervention. However, this should not be an issue for testing interrelations of the variables, as the study has a fractioned factorial design. Furthermore, this study is not part of the original analysis but a secondary data analysis testing the model as a whole. For more information on the study design and interventional manipulation, refer to the study protocol [ 7 ].

Sample & power analysis

Participants without current professional treatment and with at least mild depressive symptoms were included (PHQ-9 sum score ≥ 8; 48). In total, N  = 1867 participants completed the questionnaire, which assessed stigmatising attitudes, intermediary variables and help-seeking variables. The final sample size consisted of N  = 1368, because participants were excluded if they completed the study under half the median duration [ 48 ] or had apparent monotone answer profiles ( n  = 116), if their PHQ-9 score was < 8 after the second assessment time 36 hours later ( n  = 362), or due to conflicting information about an individual’s gender between the study points ( n  = 12). Our sample only consisted of n  = 9 people who reported being of diverse gender. Because of the small case number we decided to exclude them from the analyses, however we emphasize the importance of focusing on hard to reach, yet especially vulnerable gender groups [ 49 ], because otherwise this methodologically reasonable exclusion only reproduces discrimination regarding minorities access to care [ 50 ]. All participants were contacted for follow-ups after three and six months in which help-seeking behaviour was assessed. Altogether, N  = 829 participated till the end of the study six months later. Refer to the study protocol for information on participant recruitment and content of assessment [ 7 ].

Because the path analysis is done in addition to the analyses reported in the study protocol [ 7 ] we recalculated the necessary sample size for this specific analysis. The estimated minimum sample size had to be N  = 200 (as proposed by Boomsma [ 51 ];). With a stricter rule of thumb, with five to ten needed observations per estimated parameter [ 52 , 53 ], we estimated a required sample size between N  = 645 to 1290. Therefore, we concluded that our sample size and statistical power is sufficient.

All measures used for the path model analysis are listed in Table  1 . The operationalisation of help-seeking intention and behaviour as well as other adapted variables are elucidated in further detail below. For extensive descriptions of all measures employed in the study refer to the study protocol [ 7 ].

With the Brief Illness Perception Questionnaire (B-IPQ; [ 46 ]) we assessed the participants subjective sense of illness. Eight items are rated on a 7-point Likert scale. One item assessing causal beliefs was excluded due to its open response format. A mean score was calculated, representing the degree to which the illness is perceived as threatening or benign, which we assume to be an important trigger point for the model. A higher score reflects a more threatening view of the illness. This operationalisation is suggested by Broadbent [ 64 ].

Causal beliefs of mental illness were assessed with a list of 18 possible causes [ 57 ]. Participants were asked to rate whether they believe a cause (e.g., “loneliness”) could be responsible for their experienced complaints. Rating was assessed on a 5-point Likert scale from 1=“definitely is not a cause” to 5=“definitely is a cause”. Internal consistency was acceptable with α  = .78. With the aim of determining a balanced biopsychosocial causal model we calculated the BPS-CM index , which represents to what extent five different factors (i.e., biogenetic, psychological, social, environmental, comparable to Stolzenburg et al. [ 16 ]) are seen as possible causes for one’s own mental complaints. Between-factor variance is considered. A higher score indicates a more heterogeneous belief system. To determine the index, the 18 items were subsumed into factors and the within-factor agreement as well as the between-factor variance was calculated and multiplied with each other to consider the homogeneity of the belief system. Then, all items were recoded into a binary format: 0 = “definitely is not a cause” and 1 = “definitely is a cause”. The within-factor agreement was determined 0% representing the persons belief that none of the items belonging to one factor are a possible cause whilst 100% represents the belief that all items of one factor are considered to be possible causes (each factor contributing 20% equally). The between-factor variance was calculated to consider the homogeneity of the belief system. Higher inverted variance can be interpreted as higher similarity between factor means. The BPS-CM index ranges from 2.12 to 42.80. The range is specific to the sample, seeing as the variance is used to calculate the index.

Previous treatment experience was assessed with the question “Have you ever received treatment for mental illness in your life?”. Multiple responses were possible for: “medical treatment”, “psychotherapy”, “art-, music- and/or sport-therapy”, “self-help groups”, “coaching and counselling”, and “online or telephone therapy”. The answers were collapsed into a dichotomous variable with 0 = “no experience”, 1 = “treatment experience”.

Intention to seek help from a health professional was assessed with an 15-item list adapted from Pescosolido and Boyer [ 62 ]. Participants rated the probability of seeking help from potential persons (e.g., psychiatrist) and institutions (e.g., counselling centre) on a 7-point Likert scale from 1 = “extremely unlikely” to 7 = “extremely likely”. Internal consistency was good with α  = .87. To operationalize intention to seek professional help, maximum scores across the items counselling centre , general practitioner , psychologists , psychotherapists , psychiatrists , and neurologist are determined reflecting the diversity of professional help sources. The final choice was based on the results of an explorative factor analysis in which these items loaded best together.

Help-seeking behaviour was assessed with the same list as intention . Respectively, participants were asked if they sought help in the past 3 months (0 = “no”, 1 = “yes”). When stating “yes”, a subsequent question specified whether they sought help for their psychological complaints (1 = “yes, exclusively”, 2=“yes, amongst other complaints”, 3=“no, because of other complaints). Only if they stated 1 or 2, were their answers coded as seeking help for their depressive complaints. To recode this, we collapsed responses for both follow-ups into dichotomous variables of help-seeking within the last three or six months with 0=“did not seek help” and 1=“sought help during either the three or six month follow-up”. The same persons and institutions described above were used to operationalize professional help-seeking behaviour.

Statistical analysis

No missing scale values are detected within the relevant data. Total drop-out rate was 28.14% between baseline assessment and both follow-ups together (i.e., participation in either three- or six-month follow up). To examine potential reasons for attrition we conducted logistic regressions in which dropout is defined as not providing any follow-up data, the variable is dummy-coded as 0 = “no missing variable” and 1 = “missing value due to drop-out” [ 65 ]. Predictors were self-identification, general health condition, depression severity, treatment experience, and various sociodemographic variables chosen broadly to accurately analyse possible reasons for attrition. We report Odds Ratios ( OR ) and 95% confidence intervals ( CI ) for the significant coefficients.

To assess the proposed influences as shown in the Seeking Mental Health Care Model (Fig. 1 ), we conducted a path model analysis [ 66 , 67 , 68 ]. To check the hypothesised assumptions concerning the associations between the respective variables we performed Pearson’s product-moment and Kendal-Tau correlation analysis. We then conducted the path model analysis with the lavaan package [ 69 ] using the statistics software R version 4.0.3 [ 70 ]. The algorithm for the path model correlation matrix, exact specifications, and fitting commands, i.e., WLSMV estimator and pairwise deletion of missing values (refer to [ 71 ]), can be seen in the supplement (Table S 1 ). We controlled for depressive complaints (PHQ sum score), age, and gender (dummy variable, “female” is the reference category), as well as for exogenous variables without specific hypotheses. All continuous variables were z -standardised. Standardised path estimates (interpretable as partial β-coefficients) for the different paths as well as corrected R 2 estimates for the respective explained variances for the endogenous variables are reported. The usual model fit indices Χ 2 (df and p -value), RMSEA, CFI, NFI, SRMR, and AGFI are reported.

Sample characteristics

The final sample size consisted of N  = 1368, of which 65.6% identified as female and the mean age was 42.38 ( SD  = 15.22). The mean depression score was 12.50 ( SD  = 4.08), indicating that the severity of depressive symptoms ranged mainly from mild to moderate [ 72 ]. People graduated school after 12/13 years (52.4%), 10 years (34.1%), or 9 years of schooling (11.3%) and some were still in school or had not graduated (2.2.%). 49.2% had professional training or finished an apprenticeship, and 22.7% had a university degree (i.e., bachelor’s degree = 7.8%, master’s degree = 13.9%, PhD = 1.0%). Collapsed sample size after 6 months was N  = 983. Attrition analysis revealed that dropout was more likely if the participants were younger ( OR  = 0.963; CI  = 0.952, 0.974), came from bigger households ( OR  = 1.174; CI  = 1.047, 1.317), and if they had nine compared to 12 years of schooling ( OR  = 1.788; CI  = 1.141, 2.803) while 11 other variables had no significant influence on dropout.

Path model analysis: the Seeking Mental Health Care model

The associations between the superordinate, intermediary, and help-seeking process variables are presented in Table  2 .

Figure  2 shows the path model for seeking mental health care from a professional source (i.e., general practitioner, psychologist, therapist, psychiatrist, neurologist, or counselling centre). Significant standardised path estimates and non-significant yet hypothesised associations are reported. In the supplementary material we report the full model with all coefficients predicting or associated with the endogenous variables (Table S 2 ).

Path model for seeking mental health care from a professional source.

(Note: N  = 1368. Standardized estimates with solid lines indicating significant relationships at * p  < 0.05, ** p  < 0.01, *** p  < 0.001; broken lines non-significant, hypothesised relationships. Double headed arrows represent associations between the variables. One headed arrows represent predictions on endogenous variables. In brackets the estimated R 2 for the endogenous variables. Modell is controlled for depression severity, age, and gender)

The model confirmed most of the proposed predictions of the help-seeking process and the associations between the superordinate and intermediary variables except for the prediction of previous treatment experience on self-efficacy to seek help and the prediction of self-efficacy to seek help on help-seeking behaviour. Overall, the model explained 35% of the variance of self-identification, 10% of intention to seek help and 16% of the variance of seeking a health-care professional after either three or six months. Model fit was excellent with Χ 2  = 24.968, df  = 7, p  < .001, RMSEA = 0.059, CFI = 0.989, NFI = 0.988, SRMR = 0.012, and AGFI = 0.999.

The aim of this study was to test a comprehensive Seeking Mental Health Care Model in a sample of people with currently untreated depressive symptoms. The model contains key internal influencing variables, from superordinate over intermediary to help-seeking process variables, to explain professional help-seeking behaviour due to mental health problems. A path analysis confirmed the general structure of the model with an excellent model fit, significantly predicting help-seeking behaviour while revealing reciprocal influences between process variables. Therefore, we can conclude that there are interdependent attitudinal and cognitive variables determining how symptoms are identified and processed in order to seek professional help. They support a theoretical proposed process comparable to processing according to CSM.

The subjective sense of illness is the starting point of the model triggering further intra-psychological variables and representing the dynamic nature of the model with subsequent variables relying on preceding processes. We operationalised the B-IPQ-R variables using the mean score, according to Broadbent [ 64 ], even if this is less subtle then the CSM would suggest [ 14 ]. When the illness is subjectively perceived as more threatening, the mean self-identification as having mental illness increased, which is in line with the work from O’Mahen et al. [ 73 ]. As expected, self-identification was higher the more heterogeneous the causal belief system and the higher depression literacy, which is in line with our previous findings [ 13 , 15 ]. Further, on average, participants were more likely to recognize their current complaints as signs of mental illness if they report higher belief in a continuum of mental health and illness. To our knowledge, this is an addition to previous findings, which were rather focused on enhancing problem recognition for at-risk drinking through continuum beliefs [ 27 ]. The direct link between continuum beliefs and self-identification of having a mental illness should be investigated further (e.g., [ 74 ]).

For the prediction of help-seeking intention all hypothesized paths were significant. Higher self-identification lead to higher help-seeking intention meaning that identifying one’s own complaints as signs of a mental illness is an antecedent of intention to seek help [ 11 , 12 , 13 ]. Self-efficacy for professional help had the strongest influence on intention. The belief in a balanced causal model [ 35 ] as well as self-efficacy to help oneself had positive but small (ß < .10) influences. We did not assume the positive effect of self-help self-efficacy on intention, as this self-efficacy implies a desire to help oneself found to reduce the intention to seek professional help [ 75 ]. However, the moderate correlation between the two forms of self-efficacy supports that forming an intention to search for help could also be partly interpreted as an act of self-help. Self-help should therefore not solely be understood as having to deal with problems completely by oneself but rather as a set of behaviours engaged towards strengthening one’s health and self-care [ 76 ]. In contrast to other studies [ 8 , 9 ], help-seeking intention was predicted with less explained variance, probably due to the lack of the well-established predictor help-seeking attitudes which was omitted because we aimed to examine less established variables.

For help-seeking behaviour , we found a well-established pattern of results. The influences of most variables were mediated through help-seeking intention as the strongest predictor [ 9 , 13 ]. Along with that, our hypothesized influence of self-efficacy for professional help against our expectation was not significant, once again speaking for indirect effects of internal variables on behaviour via intention. Furthermore, having had treatment experience increased the probability to seek help, which is in line with other findings [ 13 , 77 , 78 ]. Our path model was able to explain 16% of variance of help-seeking behaviour. Keeping in mind that the strength of our study is that we used an outcome of actual utilisation of professional care within 6 months, uncontrolled external influences are probable. Moreover, the investigation of structural barriers was outside of our research scope, although their influences on help-seeking behaviour are evident as well [ 5 , 79 ]. It should be noted that the resulting healthcare use might be influenced by the Covid-19 pandemic which was shown to overall decrease help-seeking behaviour for mental health [ 80 ]. Reinforced gender differences in help-seeking during Covid-19 were found for young people [ 81 ], which points to important future research directions. Moreover, sources of treatment like virtual treatments or other related (non-mental health) professionals like priests, teachers, police etc. should be investigated. This was outside our scope but could be differently affected by the influencing variables analysed in this study.

Regarding superordinate variables, t reatment experience was significantly associated with stigma with small to moderate coefficients, which is in line with other research [ 16 , 82 ]. The proposed associations between treatment experience and self-efficacy to seek help was not significant. Treatment experience per se might not influence the self-efficacy to seek help for subsequent health care utilisation. However, we didn’t include quality of treatment experience although it might be worthwhile to further investigate how quality of treatment experience actually affects stigma [ 83 ] and how specific experiences can be highlighted in interventions. Furthermore, it might be interesting to investigate how treatment experience and self-efficacy might both contribute to another construct, e.g., disease self-management [ 84 ], or are moderated, e.g., through trust towards healthcare providers [ 85 ]. Also, multiple associations of treatment experience with other variables were controlled for as to not overload the scope of this work.

We hypothesised associations between stigma and intermediary variables , i.e., continuum beliefs, mental health literacy, and causal beliefs. Lowest and mostly non-significant influences emerged with stereotype awareness replicating findings of its low influence on intrapsychic help-seeking processes [ 78 ]. We found a significant negative correlation of β = −.30 for stereotype agreement and β = −.22 for self-stigma of seeking help with continuum beliefs, which is in line with the overall negative associations found in public samples [ 25 ]. There is an absence of comparable samples, except for the work by Thibodeau et al. [ 86 ] who reported non-significant results. Because our results refer to a sample of people reporting depressive symptoms themselves, these results are an addition to existing literature, showing a tendency towards the effectiveness of continuum messages. Similarly, directed associations could be found for stigma and depression literacy opposing findings that stigma isn’t influenced by depression literacy [ 87 ]. For causal beliefs, we opted for a balanced biopsychosocial model, which we operationalised integrating the homogeneity of the belief system across different causal factors. Our aim was to balance the stigmatising potential of different causal beliefs [ 16 , 57 ]. Still, our results indicate that more heterogeneous consideration of types of causes is associated with higher stigma. Due to these consistent findings across different operationalisations, future studies should use caution when incorporating causal belief messages as part of psychoeducative public health campaigns that aim to reduce stigma on an individual level. Importantly, we leave investigations of people with clinical diagnoses to future studies [ 4 ], since we wanted to include a population without current treatment.

Limitations

Our analyses are based exclusively on self-reported data. New instruments yet lacking full psychometric validation were used for continuum beliefs, causal beliefs, self-efficacy measures and treatment experience. However, the new questionnaires are based on existing validated items and therefore should still be interpretable, yet not fully comparable to other studies and thus need validation. We opted for a broad operationalisation of help-seeking including general practitioners, counselling centres, or neurologists, additional to psychotherapeutic or psychiatric professionals. We aimed to reflect help-seeking with high external validity since, for example, nearly three of four people with depression are treated by general practitioners [ 88 ]. Future studies could, on the one hand, investigate single health care providers to understand specific paths to health care, and on the other hand, incorporate informal sources as a mediating first step towards professional health care use [ 89 ].

Additionally, limitations to the representativeness of the sample are raised. On the one hand, we investigated a sample in Germany, limiting generalisability to other countries, partly due to differences regarding healthcare accessibility and statutory health insurance. Moreover, we limited our analyses to intrapersonal processes and their influencing factors. It would be important to replicate our analyses with focus on structural barriers, including factors of perceived and actual costs, availability and accessibility (e.g., transportation, hours of work, childcare requirements). Furthermore, even though we controlled for the influence of age, gender, and depression severity, there might be an influence of the socioeconomic status [ 79 ], including education, occupation and income. We did not include these control variables, due to the models already extensive inclusion of multiple variables and our aim of analysing internal processes of help-seeking. An interplay between internal and external factors could be a beneficial adaptation of the model, though the complexity might be an issue when statistically analysing such a comprehensive model.

The study is likely to contain a self-selection bias, as only motivated people with computer skills and access to the online panel might have been interested and able to participate. This longitudinal study assessed help-seeking behaviour over a period of up to three to six months with a drop-out from baseline to follow-ups. Attrition analyses have shown that those who drop out systematically differ from the rest of the sample in certain characteristics, further limiting representativeness. Additionally, this attrition is an indication of variables to address in further research, such as household size. So far, we limited our analyses to direct influences of the intermediary variables to provide insight on the influences of direct processes not considering combined influences nor possible reciprocal interactions between the intermediary variables. Correlational analyses revealed that they are partly negatively associated, suggesting that further analyses on the most effective combinations are needed, e.g., for drawing in-depth practical implications for creating help-seeking interventions with combined psychoeducational content.

In summary, we were able to replicate findings of various influences on the help-seeking process expanding existing research of help-seeking variables and stigma through an intermediary level of subjective illness representations according to the Common-Sense Model of Self-Regulation [ 14 ]. We examined a comprehensive approach and focused on internal attitudes of people currently not receiving treatment. Further studies should allow for an interaction between intermediary variables and expand the model to include both internal and external factors, as well as reciprocal associations. Although results need assurance in a sample with diagnosed depression, we see clinical implications of the discussed findings. Strengthening intermediary variables to decrease stigmatising attitudes and increase help-seeking behaviour in an interventional setting needs to be done with a comprehensive and holistic understanding of such a multifactorial model, for example by focusing on a destigmatising way to increase the likelihood that people with ill-health self-identify as having mental health symptoms. In sum, the Seeking Mental Health Care Model provides an empirically validated framework to consider the help-seeking process of people with untreated depressive symptoms within a widened approach considering many internal variables.

Availability of data and materials

The datasets generated during the current study are available from the corresponding author on reasonable request.

Abbreviations

Brief Illness Perception Questionnaire

Berlin Risk Appraisal and Health Motivation Study, 1996

Biopsychosocial Causal belief Model index

Common Sense Model of Self-Regulation

Deutsche Forschungsgemeinschaft (i.e., German Research Foundation)

Patient Health Questionnaire (Depression Sub-Scale)

Self-identification as having a mental illness

Short-Form of the Self-Stigma of Mental Illness Questionnaire

Short-Form of the Self-Stigma for Seeking Help Questionnaire

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Acknowledgements

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Open Access funding enabled and organized by Projekt DEAL. The study was funded by the DFG (German Research Foundation, www.dfg.de : SCHO 1337/4–2 and SCHM 2683/4–2). The funding body is neither involved in the design of the study, the preparation, collection, analysis, and interpretation of data, nor in the writing of this article and deciding to submit it for publication. The study design was approved by external consultants of the funding body.

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Thomas McLaren and Lina-Jolien Peter are first authors and contributed equally to this work.

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Department of Health and Prevention, Institute of Psychology, University of Greifswald, Robert-Blum Str. 13, 17489, Greifswald, Germany

Thomas McLaren, Samuel Tomczyk, Holger Muehlan & Silke Schmidt

Department of Psychiatry and Psychotherapy, Medical Faculty, University Leipzig, Semmelweisstr. 10, 04103, Leipzig, Germany

Lina-Jolien Peter & Georg Schomerus

Department of Psychiatry and Psychotherapy, University of Leipzig Medical Center, Semmelweisstr. 10, 04103, Leipzig, Germany

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The manuscript was equally developed and drafted by TM and LJP. TM and LP contributed to the design of the study and the acquisition of the data. TM and LJP analysed and interpreted the data. ST and HoM contributed to the conception of the work. ST, HoM, SiS, and GS revised the draft. GS and SiS manage the project. All authors have read and approved the final manuscript.

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Correspondence to Thomas McLaren or Lina-Jolien Peter .

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Supplementary Information

Additional file 1: table s1..

R syntax and fitting commands for the path model analysis for the Seeking Mental Health Care Model. Table S2. Identified path model for seeking mental health care from a professional source.

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McLaren, T., Peter, LJ., Tomczyk, S. et al. The Seeking Mental Health Care model: prediction of help-seeking for depressive symptoms by stigma and mental illness representations. BMC Public Health 23 , 69 (2023). https://doi.org/10.1186/s12889-022-14937-5

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Factors associated with help-seeking behaviour among individuals with major depression: A systematic review

* E-mail: [email protected]

Affiliation Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany

Affiliations Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany, Department of Health Services Research, Carl von Ossietzky University, Oldenburg, Germany

• Julia Luise Magaard, 
• Tharanya Seeralan, 
• Holger Schulz, 
• Anna Levke Brütt

• Published: May 11, 2017
• https://doi.org/10.1371/journal.pone.0176730
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Psychological models can help to understand why many people suffering from major depression do not seek help. Using the ‘Behavioral Model of Health Services Use’, this study systematically reviewed the literature on the characteristics associated with help-seeking behaviour in adults with major depression. Articles were identified by systematically searching the MEDLINE, EMBASE and PsycInfo databases and relevant reference lists. Observational studies investigating the associations between individual or contextual characteristics and professional help-seeking behaviour for emotional problems in adults formally diagnosed with major depression were included. The quality of the included studies was assessed, and factors associated with help-seeking behaviour were qualitatively synthesized. In total, 40 studies based on 26 datasets were included. Several studies investigated predisposing (age (N = 17), gender (N = 16), ethnicity (N = 9), education (N = 11), marital status (N = 12)), enabling (income (N = 12)), need (severity (N = 14), duration (N = 9), number of depressive episodes (N = 6), psychiatric comorbidity (N = 10)) and contextual factors (area (N = 8)). Socio-demographic and need factors appeared to influence help-seeking behaviour. Although existing studies provide insight into the characteristics associated with help seeking for major depression, cohort studies and research on beliefs about, barriers to and perceived need for treatment are lacking. Based on this review, interventions to increase help-seeking behaviour can be designed.

Citation: Magaard JL, Seeralan T, Schulz H, Brütt AL (2017) Factors associated with help-seeking behaviour among individuals with major depression: A systematic review. PLoS ONE 12(5): e0176730. https://doi.org/10.1371/journal.pone.0176730

Editor: Ali Montazeri, Iranian Institute for Health Sciences Research, ISLAMIC REPUBLIC OF IRAN

Received: November 23, 2016; Accepted: April 14, 2017; Published: May 11, 2017

Copyright: © 2017 Magaard et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This study was not funded and part of the dissertation of Julia Luise Magaard (JLM). However, JLM, Anna Levke Brütt (ALB) and Tharanya Seeralan (TS) received grants from the German Research Foundation for a pilot study about help-seeking behavior of patients with depression (DFG BR4859/3-1). The German Research Foundation had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper.

Competing interests: The authors declare that they have no competing interests.

Introduction

Major depression is a common mental disorder and one of the leading causes of health impairment worldwide [ 1 ], resulting in serious impairment of functioning and decreased quality of life [ 2 , 3 ]. To treat major depression depending on severity, American and European guidelines (e.g. [ 4 , 5 ]) recommend treatment options as psychotherapy, pharmacotherapy, or a combination of both. Despite the availability of effective treatment options, researchers continue to find that a significant number of individuals suffering from major depression do not seek professional help. Using studies on service utilization rates for major depression in community-based surveys, Kohn, Saxena [ 6 ] reported that the percentage difference between number of people needing treatment for major depression and number of people seeking professional help ranged between 15.9% (12 month, Florence) [ 7 , 8 ] and 83.9% (current, UK) [ 9 ]. They estimated that the median untreated rate for depression is 56.3% worldwide [ 6 ].

Various psychological models have been used to explain variations in help-seeking behaviour among populations, such as the Self-Regulation Model [ 10 ], the Health Belief Model [ 11 ] and the Theory of Planned Behavior [ 12 ]. From the sociological perspective models like the Pescosolido’s Network Episode Model [ 13 ], Kadushin’s theory about why people go to psychiatrists [ 14 ] and the Behavioral Model of Health Services Use [ 15 ] were specifically constructed to explain help-seeking behaviour. The ‘Behavioral Model of Health Services Use’ suggests that people’s predisposition to use services, factors which enable or impede the use of services and people’s need of care predict and explain health behaviours like use of health services [ 15 ]. According to the model, all health behaviours influence health related outcomes. The model includes feedback loops to demonstrate that outcomes can affect health behaviours, predisposing, enabling and need factors and health behaviours can influence predisposing, enabling and need factors. In the current version of his ‘Behavioral Model of Health Services Use’, Andersen [ 15 ] distinguishes between contextual and individual characteristics influencing service utilization and health-related outcomes ( Fig 1 ). The model asserts that contextual and individual characteristics consist of predisposing, enabling and need factors [ 15 ]. Individual characteristics are measured at the individual level, whereas contextual characteristics are measured at an aggregate level (e.g., families, communities, national health care system). Contextual characteristics include health organizations and provider-related factors as well as community characteristics [ 15 ]. At the individual level, a person’s beliefs (e.g., attitudes towards health services), demographic characteristics (e.g., age) and social factors (e.g., education) define his or her predisposition to use health services. Additionally, the availability of financial resources to pay for services as well as organizational factors (e.g., regular source of care, means of transportation to care) enable or impede the use of health services at the individual level. In the “Behavioral Model of Health Service Use” it is not clearly defined if social relationships and social support are considered as predisposing or enabling factors. We agree with Andersen’s argumentation that social support can facilitate or impede help-seeking behaviour and therefore serves as an enabling resource [ 15 ] whereas the social structure including family situation predisposes help-seeking. Furthermore, perceived and evaluated need influences help-seeking behaviour. Professional judgement about people’s health and need for treatment is represented by evaluated need whereas perceived need includes people’s perspective on their own health [ 15 ]. The model has frequently used in studies and systematic reviews (e.g. [ 16 , 17 , 18 ]). According to validity, associations between different individual characteristics and services use were found empirically. However, causal conclusions cannot be drawn from analyses on the basis of mainly cross-sectional data (e.g. [ 16 ]). Individual characteristics of the current model can be expanded to include predictors of help-seeking behaviour like treatment and illness beliefs [ 10 ], perceived susceptibility and severity of symptoms as well as perceived expectations regarding treatment and self-efficacy [ 11 , 12 ] and motivational factors [ 12 ].

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https://doi.org/10.1371/journal.pone.0176730.g001

The current review focusses on contextual and individual characteristics as well as use of personal health services and relations between characteristics and use of personal health services (printed in bold).

In recent years, several quantitative studies have used Andersen’s model to investigate the factors influencing professional help-seeking behaviour among individuals suffering from depression (e.g. [ 17 , 18 ]). Additional quantitative studies on this subject have been conducted without referral to Andersen’s model (e.g. [ 19 ]). However, a systematic review of these findings has not been performed. The only existing review [ 20 ] was published 14 years ago and focused on studies using heterogeneous definitions of depression or depressive symptoms and help-seeking behaviour, finding that the help-seeking behaviour of individuals with depression or depressive symptoms was influenced by age, ethnicity, social support and clinical and psychiatric factors. Further studies focussed on specific populations [ 21 ] or specific factors associated to help-seeking [ 22 , 23 ]. Recently, a qualitative synthesis of interview studies about help-seeking behaviour among people with depression was published [ 24 ].

The purpose of this review was to apply a theoretical framework to investigate the individual and contextual characteristics associated with professional help-seeking behaviour for emotional problems in adults with major depression. Therefore, the current review addresses two questions: (1) Which characteristics associated with help-seeking behaviour in adults suffering from major depression are investigated in the literature? (2) How are these characteristics related to help-seeking behaviour in adults suffering from major depression?

In addition to including new literature, this review expands upon previous reviews in two ways: first, it embeds the findings within the ‘Behavioral Model of Health Services Use’ framework and integrates aspects of different models. By systematically reviewing observational studies using standardized diagnostic instruments to assess major depression, this review aims to synthesize the results of studies assessing help-seeking behaviour in a homogeneous population.

To the extent that they were applicable to observational studies and to the qualitative synthesis of results, the methods and results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [ 25 ] ( S1 Appendix ) and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement [ 26 ]. No review protocol exists.

Search strategy

Two researchers (JLM, ALB) searched the MEDLINE, EMBASE and PsycInfo electronic databases in February 2017 (09.02.2017) using key words and a standardized vocabulary (e.g., MeSH) presented in S2 Appendix . These terms aimed to represent the concepts of ‘Depression’ and ‘Help-Seeking’. The search was restricted to ‘human’ and ‘English or German’. Additionally, the EMBASE search was restricted to ‘article’, and the search in PsycInfo to ‘all journals’.

Study selection

After excluding double hits, the title and abstracts of all articles (published in English or German) identified through the electronic search were screened to exclude clearly irrelevant articles. Two researchers (TS, JLM) independently screened the title and abstracts of 150 records. If at least moderate agreement was achieved (Kappa ≥ .41) [ 27 ], the remaining records were screened by JLM. Additionally, the reference lists of the relevant studies and reviews identified in the electronic search were manually examined.

In the second step, the full texts of all potentially relevant studies were independently reviewed by two researchers (TS, JLM). The decision to include studies was based on a priori defined inclusion criteria (IC) ( S3 Appendix ).

Study design

To identify the factors associated with help-seeking behaviour, we relied on observational quantitative studies because randomization of these influencing factors is not possible. Therefore, cohort, case-control and cross-sectional studies were included (IC 1), but intervention studies were excluded unless they retrospectively assessed help-seeking behaviour at baseline.

To investigate the factors of interest in a population with a comparable depression status, studies reporting on the help-seeking behaviour of individuals with a major depressive episode or major depression disorder were included (IC 2). To ensure the validity of the diagnoses, a sample or subsample with formally diagnosed major depression disorder or a major depression episode according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), International Statistical Classification of Diseases (ICD) or Research Diagnostic Criteria (RDC) was required (IC 3). We included studies investigating adult populations (IC 4) with depressive subsamples of population-based datasets to ensure that the samples included individuals not seeking care (IC 5).

Based on the guidelines and in accordance with other reviews on help-seeking [ 16 , 23 , 28 ], we defined professional help-seeking as contacting a health practitioner or service for mental health reasons at least once or receiving therapy including primary care and specialized care in outpatient and inpatient settings in a defined time period (IC 6). To ensure the homogeneity of our outcome, we decided to exclude studies assessing lifetime help seeking. Studies had to include results on the factors influencing help-seeking behaviour (IC 7).

We included studies if they fulfilled all of the inclusion criteria. If there were disagreements about the in- or exclusion of a study, the decision was discussed until consensus was reached (JLM, TS, ALB).

Data extraction and synthesis

The study characteristics, factors associated with help seeking, results and methodological quality were extracted by JLM and TS. Qualitative data synthesis was performed to illustrate which influencing factors were investigated and to discuss heterogeneous findings (e.g., adjusted and unadjusted results) from samples in heterogeneous contexts (e.g., countries, health care systems). Therefore, JLM and TS classified all investigated variables into individual and contextual predisposing, enabling and need factors according to the ‘Behavioral Model of Health Service Use’ [ 15 ]. Data synthesis was performed by vote counting because of the heterogeneity of settings, measures, adjustments and the number of investigated variables. Therefore, measures (e.g., odds ratios, chi-square, and regression coefficients) of the association between each variable and help seeking were grouped into significant positive, significant negative and non-significant results and were listed for each variable. Any disagreements between JLM and TS were discussed until agreement was reached. We documented if and which potential confounding variables were adjusted for in the analyses.

Assessment of methodological quality

Two researchers (JLM, TS) evaluated the methodological quality of all of the included studies. Because of the high level of homogeneity in study design, we considered only criteria with variance between studies. Consequently, three criteria were used ( S4 Appendix ). Two criteria of 14 from the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies [ 29 ] were selected to examine internal validity (Q1 and Q2, S4 Appendix ). We added one criterion about the recruitment of a cohort from the Critical Appraisal Skills Programme [ 30 ] to focus on external validity (Q3, S4 Appendix ). A score of 1 was awarded for each criterion adequately fulfilled, with a potential score ranging from 0 (poor) to 3 (excellent). No studies were excluded because of poor quality rating.

Study characteristics

Altogether, 40 studies based on 26 datasets were included in the systematic review (see Fig 2 for an overview of the search process). The study characteristics are summarized in S5 Appendix . The 26 included datasets comprised 24 cross-sectional studies, one case-control study [ 31 ] and one cohort study [ 32 ]. The years of publication for these studies ranged from 1987 [ 33 ] to 2016 [ 34 ]. In 24 of the 26 datasets, the help-seeking behaviour of individuals with major depression was assessed in population-based samples within a certain region or country. The exceptions included a study investigating white-collar professionals from a specific corporation [ 35 ] and a study investigating the relatives and spouses of people seeking treatment for mental disorders and matched controls [ 31 ]. Most datasets were collected in the US (N = 10) and Canada (N = 8). The other datasets were collected in Finland (N = 3), Ethiopia (N = 1), Mexico (N = 1), Estonia (N = 1), Netherlands (N = 1) and Europe (N = 1). The sample sizes ranged between 102 and 18,927 participants with major depression [ 36 ].

https://doi.org/10.1371/journal.pone.0176730.g002

Quality of studies

The study quality was rated as ‘good’ (60%) for more than half of the studies, ‘excellent’ for one study [ 32 ], ‘fair’ for 35% of the studies, and ‘poor’ for one study [ 35 ]. S5 Appendix displays the ratings of methodological quality.

Individual predisposing factors

Thirty-nine studies and all 26 datasets reported results on individual characteristics, as shown in S6 Appendix .

Five studies assessed stigma and help-seeking beliefs; feeling comfortable with seeking help [ 37 , 38 ] and having the intention to seek help [ 38 ] were positively associated with help-seeking behaviour. Negative attitudes towards antidepressants were negatively related to help-seeking behaviour [ 39 ]. Lin and Parikh [ 38 ] reported no significant associations between help seeking and beliefs about improving through or without professional care and feeling embarrassed about seeking help. This finding is inconsistent with Diala, Muntaner [ 37 ], who found that participants who said they would be embarrassed if their friends knew they were getting mental health care were less likely to use it than others. Aromaa, Tolvanen [ 39 ] found no association between help-seeking behaviour and prejudices against mentally ill people. However, they found that a stronger desire for social distance was negatively related to help seeking. Boerema, Kleiboer [ 34 ] reported that own negative attitudes towards people with depression are negatively related to help-seeking, whereas participants’ beliefs about how other people think about depression was unrelated to help-seeking.

Kleinberg, Aluoja [ 19 ] found that a higher external locus of control was associated with increased help seeking.

Demographic factors

The associations between gender and help seeking were analysed in 16 datasets. In three US samples [ 18 , 32 , 40 ] and one Finish sample [ 39 ], being female was positively related to help-seeking behaviour. Sussman, Robins [ 33 ] reported the same association only among white Americans, not among black Americans. An association between gender and help-seeking was not found in Spanish [ 41 ], Ethiopian [ 42 ], Canadian [ 38 , 40 , 43 – 45 ], American [ 31 , 35 ], Finnish [ 46 , 47 ], Netherlands [ 34 ] or Mexican [ 48 ] samples.

The association between age and help seeking was analysed in 17 different datasets and was mainly computed comparing different age groups. In eight datasets, age was significantly associated with help-seeking behaviour. Two of these studies reported a positive association between age in years and help seeking [ 31 , 39 ]. In the other five datasets, being middle-aged was significantly related to higher help-seeking rates [ 32 , 41 , 49 – 51 ].

Social factors

The associations between help-seeking behaviour and social factors are shown in S6 Appendix . Results were available for educational status (N = 11 datasets), ethnicity (N = 9 datasets), family and living situation (N = 15 datasets) and employment (N = 4 datasets)

The associations between help seeking and education in individuals with major depression were significantly positive or non-significant in the eleven datasets. For example, in three datasets, more years of education and a higher degree were positively associated with help-seeking behaviour after adjusting for clinical and socio-demographic variables [ 32 , 42 , 44 , 52 ]. After adjusting for clinical and socio-demographic variables, this positive association remained significant only in the Canadian dataset [ 40 ] and the US dataset [ 53 ].

Differences between help seeking by ethnic group were assessed in four Canadian and five US datasets. Belonging to a different ethnic group was defined differently between the studies. Differences in help-seeking between different ethnic groups were reported in seven studies [ 18 , 32 , 33 , 37 , 40 , 54 , 55 ]. For example, black Americans [ 55 ], African Americans [ 18 , 37 ], Mexican Americans [ 18 ], and ethnic minorities [ 40 ] had lower rates of seeking help compared to whites. No differences were reported between the help-seeking behaviours of people born in Canada and of Canadian migrants [ 44 ], except that lower rates of help-seeking were observed in a group of Chinese immigrants compared to a group of Canadians born in Canada [ 52 , 54 ]. The results from the ‘National Survey of American Life’ (NSAL) showed that although African Americans reported higher rates of seeking help than Caribbean Blacks, this difference was only significant in a sample of adults with severe or very severe symptoms [ 56 ] and was not significant in a sample of adults with mild to moderate symptoms [ 56 ] or in a subsample of mothers [ 57 ]. Sussman, Robins [ 33 ] reported that blacks had lower odds of seeking help than whites only in people with less severe depression.

Eight [ 33 , 34 , 38 , 40 – 42 , 44 , 52 ] out of 15 datasets found no association between help-seeking behaviour and marital status or living as married. In addition, no significant associations were reported for cohabitation [ 19 , 47 ], household size [ 19 ] or pregnancy [ 58 ]. However, four studies showed that being married or living as married was negatively associated with help-seeking behaviour [ 17 , 31 , 35 , 59 ]; in contrast, Chartrand, Robinson [ 32 ] found the opposite relationship. Gadalla [ 52 ] reported that single mothers with adult children had the lowest odds of seeking treatment in comparison to other women.

Individual enabling characteristics

Financial aspects were addressed in ten datasets, focusing mainly on income or household wealth. In Spanish respondents from the ‘European Study of the Epidemiology of Mental Disorders’ (ESEMeD), the low to average income group was negatively related to help seeking compared to the highest income group [ 41 ]. Diala, Muntaner [ 37 ] found a similar association in respondents from the ‘National Comorbidity Survey’ (NCS). Conflicting results were found in male respondents from the CCHS 1.2, in which help-seeking was positively related to a lower adjusted household income [ 17 ]. All other studies reported non-significant results regarding this association [ 18 , 31 , 32 , 38 , 40 , 42 , 44 , 52 , 53 ]. In the ‘Collaborative Psychiatric Epidemiology Survey’ (CPES), health insurance coverage doubled the odds of any use of depression therapy in the past year [ 18 ], while in the American samples in the ‘Joint Canada/United States Survey on Health’, this association lost significance in the multivariate model [ 40 ].

Regarding the influence of organizational factors on help-seeking behaviour, findings on the availability, accessibility and acceptability of care were available from the CCHS 1.2 [ 17 ]. Additionally, findings on the influence of having a regular medical doctor were available in the ‘Joint Canada/United States Survey on Health’ [ 40 ]. Availability, including waiting times and help not available in the area, was positively related to help-seeking among female Canadian respondents, whereas accessibility and acceptability were not related to help-seeking [ 17 ].

Social support was addressed in three datasets. In the CCHS 1.2, social support and help seeking were positively related in women only [ 17 , 52 ]. Although social support was not directly associated with help-seeking behaviour in the Estonian health survey, emotional loneliness was associated with increased help seeking among depressed persons with an external locus of control [ 19 ]. Dew, Bromet [ 35 ] found that receiving social support during the index episode was negatively related to help seeking, whereas receiving recommendations from others to seek professional help was positively related to help seeking.

Individual need characteristics

Studies on the need factors influencing help-seeking behaviour often focused on the severity of depression (14 datasets), psychiatric comorbidity (11 datasets), duration of episode (9 datasets), subjective disability (5 datasets), number of depressive episodes (6 datasets), somatic comorbidity (6 datasets), and presence of certain depressive symptoms (7 datasets) ( S6 Appendix ). Illness and symptom based need factors were assessed through structured interviews or questionnaires and were defined as professional judgements about people’s mental health status and therefore can be allocated to evaluated need, according to the “Behavioral Model of Health Services Use” [ 15 ]. Specifically, severity of depression was positively related to help-seeking in seven of the 16 datasets [ 31 , 39 , 40 , 46 , 47 , 60 , 61 ]. In addition, a longer duration of illness was positively related to help-seeking behaviour in six datasets [ 31 , 34 , 35 , 40 , 46 ] and was non-significantly related in three datasets [ 33 , 38 , 53 ]. After adjusting for socio-demographic and clinical variables, having more than one major depressive episode was no longer significantly associated with help seeking in the ‘Ontario Health Study’ (OHS) [ 38 , 53 ]. Furthermore, in three other datasets, no significant association occurred [ 31 , 35 , 53 ]. However, in the group of black US participants [ 33 ] and female Canadians [ 52 ], there was a significant positive association. Having trouble concentrating [ 31 , 35 , 46 ] and suicidal thoughts or ideation [ 31 , 35 , 46 , 52 ] were positively related to help-seeking behaviour. Conversely, three studies found no significant results for the latter association [ 32 , 38 , 53 ].

Psychiatric comorbidity was assessed in eleven datasets, and somatic comorbidity in seven ( S6 Appendix ). Having comorbid generalized anxiety disorder [ 17 , 44 , 47 ] or a panic disorder [ 31 , 62 ] was positively related to help-seeking behaviour. Interestingly, after adjusting for several clinical and socio-demographic factors, having a generalized anxiety disorder, agoraphobia or panic disorder in the previous 12 months was significantly related to higher help-seeking rates in OHS respondents but not in NCS respondents [ 53 ]. In contrast with the findings from the Ontario study, Lin and Parikh [ 38 ] found no significant differences analysing the same dataset. Moreover, comorbid phobic disorders were not related to help-seeking behaviour [ 31 ].

Chen, Crum [ 36 ] showed that people suffering from major depression and substance dependence were more likely to seek help than people suffering from major depression only. Other findings indicate no significant difference in help-seeking behaviour with comorbid substance dependence disorder [ 17 , 38 , 44 , 63 ] or alcohol or drug abuse [ 31 ]. Having any additional mental disorder was positively related to help-seeking behaviour in one [ 41 ] of four relevant studies [ 38 , 44 , 64 ].

Suffering from chronic somatic disorders was significantly associated with higher help-seeking rates in two datasets [ 17 , 44 , 52 , 65 ]. However, in five datasets, this association was non-significant [ 34 , 38 , 40 , 41 , 60 ]. Demyttenaere, Bonnewyn [ 65 ] found that people with depression who had comorbid painful physical symptoms had lower rates of help seeking than those without these comorbid symptoms. In older people from the same dataset, this association was not significant [ 66 ].

Contextual characteristics

Studies on the contextual characteristics of help seeking in individuals with major depression have focused on region or different countries. Living in an urban or rural area was not related to help-seeking behaviour in Spanish [ 41 ], Ethiopian [ 42 ], Canadian [ 38 , 44 ] or American [ 32 ] samples. Additionally, no differences in help-seeking behaviour were found between the American and Canadian samples [ 40 ] or between the Francophone Canadian and European samples [ 67 ]. Differences in individuals’ help-seeking behaviour between different regions of the US were found in one [ 32 ] of two studies [ 31 ].

This paper aimed to systematically review the individual and contextual characteristics associated with professional help-seeking behaviour in adults suffering from major depression based on the ‘Behavioral Model of Health Service Use’. Several studies investigated the association between help-seeking behaviour and individual characteristics, such as socio-demographic predisposing factors (e.g., age, gender, ethnicity, education, and family status), enabling factors (financial situation/income) and need factors (e.g., severity of depression, comorbidity, and duration and number of episodes). Some studies focused on beliefs (n = 4) (predisposing factors), social support (n = 4), organization (n = 3) (enabling factors), and context (n = 8) (e.g., urban vs. rural, country) and help-seeking behaviour. No study focusing on need for mental health treatment was included. Similarly, studies investigating help-seeking behaviour for different diseases based on the ‘Behavioral Model of Health Services Use’ examined characteristics similar to those of the studies included in our review [ 16 ].

Based on the current review, it appears that several factors may influence the likelihood that an individual suffering from major depression will seek professional help.

Predisposing factors that seem most likely to decrease help-seeking behaviour in individuals with major depression are, being young or elderly, being male, belonging to certain ethnic groups and having a lower educational status. Although these groups may be at a higher risk for not seeking professional help for major depression, the reasons for this higher risk need to be clarified. Certain structural or attitude-related barriers to seeking care among individuals in these groups may explain the findings. For instance, synthesizing qualitative studies, Doblyte and Jiménez-Mejías [ 24 ] identified attitudinal barriers for help seeking among depressed man, ethnic minorities and young adults: They concluded that help seeking is a threat to hegemonic masculinity, that the fear of disclosure and being judged was strongest among young adults and that ethnic minorities were more willing to keep depression within family [ 24 ]. Apart from attitudinal barriers, structural barrier like cultural inappropriateness of interventions could explain lower help-seeking rates among ethnic minorities [ 24 ].

The majority of studies reported no association between income and help-seeking behaviour. A possible explanation for this finding might be that income as an indicator is not sensitive enough to detect socioeconomic differences in the use of health care services [ 68 ]. Regardless, accounting for the financing of health care systems it is necessary to interpret these associations [ 15 ].

There is some evidence that the severity of depression, longer and more depressive episodes and the presence of anxiety disorders are related to higher help-seeking rates. These findings are consistent with those on help-seeking behaviour in individuals with depressive symptoms or depressive disorder [ 20 ]. However, as these findings were mainly based on retrospective cross-sectional studies, it remains unclear whether individuals affected by more severe depression are more likely to seek help. It is possible that individuals receiving treatment perceive their condition to be more severe than individuals without treatment. Qualitative findings indicate that the first hypothesis is more likely, because professional help-seeking is seen as the “final step”, because it “damages one’s self-definition” [ 24 ].

Based on the reviewed literature, the effects of additional individual predisposing factors such as attitudes on help-seeking behaviour and enabling factors like social support remain unclear. These psychosocial variables are mentioned in the ‘Behavioral Model of Health Service Use’, but which factors influence help-seeking behaviour in what way is not specified. Nonetheless, the initial findings show that social support might be associated with help-seeking behaviour [ 17 , 35 , 52 ]. Therefore, it might be worth distinguishing between informational social support (e.g., recommending seeking care) and emotional social support and investigating the interactions with other psychological concepts such as locus of control. Although the former could facilitate help seeking (e.g. [ 35 ]), the latter may only be associated with help seeking in certain populations (e.g., in individuals with an external locus of control [e. g. 19]). Regarding the influence of beliefs, feeling comfortable seeking care [ 37 , 38 ] was positively associated with help-seeking, whereas having negative beliefs about antidepressants and having a stronger desire for social distance from people who are mentally ill [ 39 ] and having negative attitudes towards them [ 34 ] might have a negative impact on help-seeking behaviour. Within the ‘Health Beliefs Model’ [ 11 ], these beliefs could be considered the perceived benefits and barriers to taking action. Henshaw and Freedman‐Doan [ 69 ] conceptualised help-seeking for mental illnesses using this model and examined the role of fears about treatment and stigma as psychological barriers. The desire for social distance from mentally ill people is known to be an indirect measure of stigmatizing beliefs towards people belonging to this group, and a dissonance between these negative stereotypes and the preferred self can impede help-seeking for mental health problems [ 23 ]. Fears about antidepressant treatment could be a particular problem if practical or psychological barriers to seeking psychotherapy exist.

As evidenced by the findings presented in the results section, several factors of the ‘Behavioral Model of Health Service Use’ seem to be not validated through the systematic review. For instance, mainly no associations between certain predisposing factors (e.g. employment status), enabling factors (e.g. income, organisation), need factors (e.g. somatic symptoms, general health) and help-seeking were identified.

Practical implications

The studies included in this review revealed that men, young and elderly adults, and people of certain ethnicities as well as individuals with a lower educational status with major depression are at risk of not seeking help, and these populations could be addressed in individually tailored interventions to increase help-seeking. In a review of randomized controlled trials, the majority of help-seeking interventions for depression, anxiety and psychological distress targeted young people [ 28 ]. In that review, Gulliver, Griffiths [ 28 ] provided some evidence that mental health literacy interventions (e.g., delivering destigmatisation information and/or providing information about help-seeking sources) can be effective in improving help-seeking attitudes. Mental health literacy is defined as “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” [ 70 ]. However, this positive association could not confirmed for help-seeking behaviour for these interventions [ 28 ]. According to Doblyte and Jiménez-Mejías [ 24 ] who stressed out the role of hegemonic masculine identity and its influence in limiting men’s help seeking behaviour, educational campaigns for primary care providers can facilitate communication between male patients and GPs. Additionally a slighter entrance into care can be achieved. In this spirit, trainings which increase GPs intercultural competence and awareness of cultural differences regarding e.g. illness definition should also be considered [ 24 ]. However, further research on interventions that increase help-seeking intentions and behaviour among individuals suffering from major depression is needed.

Limitations

The results of this review should be considered in light of several limitations. First, the vast majority of the studies reviewed were conducted in the US and Canada, which reduces the external validity of the findings. Second, the synthesis of results was limited because of the heterogeneity of the studies. Although the samples were homogenous regarding the formal diagnosis of major depression, the studies differed in terms of the samples’ age, gender and ethnicity as well as the health care systems affecting the participants. According to the ‘Behavioral Model of Health Service Use’, these contextual characteristics directly influence service utilization and indirectly influence service utilization through individual characteristics [ 15 ]. In addition, the results included different levels of adjustment. Third, reliable conclusions concerning whether a factor causes help-seeking behaviour were not possible, because the large majority of the studies used cross-sectional designs and retrospective data. Fourth, there was a lack of studies that quantitatively investigated the influence of individuals’ beliefs and perceptions on their help-seeking behaviour. Finally, because of the heterogeneous measures and adjustment methods used, a quantitative synthesis was not appropriate.

Plea for consideration of the subjective perspective in help-seeking behaviour

The focus on socio-demographic and clinical variables in the reviewed literature is understandable, as the majority of the studies utilized secondary datasets, thus limiting the variables available for analysis. Nevertheless, it is important to obtain information on the subjective perspective to better understand the complex process of help seeking. Furthermore, including this perspective could provide insight into the associations between certain socio-demographic variables and help seeking. For instance, several studies have already been conducted to shed light on depressed men’s lower help-seeking rates (for review see [ 21 ]) and on men’s delays in medical and psychological help-seeking (for review see [ 71 ]). Specifically, embarrassment, distress or anxiety related to using health care services, need for emotional control, the perception of symptoms as minor and poor communication with health professionals were identified as barriers for help-seeking among men [ 71 ]. Although the ‘Behavioral Model of Health Service Use’ [ 15 ] does not focus on this subjective perspective, it is explicitly included in the predisposing contextual individual beliefs and implicitly included in perceived need . Psychological models such as the Self-Regulation Model of Illness Behavior [ 10 ], the Health Belief Model [ 11 ] and the Theory of Planned Behavior [ 12 ] focus on the individual’s perspective in the help-seeking process. According to these models, illness beliefs [ 10 ], perceived susceptibility and severity of symptoms as well as perceived expectations regarding treatment and self-efficacy [ 11 , 12 ] and motivational factors [ 12 ] influence help-seeking behaviour. For instance, a qualitative analysis using the Self-Regulation Model found that primary care patients with depression who did not seek treatment believed that the treatment would not be effective, that depression would be short-lived and that it would not affect their daily lives [ 72 ]. Accordingly, it is promising to focus on psychological variables that affect the decision-making process of seeking help to better predict behaviour.

Future directions for research

We suggest that future quantitative research on help-seeking behaviour among individuals suffering from major depression should focus more on the individuals’ perspective and include psychological theories as a framework for understanding the help-seeking process. Additionally, the influence of illness beliefs, treatment beliefs, anticipated stigmatization and perceived need for mental health care on help seeking may be worth investigating. Future research should provide insight into the associations between predisposing, enabling and need factors to improve the understanding of the complex process of help seeking. Therefore, the characteristics identified in the literature should be further considered.

Future prospective cohort studies on the causal relations between predisposing, enabling and need factors and help-seeking behaviour among individuals suffering from major depression should also be conducted. Measuring predisposing beliefs, perceived barriers, clinical variables, and perceived need prior to assessing help-seeking behaviour is important because these characteristics can change due to treatment and over time.

This review found that the associations of help-seeking behaviour with socio-demographic predisposing (e.g., age, gender, ethnicity, education, and family status), enabling (financial situation/income), need (e.g., severity of depression, comorbidity, and duration and number of episodes) and contextual factors were investigated in several studies. Gender, age, education, ethnicity, marital status, severity of depression, duration and number of depressive episodes, and comorbid anxiety disorders appeared to influence help-seeking behaviour. Further research investigating the influence of these characteristics on help-seeking behaviour by individuals suffering from major depression in prospective cohorts and research specifically focused on beliefs, social support, organizational factors and perceived need for treatment would address a significant gap in the literature. A better understanding of the process of help-seeking by individuals suffering from major depression and improved knowledge of the factors that influence this process are important for identifying groups at risk of failing to seek adequate professional help and for improving their access to depression care.

Supporting information

S1 appendix. prisma checklist..

https://doi.org/10.1371/journal.pone.0176730.s001

S2 Appendix. Search strategy.

https://doi.org/10.1371/journal.pone.0176730.s002

S3 Appendix. Inclusion criteria (IC).

https://doi.org/10.1371/journal.pone.0176730.s003

S4 Appendix. Quality characteristics.

Q1 and Q2 from the ‘Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies” [ 29 ] Q3 from the Critical Appraisal Skills Programme [ 73 ].

https://doi.org/10.1371/journal.pone.0176730.s004

S5 Appendix. Summary of the main characteristics of the published articles.

ws = whole sample; MDE = major depressive episode; MDD = major depressive disorder; NR = not reported; DIS = Diagnostic Interview Schedule; WHO-CIDI / CIDI = World Health Organization’s composite international diagnostic interview; SFMD = Short form for major depression; SF = Short form; UM = Short Form (University of Michigan) ESEMeD = European Study on the Epidemiology of Mental Disorders; CCHS = Canadian Community Health Study; NESARC = National Epidemiologic Survey on Alcohol and Related Conditions; CPES = Collaborative Psychiatric Epidemiology Survey; NSAL = National Survey of American Life; NCS = National Comorbidity Survey; NCS-R = National Comorbidity Survey–Replication; NLAAS = National Latino and Asian American Study; JUCSH = Joint Canada/US Survey of Health; NSDUH = National Study on Drug Use and Health; OHS = Ontario Health Study; ENHS = Ethiopian National Health Survey; NPHS = National Population Health Survey; ENHS = Ethiopian National Health Survey.

https://doi.org/10.1371/journal.pone.0176730.s005

S6 Appendix. Summary of results of the systematic review.

If adjusted and unadjusted results were reported in the same study for the same variable, only the adjusted results were listed in the table. + = significant positive association between characteristic and help-seeking behaviour;— = significant negative association between characteristic and help-seeking behaviour; Ø = no significant association between characteristic and help-seeking behaviour; x = significant differences between different groups; ESEMeD = European Study of the Epidemiology of Mental Disorders; CCHS = Canadian Community Health Survey on Mental Health and Well Being; NESARC = National Epidemiologic Survey on Alcohol and Related Conditions; NSDUH = National Survey on Drug Use and Health; NCS = National Comorbidity Survey; OHS = Ontario Health Study; EHS = Estonian Health Survey; CPES = Collaborative Psychiatric Epidemiology Survey.

https://doi.org/10.1371/journal.pone.0176730.s006

Acknowledgments

This study as not funded and part of the dissertation of Julia Luise Magaard (JLM). However, Anna Levke Brütt (ALB), Tharanya Seeralan (TS) and JLM received grants from the German Research Foundation for a pilot study about help-seeking behavior of patients with depression. The German Research Foundation had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper. The authors declare that they have no competing interests. The authors wish to thank Mr. PD Dr. Levente Kriston for valuable and constructive comments on conduction of systematic reviews. We thank American Journal Experts (AJE) for English language editing.

Author Contributions

• Conceptualization: ALB HS JLM.
• Data curation: JLM TS.
• Formal analysis: ALB JLM TS.
• Funding acquisition: ALB.
• Investigation: JLM TS ALB.
• Methodology: JLM ALB HS TS.
• Project administration: ALB HS JLM.
• Resources: HS ALB.
• Supervision: HS.
• Validation: JLM ALB TS.
• Visualization: JLM TS.
• Writing – original draft: JLM.
• Writing – review & editing: ALB HS TS.
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• 5. NICE. Depression: the Treatment and Management of Depression in Adult (Update)2009 Available at Available from: www.nice.org.uk/CG90 [NICE guideline].
• 10. Leventhal H, Nerenz DR, Steele DJ. Illness representations and coping with health threats. In: Baum A, Taylor SE, Singer JE, editors. Handbook of Psychology and Health. Volume IV: Social Psychological Aspects of Health. Hillsdale, NJ: Erlbaum; 1984. p. 219–52.
• 14. Kadushin C. Why people go to psychiatrists: Transaction Publishers; 1969.
• 29. National Heart Lung and Blood Institute. Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies http://www.nhlbi.nih.gov/health-pro/guidelines/in-develop/cardiovascular-risk-reduction/tools/cohort2014 [updated March 2014].
• 30. National Health Service. Critaical Appraisal Skills Programm (CASP) making sense of evidence: Cohort Study Checklist 2013 [updated 31.05.2013].
• 73. National Health Service. Critaical Appraisal Skills Programm (CAPS) making sense of evidence: Cohort Study Checklist 2013 [updated 31.05.2013].

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Filipino help-seeking for mental health problems and associated barriers and facilitators: a systematic review

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• Volume 55 , pages 1397–1413, ( 2020 )

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• Andrea B. Martinez   ORCID: orcid.org/0000-0002-4437-769X 1 , 2 ,
• Melissa Co 3 ,
• Jennifer Lau 2 &
• June S. L. Brown 2  

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This systematic review aims to synthesise the evidence on behavioural and attitudinal patterns as well as barriers and enablers in Filipino formal help-seeking.

Using PRISMA framework, 15 studies conducted in 7 countries on Filipino help-seeking were appraised through narrative synthesis.

Filipinos across the world have general reluctance and unfavourable attitude towards formal help-seeking despite high rates of psychological distress. They prefer seeking help from close family and friends. Barriers cited by Filipinos living in the Philippines include financial constraints and inaccessibility of services, whereas overseas Filipinos were hampered by immigration status, lack of health insurance, language difficulty, experience of discrimination and lack of acculturation to host culture. Both groups were hindered by self and social stigma attached to mental disorder, and by concern for loss of face, sense of shame, and adherence to Asian values of conformity to norms where mental illness is considered unacceptable. Filipinos are also prevented from seeking help by their sense of resilience and self-reliance, but this is explored only in qualitative studies. They utilize special mental health care only as the last resort or when problems become severe. Other prominent facilitators include perception of distress, influence of social support, financial capacity and previous positive experience in formal help.

We confirmed the low utilization of mental health services among Filipinos regardless of their locations, with mental health stigma as primary barrier, while resilience and self-reliance as coping strategies were cited in qualitative studies. Social support and problem severity were cited as prominent facilitators.

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Introduction

Mental illness is the third most common disability in the Philippines. Around 6 million Filipinos are estimated to live with depression and/or anxiety, making the Philippines the country with the third highest rate of mental health problems in the Western Pacific Region [ 1 ]. Suicide rates are pegged at 3.2 per 100,000 population with numbers possibly higher due to underreporting or misclassification of suicide cases as ‘undetermined deaths’ [ 2 ]. Despite these figures, government spending on mental health is at 0.22% of total health expenditures with a lack of health professionals working in the mental health sector [ 1 , 3 ]. Elevated mental health problems also characterise ‘overseas Filipinos’, that is, Filipinos living abroad [ 4 ]. Indeed, 12% of Filipinos living in the US suffer from psychological distress [ 5 ], higher than the US prevalence rate of depression and anxiety [ 1 ]. Long periods of separation from their families and a different cultural background may make them more prone to acculturative stress, depression, anxiety, substance use and trauma especially those who are exposed to abuse, violence and discrimination whilst abroad [ 6 ].

One crucial barrier to achieving well-being and improved mental health among both ‘local’ and overseas Filipinos is their propensity to not seek psychological help [ 7 , 8 ]. Not only are help-seeking rates much lower than rates found in general US populations [ 9 ], they are also low compared to other minority Asian groups [ 10 ]. Yet, few studies have been published on Filipino psychological help-seeking either in the Philippines or among those overseas [ 11 ]. Most available studies have focused on such factors as stigma tolerance, loss of face and acculturation factors [ 12 , 13 ].

To date, no systematic review of studies on Filipino psychological help-seeking, both living in the Philippines and overseas, has been conducted. In 2014, Tuliao conducted a narrative review of the literature on Filipino mental health help-seeking in the US which provided a comprehensive treatise on cultural context of Filipino help-seeking behavior [ 11 ]. However, new studies have been published since which examine help-seeking in other country contexts, such as Norway, Iceland, Israel and Canada [ 6 , 14 , 15 , 16 ]. Alongside recent studies on local Filipinos, these new studies can provide basis for comparison of the local and overseas Filipinos [ 7 , 8 , 12 , 17 ].

This systematic review aims to critically appraise the evidence on behavioural and attitudinal patterns of psychological help-seeking among Filipinos in the Philippines and abroad and examine barriers and enablers of their help-seeking. While the majority of studies undertaken have been among Filipino migrants especially in the US where they needed to handle additional immigration challenges, studying help-seeking attitudes and behaviours of local Filipinos is important as this may inform those living abroad [ 10 , 13 , 18 ]. This review aims to: (1) examine the commonly reported help-seeking attitudes and behaviors among local and overseas Filipinos with mental health problems; and (2) expound on the most commonly reported barriers and facilitators that influence their help-seeking.

The review aims to synthesize available data on formal help-seeking behavior and attitudes of local and overseas Filipinos for their mental health problems, as well as commonly reported barriers and facilitators. Formal psychological help-seeking behavior is defined as seeking services and treatment, such as psychotherapy, counseling, information and advice, from trained and recognized mental health care providers [ 19 ]. Attitudes on psychological help-seeking refer to the evaluative beliefs in seeking help from these professional sources [ 20 ].

Eligibility criteria

Inclusion criteria for the studies were the following: (1) those that address either formal help-seeking behavior OR attitude related to a mental health AND those that discuss barriers OR facilitators of psychological help-seeking; (2) those that involve Filipino participants, or of Filipino descent; in studies that involve multi-cultural or multi-ethnic groups, they must have at least 20% Filipino participants with disaggregated data on Filipino psychological help-seeking; (3) those that employed any type of study designs, whether quantitative, qualitative or mixed-methods; (4) must be full-text peer-reviewed articles published in scholarly journals or book chapters, with no publication date restrictions; (5) written either in English or Filipino; and (6) available in printed or downloadable format. Multiple articles based on the same research are treated as one study/paper.

Exclusion criteria were: (1) studies in which the reported problems that prompted help-seeking are medical (e.g. cancer), career or vocational (e.g., career choice), academic (e.g., school difficulties) or developmental disorders (e.g., autism), unless specified that there is an associated mental health concern (e.g., anxiety, depression, trauma); (2) studies that discuss general health-seeking behaviors; (3) studies that are not from the perspective of mental health service users (e.g., counselor’s perspective); (4) systematic reviews, meta-analyses and other forms of literature review; and (5) unpublished studies including dissertations and theses, clinical reports, theory or methods papers, commentaries or editorials.

Search strategy and study selection

The search for relevant studies was conducted through electronic database searching, hand-searching and web-based searching. Ten bibliographic databases were searched in August to September 2018: PsychInfo, Global Health, MedLine, Embase, EBSCO , ProQuest , PubMed , Science Direct, Scopus and Emerald Insight. The following search terms were used: “help-seeking behavior” OR “utilization of mental health services” OR “access to mental health services” OR “psychological help-seeking” AND “barriers to help-seeking” OR “facilitators of help-seeking” AND “mental health” OR “mental health problem” OR “mental disorder” OR “mental illness” OR “psychological distress” OR “emotional problem” AND “Filipino” OR “Philippines”. Filters were used to select only publications from peer-reviewed journals. Internet searches through Google Scholar and websites of Philippine-based publications were also performed using the search term “Filipino mental health help-seeking” as well as hand-searching of reference lists of relevant studies. A total of 3038 records were obtained. Duplicates were removed and a total of 2659 records were screened for their relevance based on their titles and abstracts.

Preliminary screening of titles and abstracts of articles resulted in 162 potentially relevant studies, their full-text papers were obtained and were reviewed for eligibility by two reviewers (AM and MC). Divergent opinions on the results of eligibility screening were deliberated and any further disagreement was resolved by the third reviewer (JB). A total of 15 relevant studies (from 24 papers) published in English were included in the review and assessed for quality. There were seven studies with multiple publications (two of them have 3 papers) and a core paper was chosen on the basis of having more comprehensive key study data on formal help-seeking. Results of the literature search are reported in Fig.  1 using the PRISMA diagram [ 21 ]. A protocol for this review was registered at PROSPERO Registry of the Centre for Reviews and Dissemination of the University of York ( https://www.crd.york.ac.uk/PROSPERO ; ID: CRD42018102836).

PRISMA flow diagram

Data extraction and quality assessment

Data extracted by the main author were crosschecked by a second reviewer (JB). A data extraction table with thematic headings was prepared and pilot tested for two quantitative and two qualitative studies to check data comparability. Extraction was performed using the following descriptive data: (1) study information (e.g. name of authors, publication date, study location, setting, study design, measurement tools used); (2) socio-demographic characteristics of participants (e.g. sample size, age, gender); and (3) overarching themes on psychological help-seeking behavior and attitudes, as well as barriers and facilitators of help-seeking.

Two reviewers (AM and MC) did quality assessment of the studies separately, using the following criteria: (1) relevance to the research question; (2) transparency of the methods; (3) robustness of the evidence presented; and (4) soundness of the data interpretation and analysis. Design-specific quality assessment tools were used in the evaluation of risk of bias of the studies, namely: (1) Critical Appraisal Skills Programme Qualitative Checklist [ 22 ]; and (2) Quality Assessment Tool for Quantitative Studies by the Effective Public Health Practice Project [ 23 ]. The appraisals for mixed-methods studies were done separately for quantitative and qualitative components to ensure trustworthiness [ 24 ] of the quality of each assessment.

For studies reported in multiple publications, quality assessment was done only on the core papers [ 25 ]. All the papers ( n  = 6) assessed for their qualitative study design (including the 4 mixed-methods studies) met the minimum quality assessment criteria of fair ( n  = 1) and good ( n  = 5) and were, thus, included in the review. Only 11 out of the 13 quantitative studies (including the 4 mixed-methods studies) satisfied the minimum ratings for the review, with five getting strong quality rating. The two mixed-methods studies that did not meet the minimum quality rating for quantitative designs were excluded as sources of quantitative data but were used in the qualitative data analysis because they satisfied the minimum quality rating for qualitative designs.

Strategy for data analysis

Due to the substantial heterogeneity of the studies in terms of participant characteristics, study design, measurement tools used and reporting methods of the key findings, narrative synthesis approach was used in data analysis to interpret and integrate the quantitative and qualitative evidence [ 26 , 27 ]. However, one crucial methodological limitation of studies in this review is the lack of agreement on what constitutes formal help-seeking. Some researchers include the utilization of traditional or indigenous healers as formal help-seeking, while others limit the concept to professional health care providers. As such, consistent with Rickwood and Thomas’ definition of formal help-seeking [ 19 ], data extraction and analysis were done only on those that reported utilization of professional health care providers.

Using a textual approach, text data were coded using both predetermined and emerging codes [ 28 ]. They were then tabulated, analyzed, categorized into themes and integrated into a narrative synthesis [ 29 ]. Exemplar quotations and author interpretations were also used to support the narrative synthesis. The following were the themes on barriers and facilitators of formal help-seeking: (1) psychosocial barriers/facilitators, which include social support from family and friends, perceived severity of mental illness, awareness of mental health issues, self-stigmatizing beliefs, treatment fears and other individual concerns; (2) socio-cultural barriers/facilitators, which include the perceived social norms and beliefs on mental health, social stigma, influence of religious beliefs, and language and acculturation factors; and (3) systemic/structural and economic barriers/facilitators, which include financial or employment status, the health care system and its accessibility, availability and affordability, and ethnicity, nativity or immigration status.

Study and participant characteristics

The 15 studies were published between 2002 and 2018. Five studies were conducted in the US, four in the Philippines and one study each was done in Australia, Canada, Iceland, Israel and Norway. One study included participants working in different countries, the majority were in the Middle East. Data extracted from the four studies done in the Philippines were used to report on the help-seeking behaviors and attitudes, and barriers/facilitators to help-seeking of local Filipinos, while the ten studies conducted in different countries were used to report on help-seeking of overseas Filipinos. Nine studies were quantitative and used a cross-sectional design except for one cohort study; the majority of them used research-validated questionnaires. Four studies used mixed methods with surveys and open-ended questionnaires, and another two were purely qualitative studies that used interviews and focus group discussions. Only three studies recruited participants through random sampling and the rest used purposive sampling methods. All quantitative studies used questionnaires in measures of formal help-seeking behaviors, and western-standardized measures to assess participants’ attitudes towards help-seeking. Qualitative studies utilized semi-structured interview guides that were developed to explore the psychological help-seeking of participants.

A total of 5096 Filipinos aged 17–70 years participated in the studies. Additionally, 13 studies reported on the mean age of participants, with the computed overall mean age at 39.52 (SD 11.34). The sample sizes in the quantitative studies ranged from 70 to 2285, while qualitative studies ranged from 10 to 25 participants. Of the participants, 59% ( n  = 3012) were female which is probably explained by five studies focusing on Filipino women. Ten studies were conducted in community settings, five in health or social centre-based settings and 1 in a university (Table 1 ).

Formal help-seeking behaviors

12 studies examined the formal help-seeking behaviors of Filipinos (Table 2 ), eight of them were from community-based studies and four were from centre-based studies. Nine studies reported on formal help-seeking of overseas Filipinos and three reported on local Filipinos.

Community-based vs health/social centres Data from quantitative community studies show that the rates of formal help-seeking behaviors among the Filipino general population ranged from 2.2% [ 30 ] to 17.5% [ 6 ]. This was supported by reports from qualitative studies where participants did not seek help at all. The frequency of reports of formal help-seeking from studies conducted in crisis centres and online counseling tended to be higher. For instance, the rate of engagement in online counseling among overseas Filipinos was 10.68% [ 31 ], those receiving treatment in crisis centers was 39.32% [ 17 ] while 100% of participants who were victims of intimate partner violence were already receiving help from a women’s support agency [ 8 , 32 ].

Local vs overseas Filipinos’ formal help-seeking The rate of formal psychological help-seeking of local Filipinos was at 22.19% [ 12 ] while overseas rates were lower and ranged from 2.2% of Filipino Americans [ 30 ] to 17.5% of Filipinos in Israel [ 6 ]. Both local and overseas Filipinos indicated that professional help is sought only as a last resort because they were more inclined to get help from family and friends or lay network [ 7 , 16 ].

Attitudes towards formal help-seeking

13 studies reported on participants’ attitudes towards seeking formal help. Seven studies identified family and friends as preferred sources of help [ 7 , 14 , 16 ] rather than mental health specialists and other professionals even when they were already receiving help from them [ 17 , 32 ]. When Filipinos seek professional help, it is usually done in combination with other sources of care [ 13 ] or only used when the mental health problem is severe [ 14 , 16 , 33 ]. Other studies reported that in the absence of social networks, individuals prefer to rely on themselves [ 32 , 33 ].

Community-based vs health/social centres Community-based studies reported that Filipinos have negative attitudes marked by low stigma tolerance towards formal help-seeking [ 7 , 14 , 16 ]. However, different findings were reported by studies conducted in crisis centres. Hechanova et al. found a positive attitude towards help-seeking among users of online counseling [ 31 ], whereas Cabbigat and Kangas found that Filipinos in crisis centres still prefer receiving help from religious clergy or family members, with mental health units as the least preferred setting in receiving help [ 17 ]. This is supported by the findings of Shoultz and her colleagues who reported that Filipino women did not believe in disclosing their problems to others [ 32 ].

Local vs overseas Filipinos Filipinos, regardless of location, have negative attitudes towards help-seeking, except later-generation Filipino migrants who have been acculturated in their host countries and tended to have more positive attitudes towards mental health specialists [ 10 , 13 , 15 , 34 ]. However, this was only cited in quantitative studies. Qualitative studies reported the general reluctance of both overseas and local Filipinos to seek help.

Barriers in formal help-seeking

All 15 studies examined a range of barriers in psychological help-seeking (Table 3 ). The most commonly endorsed barriers were: (1) financial constraints due to high cost of service, lack of health insurance, or precarious employment condition; (2) self-stigma, with associated fear of negative judgment, sense of shame, embarrassment and being a disgrace, fear of being labeled as ‘crazy’, self-blame and concern for loss of face; and (3) social stigma that puts the family’s reputation at stake or places one’s cultural group in bad light.

Local vs overseas Filipinos In studies conducted among overseas Filipinos, strong adherence to Asian values of conformity to norms is an impediment to help-seeking but cited only in quantitative studies [ 10 , 13 , 15 , 34 ] while perceived resilience, coping ability or self-reliance was mentioned only in qualitative studies [ 14 , 16 , 33 ]. Other common barriers to help-seeking cited by overseas Filipinos were inaccessibility of mental health services, immigration status, sense of religiosity, language problem, experience of discrimination and lack of awareness of mental health needs [ 10 , 13 , 18 , 34 ]. Self-reliance and fear of being a burden to others as barriers were only found among overseas Filipinos [ 6 , 16 , 32 ]. On the other hand, local Filipinos have consistently cited the influence of social support as a hindrance to help-seeking [ 7 , 17 ].

Stigmatized attitude towards mental health and illness was reported as topmost barriers to help-seeking among overseas and local Filipinos. This included notions of mental illness as a sign of personal weakness or failure of character resulting to loss of face. There is a general consensus in these studies that the reluctance of Filipinos to seek professional help is mainly due to their fear of being labeled or judged negatively, or even their fear of fueling negative perceptions of the Filipino community. Other overseas Filipinos were afraid that having mental illness would affect their jobs and immigration status, especially for those who are in precarious employment conditions [ 6 , 16 ].

Facilitators of formal help-seeking

All 15 studies discussed facilitators of formal help-seeking, but the identified enablers were few (Table 4 ). Among the top and commonly cited factors that promote help-seeking are: (1) perceived severity of the mental health problem or awareness of mental health needs; (2) influence of social support, such as the presence/absence of family and friends, witnessing friends seeking help, having supportive friends and family who encourage help-seeking, or having others taking the initiative to help; and (3) financial capacity.

Local vs overseas Filipinos Studies on overseas Filipinos frequently cited financial capacity, immigration status, language proficiency, lower adherence to Asian values and stigma tolerance as enablers of help-seeking [ 15 , 30 , 32 , 34 ], while studies done on local Filipinos reported that awareness of mental health issues and previous positive experience of seeking help serve as facilitator [ 7 , 12 ].

Community-based vs health/social centres Those who were receiving help from crisis centres mentioned that previous positive experience with mental health professionals encouraged their formal help-seeking [ 8 , 17 , 31 ]. On the other hand, community-based studies cited the positive influence of encouraging family and friends as well as higher awareness of mental health problems as enablers of help-seeking [ 12 , 14 , 16 ].

To the best of our knowledge, this is the first systematic review conducted on psychological help-seeking among Filipinos, including its barriers and facilitators. The heterogeneity of participants (e.g., age, gender, socio-economic status, geographic location or residence, range of mental health problems) was large.

Filipino mental health help-seeking behavior and attitudes The rate of mental health problems appears to be high among Filipinos both local and overseas, but the rate of help-seeking is low. This is consistent with findings of a study among Chinese immigrants in Australia which reported higher psychological distress but with low utilization of mental health services [ 35 ]. The actual help-seeking behavior of both local and overseas Filipinos recorded at 10.72% ( n  = 461) is lower than the 19% of the general population in the US [ 36 ] and 16% in the United Kingdom (UK) [ 37 ], and even far below the global prevalence rate of 30% of people with mental illness receiving treatment [ 38 ]. This finding is also comparable with the low prevalence rate of mental health service use among the Chinese population in Hong Kong [ 39 ] and in Australia [ 35 ], Vietnamese immigrants in Canada [ 30 ], East Asian migrants in North America [ 41 ] and other ethnic minorities [ 42 ] but is in sharp contrast with the increased use of professional help among West African migrants in The Netherlands [ 43 ].

Most of the studies identified informal help through family and friends as the most widely utilized source of support, while professional service providers were only used as a last resort. Filipinos who are already accessing specialist services in crisis centres also used informal help to supplement professional help. This is consistent with reports on the frequent use of informal help in conjunction with formal help-seeking among the adult population in UK [ 44 ]. However, this pattern contrasts with informal help-seeking among African Americans who are less likely to seek help from social networks of family and friends [ 45 ]. Filipinos also tend to use their social networks of friends and family members as ‘go-between’ [ 46 ] for formal help, serving to intercede between mental health specialists and the individual. This was reiterated in a study by Shoultz et al. (2009) in which women who were victims of violence are reluctant to report the abuse to authorities but felt relieved if neighbours and friends would interfere for professional help in their behalf [ 32 ].

Different patterns of help-seeking among local and overseas Filipinos were evident and may be attributed to the differences in the health care system of the Philippines and their host countries. For instance, the greater use of general medical services by overseas Filipinos is due to the gatekeeper role of general practitioners (GP) in their host countries [ 47 ] where patients have to go through their GPs before they get access to mental health specialists. In contrast, local Filipinos have direct access to psychiatrists or psychologists without a GP referral. Additionally, those studies conducted in the Philippines were done in urban centers where participants have greater access to mental health specialists. While Filipinos generally are reluctant to seek help, later-generation overseas Filipinos have more positive attitudes towards psychological help-seeking. Their exposure and acculturation to cultures that are more tolerant of mental health stigma probably influenced their more favorable attitude [ 41 , 48 ].

Prominent barrier themes in help-seeking Findings of studies on frequently endorsed barriers in psychological help-seeking are consistent with commonly reported impediments to health care utilization among Filipino migrants in Australia [ 49 ] and Asian migrants in the US [ 47 , 50 ]. The same barriers in this review, such as preference for self-reliance as alternative coping strategy, poor mental health awareness, perceived stigma, are also identified in mental health help-seeking among adolescents and young adults [ 51 ] and among those suffering from depression [ 52 ].

Social and self-stigmatizing attitudes to mental illness are prominent barriers to help-seeking among Filipinos. Social stigma is evident in their fears of negative perception of the Filipino community, ruining the family reputation, or fear of social exclusion, discrimination and disapproval. Self-stigma manifests in their concern for loss of face, sense of shame or embarrassment, self-blame, sense of being a disgrace or being judged negatively and the notion that mental illness is a sign of personal weakness or failure of character [ 16 ]. The deterrent role of mental health stigma is consistent with the findings of other studies [ 51 , 52 ]. Overseas Filipinos who are not fully acculturated to the more stigma-tolerant culture of their host countries still hold these stigmatizing beliefs. There is also a general apprehension of becoming a burden to others.

Practical barriers to the use of mental health services like accessibility and financial constraints are also consistently rated as important barriers by Filipinos, similar to Chinese Americans [ 53 ]. In the Philippines where mental health services are costly and inaccessible [ 54 ], financial constraints serve as a hindrance to formal help-seeking, as mentioned by a participant in the study of Straiton and his colleagues, “In the Philippines… it takes really long time to decide for us that this condition is serious. We don’t want to use our money right away” [ 14 , p.6]. Local Filipinos are confronted with problems of lack of mental health facilities, services and professionals due to meager government spending on health. Despite the recent ratification of the Philippines’ Mental Health Act of 2018 and the Universal Health Care Act of 2019, the current coverage for mental health services provided by the Philippine Health Insurance Corporation only amounts to US$154 per hospitalization and only for acute episodes of mental disorders [ 55 ]. Specialist services for mental health in the Philippines are restricted in tertiary hospitals located in urban areas, with only one major mental hospital and 84 psychiatric units in general hospitals [ 1 ].

Overseas Filipinos cited the lack of health insurance and immigration status without health care privileges as financial barrier. In countries where people have access to universal health care, being employed is a barrier to psychological help-seeking because individuals prefer to work instead of attending medical check-ups or consultations [ 13 ]. Higher income is also associated with better mental health [ 56 ] and hence, the need for mental health services is low, whereas poor socio-economic status is related to greater risk of developing mental health problems [ 57 , 58 ]. Lack of familiarity with healthcare system in host countries among new Filipino migrants also discourages them from seeking help.

Studies have shown that reliance on, and accessibility of sympathetic, reliable and trusted family and friends are detrimental to formal help-seeking since professional help is sought only in the absence of this social support [ 6 , 8 ]. This is consistent with the predominating cultural values that govern Filipino interpersonal relationships called kapwa (or shared identity) in which trusted family and friends are considered as “hindi-ibang-tao” (one-of-us/insider), while doctors or professionals are seen as “ibang-tao” (outsider) [ 59 ]. Filipinos are apt to disclose and be more open and honest about their mental illness to those whom they considered as “hindi-ibang-tao” (insider) as against those who are “ibang-tao” (outsider), hence their preference for family members and close friends as source of informal help [ 59 ]. For Filipinos, it is difficult to trust a mental health specialist who is not part of the family [ 60 ].

Qualitative studies in this review frequently mentioned resilience and self-reliance among overseas Filipinos as barriers to help-seeking. As an adaptive coping strategy for adversity [ 61 ], overseas Filipinos believe that they were better equipped in overcoming emotional challenges of immigration [ 16 ] without professional assistance [ 14 ]. It supports the findings of studies on overseas Filipino domestic workers who attributed their sense of well-being despite stress to their sense of resilience which prevents them from developing mental health problems [ 62 ] and among Filipino disaster survivors who used their capacity to adapt as protective mechanism from experience of trauma [ 63 ]. However, self-reliant individuals also tend to hold stigmatizing beliefs on mental health and as such resort to handling problems on their own instead of seeking help [ 51 , 64 ].

Prominent facilitator themes in help-seeking In terms of enablers of psychological help-seeking, only a few facilitators were mentioned in the studies, which supported findings in other studies asserting that factors that promote help-seeking are less often emphasized [ 42 , 51 ].

Consistent with other studies [ 44 , 49 ], problem severity is predictive of intention to seek help from mental health providers [ 18 , 30 ] because Filipinos perceive that professional services are only warranted when symptoms have disabling effects [ 5 , 53 ]. As such, those who are experiencing heightened emotional distress were found to be receptive to intervention [ 17 ]. In most cases, symptom severity is determined only when somatic or behavioral symptoms manifest [ 13 ] or occupational dysfunction occurs late in the course of the mental illness [ 65 ]. This is most likely due to the initial denial of the problem [ 66 ] or attempts at maintaining normalcy of the situation as an important coping mechanism [ 67 ]. Furthermore, this poses as a hindrance to any attempts at early intervention because Filipinos are likely to seek professional help only when the problem is severe or has somatic manifestations. It also indicates the lack of preventive measure to avert any deterioration in mental health and well-being.

More positive attitudes towards help-seeking and higher rates of mental health care utilization have been found among later-generation Filipino immigrants or those who have acquired residency status in their host country [ 10 , 15 ]. Immigration status and length of stay in the host country are also associated with language proficiency, higher acculturation and familiarity with the host culture that are more open to discussing mental health issues [ 13 ], which present fewer barriers in help-seeking. This is consistent with facilitators of formal help-seeking among other ethnic minorities, such as acculturation, social integration and positive attitude towards mental health [ 43 ].

Cultural context of Filipinos’ reluctance to seek help Several explanations have been proposed to account for the general reluctance of Filipinos to seek psychological help. In Filipino culture, mental illness is attributed to superstitious or supernatural causes, such as God’s will, witchcraft, and sorcery [ 68 , 69 ], which contradict the biopsychosocial model used by mental health care professionals. Within this cultural context, Filipinos prefer to seek help from traditional folk healers who are using religious rituals in their healing process instead of availing the services of professionals [ 70 , 71 ]. This was reaffirmed by participants in the study of Thompson and her colleagues who said that “psychiatrists are not a way to deal with emotional problems” [ 74 , p.685]. The common misconception on the cause and nature of mental illness, seeing it as temporary due to cold weather [ 14 ] or as a failure in character and as an individual responsibility to overcome [ 16 , 72 ] also discourages Filipinos from seeking help.

Synthesis of the studies included in the review also found conflicting findings on various cultural and psychosocial influences that served both as enablers and deterrents to Filipino help-seeking, namely: (1) level of spirituality; (2) concern on loss of face or sense of shame; and (3) presence of social support.

Level of spirituality Higher spirituality or greater religious beliefs have disparate roles in Filipino psychological help-seeking. Some studies [ 8 , 14 , 16 ] consider it a hindrance to formal help-seeking, whereas others [ 10 , 15 ] asserted that it can facilitate the utilization of mental health services [ 15 , 73 ]. Being predominantly Catholics, Filipinos had drawn strength from their religious faith to endure difficult situations and challenges, accordingly ‘leaving everything to God’ [ 74 ] which explains their preference for clergy as sources of help instead of professional mental health providers. This is connected with the Filipino attribution of mental illness to spiritual or religious causes [ 62 ] mentioned earlier. On the contrary, Hermansdottir and Aegisdottir argued that there is a positive link between spirituality and help-seeking, and cited connectedness with host culture as mediating factor [ 15 ]. Alternately, because higher spirituality and religiosity are predictors of greater sense of well-being [ 75 ], there is, thus, a decreased need for mental health services.

Concern on loss of face or sense of shame The enabler/deterrent role of higher concern on loss of face and sense of shame on psychological help-seeking was also identified. The majority of studies in this review asserted the deterrent role of loss of face and stigma consistent with the findings of other studies [ 51 ], although Clement et al. stated that stigma is the fourth barrier in deterring help-seeking [ 76 ]. Mental illness is highly stigmatized in the Philippines and to avoid the derogatory label of ‘crazy’, Filipinos tend to conceal their mental illness and consequently avoid seeking professional help. This is aligned with the Filipino value of hiya (sense of propriety) which considers any deviation from socially acceptable behavior as a source of shame [ 11 ]. The stigmatized belief is reinforced by the notion that formal help-seeking is not the way to deal with emotional problems, as reflected in the response of a Filipino participant in the study by Straiton et. al., “It has not occurred to me to see a doctor for that kind of feeling” [ 14 , p.6]. However, other studies in this review [ 12 , 13 ] posited contrary views that lower stigma tolerance and higher concern for loss of face could also motivate psychological help-seeking for individuals who want to avoid embarrassing their family. As such, stigma tolerance and loss of face may have a more nuanced influence on help-seeking depending on whether the individual avoids the stigma by not seeking help or prevent the stigma by actively seeking help.

Presence of social support The contradictory role of social networks either as helpful or unhelpful in formal help-seeking was also noted in this review. The presence of friends and family can discourage Filipinos from seeking professional help because their social support serves as protective factor that buffer one’s experience of distress [ 77 , 78 ]. Consequently, individuals are less likely to use professional services [ 42 , 79 ]. On the contrary, other studies have found that the presence of friends and family who have positive attitudes towards formal help-seeking can promote the utilization of mental health services [ 8 , 80 ]. Friends who sought formal help and, thus, serve as role models [ 14 ], and those who take the initiative in seeking help for the distressed individual [ 32 ] also encourage such behavior. Thus, the positive influence of friends and family on mental health and formal help-seeking of Filipinos is not merely to serve only as emotional buffer for stress, but to also favourably influence the decision of the individual to seek formal help.

Research implications of findings

This review highlights particular evidence gaps that need further research: (1) operationalization of help-seeking behavior as a construct separating intention and attitude; (2) studies on actual help-seeking behavior among local and overseas Filipinos with identified mental health problems; (3) longitudinal study on intervention effectiveness and best practices; (4) studies that triangulate findings of qualitative studies with quantitative studies on the role of resilience and self-reliance in help-seeking; and (5) factors that promote help-seeking.

Some studies in this review reported help-seeking intention or attitude as actual behaviors even though they are separate constructs, hence leading to reporting biases and misinterpretations. For instance, the conflicting findings of Tuliao et al. [ 12 ] on the negative association of loss of face with help-seeking attitude and the positive association between loss of face and intention to seek help demonstrate that attitudes and intentions are separate constructs and, thus, need further operationalization. Future research should strive to operationalize concretely these terms through the use of robust measurement tools and systematic reporting of results. There is also a lack of data on the actual help-seeking behaviors among Filipinos with mental illness as most of the reports were from the general population and on their help-seeking attitudes and intentions. Thus, research should focus on those with mental health problems and their actual utilization of healthcare services to gain a better understanding of how specific factors prevent or promote formal help-seeking behaviors.

Moreover, the majority of the studies in this review were descriptive cross-sectional studies, with only one cohort analytic study. Future research should consider a longitudinal study design to ensure a more rigorous and conclusive findings especially on testing the effectiveness of interventions and documenting best practices. Because of the lack of quantitative research that could triangulate the findings of several qualitative studies on the detrimental role of resilience and self-reliance, quantitative studies using pathway analysis may help identify how these barriers affect help-seeking. A preponderance of studies also focused on discussing the roles of barriers in help-seeking, but less is known about the facilitators of help-seeking. For this reason, factors that promote help-seeking should be systematically investigated.

Practice, service delivery and policy implications

Findings of this review also indicate several implications for practice, service delivery, intervention and policy. Cultural nuances that underlie help-seeking behavior of Filipinos, such as the relational orientation of their interactions [ 81 ], should inform the design of culturally appropriate interventions for mental health and well-being and improving access and utilization of health services. Interventions aimed at improving psychological help-seeking should also target friends and family as potential and significant influencers in changing help-seeking attitude and behavior. They may be encouraged to help the individual to seek help from the mental health professional. Other approaches include psychoeducation that promotes mental health literacy and reduces stigma which could be undertaken both as preventive and treatment strategies because of their positive influence on help-seeking. Strategies to reduce self-reliance may also be helpful in encouraging help-seeking.

This review also has implications for structural changes to overcome economic and other practical barriers in Filipino seeking help for mental health problems. Newly enacted laws on mental health and universal healthcare in the Philippines may jumpstart significant policy changes, including increased expenditure for mental health treatment.

Since lack of awareness of available services was also identified as significant barrier, overseas Filipinos could be given competency training in utilizing the health care system of host countries, possibly together with other migrants and ethnic minorities. Philippine consular agencies in foreign countries should not merely only resort to repatriation acts, but could also take an active role in service delivery especially for overseas Filipinos who experience trauma and/or may have immigration-related constraints that hamper their access to specialist care.

Limitations of findings

A crucial limitation of studies in this review is the use of different standardized measures of help-seeking that render incomparable results. These measures were western-based inventories, and only three studies mentioned using cultural validation, such as forward-and-back-translations, to adapt them to cross-cultural research on Filipino participants. This may pose as a limitation on the cultural appropriateness and applicability of foreign-made tests [ 73 ] in capturing the true essence of Filipino experience and perspectives [ 74 ]. Additionally, the majority of the studies used non-probability sampling that limits the generalizability of results. They also failed to measure the type of assistance or actual support sought by Filipinos, such as psychoeducation, referral services, supportive counseling or psychotherapy, and whether or not they are effective in addressing mental health concerns of Filipinos. Another inherent limitation of this review is the lack of access to grey literature, such as thesis and dissertations published in other countries, or those published in the Philippines and are not available online. A number of studies on multi-ethnic studies with Filipino participants do not provide disaggregated data, which limits the scope and inclusion of studies in this review.

This review has confirmed the low utilization of mental health services among Filipinos regardless of their locations, with mental health stigma as a primary barrier resilience and self-reliance as coping strategies were also cited, especially in qualitative studies, but may be important in addressing issues of non-utilization of mental health services. Social support and problem severity were cited as prominent facilitators in help-seeking. However, different structural, cultural and practical barriers and facilitators of psychological help-seeking between overseas and local Filipinos were also found.

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Martinez, A.B., Co, M., Lau, J. et al. Filipino help-seeking for mental health problems and associated barriers and facilitators: a systematic review. Soc Psychiatry Psychiatr Epidemiol 55 , 1397–1413 (2020). https://doi.org/10.1007/s00127-020-01937-2

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ORIGINAL RESEARCH article

Masculinity and help-seeking among men with depression: a qualitative study.

• 1 Department of Psychiatry II, University of Ulm and District Hospital Günzburg, Ulm, Germany
• 2 Department of Psychosomatic Medicine and Psychotherapy, University Hospital Ulm, Ulm, Germany
• 3 Department of Psychiatry, Psychotherapy and Psychosomatics, District Hospital Donauwörth, Donauwörth, Germany
• 4 Department of Psychiatry, Psychotherapy and Psychosomatics, University of Augsburg and District Hospital Augsburg, Augsburg, Germany

Background: Many studies indicate that men are more reluctant to seek help for mental health problems than women. Traditional ideas of masculinity are often seen as a cause of this phenomenon. However, little is known about the diversity of experiences during the processes of help-seeking and service use among men with depression who have already utilized mental health services. This study aims to explore men's experiences and attitudes toward depression, help-seeking, and service use in order to develop gender-sensitive services.

Methods: Narrative-biographical interviews were conducted with men treated for depression ( n = 12). Interview topics included individual experience with depression, help-seeking behavior, and mental health service use. Transcripts were analyzed using qualitative content analysis.

Results: Before seeking treatment, men's help-seeking behavior was negatively affected by internalized masculine norms. However, findings indicate a change of attitudes toward depression after mental health service use. Men with depression emphasized a salutogenic perspective toward mental health problems and critically reflected on masculine norms. The positive function of men-only groups were described as key for successful service use.

Conclusions: Men with depression reported experiences toward help-seeking and service use on four different levels: (i) attitudes toward depression, (ii) perception of societal views on depression, (iii) experiences within the family context and (iv) experiences with mental health services. Interventions to reduce the stigma of being “unmanly” and to improve men's capacity to cope with being unable to work should be developed. Peer-led men-only groups may increase participants' self-esteem and assist in disclosing weaknesses. In the context of GPs' mediating role, training for health professionals concerning the impact of masculine norms on mental health is recommended.

Introduction

There is broad evidence of men's reluctance to seek help for mental health problems. Studies support the generally-held assumption that men are less likely than women to get assistance from mental health professionals for problems ( 1 ). A body of empirical research has explored reasons for help-seeking decisions as well as service use behavior among men with depression. Research often suggests that men's help-seeking behavior regarding depression is attributed to traditional masculine norms such as being strong, successful, self-reliant, in control, and capable, along with an emphasis on avoiding emotions ( 2 ). In line with this, having depression is described as being “incompatible” with traditional masculinity due to the fact that emotional experiences in depression are linked to femininity; depression is often accompanied by feelings of powerlessness and lack of control; and the experience of depression often leaves people feeling weak and vulnerable ( 3 ). Results of a systematic review of qualitative studies on men's views of depression confirmed the impact of norms concerning masculine roles on men's attitudes toward depression and help-seeking ( 4 ). Receiving support or seeking help was associated with the risk of being ridiculed or marginalized as well as being seen as “unmanly” by others.

Further studies of a systematic review refer to the adverse effects of male role expectations and social pressures to perform well as family providers and fathers with consequences for help-seeking behavior. Depression was frequently perceived as a threat to men's roles as family provider and many participants reported feelings of inadequacy and incapability compared to their situation before depression ( 4 ). Compared to other severe illnesses, depression was described as a “particular challenge to masculinity” and experienced as “otherness” either in regard to other men or compared to the person they used to be ( 4 ). Fathers with mental health problems experienced hospitalization and medication as a disruption to their lives and the lives of their family members and prevented them from “being there” for their partners ( 5 ). A meta-analytic review on effects of paternal depression on fathers' parenting behaviors supports this assumption. Studies indicated that paternal depression has significant, though small, effects on parenting, with depressed fathers demonstrating decreased positive and increased negative parenting behaviors (i.e., parental engagement) ( 6 ). In contrast to the adverse effects of family role expectations, research highlighted the supportive function of the family during the help-seeking process ( 7 , 8 ).

In addition to the impact of expectations regarding male roles on help-seeking behavior, studies revealed positive as well as negative experiences of (mental) health service use among men with depression. A recent qualitative study referred to conflicts that men experienced in relation to antidepressant use ( 9 ). On the one hand, medication was perceived as a way in which men asserted their control over difficulties; on the other hand, antidepressants were seen as an obstacle to emotional and physical vitality, for example by undermining sexual function. Further findings referred to the role of general practitioners (GPs) in the context of treating men's depression. Although studies pointed out that men were repeatedly found to be half as likely to seek help for mental health concerns from a GP compared to women ( 7 ), others emphasized GPs' function as a pathway to mental health services ( 10 ). Further studies revealed ways men communicate their depression within in- and outpatient services. While discussions about depression with health care providers were described as atypical for men ( 11 ), studies explored whether a change of setting improved access to treatment for common mental disorders in the context of mental health services. Research found that a higher proportion of men with mental health problems sought help via psychotherapeutic consultation in the workplace compared to standard psychosomatic outpatient care ( 12 ).

Even though traditional masculine norms play an important role in reinforcing men's reluctance to seek help, qualitative studies showed that some men seemed to benefit from just the same norms by perceiving these ideals as a healthy resource ( 13 ). While some men associated depression with powerlessness and lack of control, others described the recovery as a heroic struggle from which they emerged much stronger ( 3 ). Furthermore, there is some evidence that men do not necessarily subscribe to traditional ideals but demonstrate alternative forms of masculinity ( 4 ). These studies suggested that some men dissociated themselves from traditional masculine norms by emphasizing their sensitivity in coping with and utilizing in- and outpatient services due to depressive symptoms ( 3 ).

Despite emerging evidence for the diversity of men's experiences of help-seeking and service use, many studies provide a one-dimensional understanding of mental health behavior among men with depression, including reduced service use. Beyond this, there is a lack of knowledge on how men's specific needs in cases of depression are addressed by mental health services. Moreover, the impact of norms concerning traditional masculine roles for men with depression who have already utilized mental health services is unclear. Previous studies on mental health professionals' view about the impact of male gender for the treatment of men with depression stress the need to develop gender-sensitive services ( 14 ). On the one hand, results refer to the need of awareness of the role of gender and that its implications for mental health treatment should be an integral part of mental health professionals' education and the everyday practice of mental health treatment. On the other hand, more evidence is needed to develop mental health services based on the experiences of men with depression. This study therefore aims to explore experiences and attitudes toward depression, help-seeking and service use among men with depression who have already utilized mental health services in order to develop gender-sensitive services.

Materials and Methods

This qualitative investigation is part of the mixed-methods study “Constructions of Masculinity and Mental Health Behavior of Men with Depression” (MenDe) funded by the German Research Foundation. The study aims for a comprehensive analysis of men's constructions of masculinity and the consequences for their mental health behavior. Through an analysis of the diversity of concepts of masculinity, the study contributes to a more detailed picture of depression among men.

Selection of Participants for Qualitative Interviews

In the first step, based on a sample of 250 men with depression, a latent class analysis was performed and three types of a combination of masculinity orientation and job-related attitudes were identified ( 15 ). In the second step, twelve biographical interviews with four representatives of each class were conducted in order to get a deeper understanding of class membership in respect to subjective illness theories and coping processes among men with depression ( 16 ). In a third step, these interviews were re-analyzed in order to gain a deeper understanding of men's subjective perspectives on help-seeking barriers and facilitators of service use irrespective of class membership. This article focuses on this third step by addressing men's perspectives on help-seeking decisions and service use experiences.

Recruitment

Participants were recruited both inside and outside healthcare settings in Southern Germany. Eligible patients were asked by doctors or other clinical staff about their willingness to participate in the study. After expressing their willingness to participate, research workers contacted the patients, informed them about the aims of the study and verified the patients according to the following inclusion criteria: patients must be male, aged between 18 and 64, diagnosed or self-identified as having depression and sufficient German language skills. The study's exclusion criteria were organic mental disorder, dementia, anorexia with body mass index (BMI) <17, addiction and bipolar disorder or schizophrenia.

We conducted narrative-biographical interviews ( Table 1 ) in which interviewees were given as much time as required to talk about their experiences during the help-seeking and service use process in their own words ( 17 ). Participants were encouraged to talk about their experience of depression, help-seeking behavior, and service use. In an additional part of the interview, we used a semistructured interview guide, which included the topics of illness theories, the social consequences of depression and personal coping strategies. At the end of the interviews, respondents were asked to describe whether and how masculine norms influenced their help-seeking decisions and service use experiences. One pilot interview was conducted with no changes for the interview guide.

Table 1 . Interview guide.

Data Collection

Twelve interviews were conducted by a researcher (TS) between March and June 2018. The place for the interviews was chosen by the respondents. Interviews took place either at home or in the facilities of Ulm University, from which audio was recorded, transcribed verbatim, and anonymized. The duration of the interviews was between 27 and 133 min, with a mean of 75 min. Respondents were asked to answer socio-demographic questions at the end of the interview.

Interview transcripts were analyzed using qualitative content analysis ( 18 ) via the following steps: (i) potential categories were defined, derived deductively from the research question and theoretical background (e.g., mental health service use); (ii) inductive codes were formulated based on the material (e.g., experienced stigma); (iii) codes were collated into potential themes; these themes were checked for consistency with coded extracts across the dataset, and were refined and summarized into categories. The interviews were coded independently by three researchers (MSt, SK, TS) so that coding could be compared. Discordant coding was discussed in a qualitative research group until consensus was reached. It should be reflected that the interviewer was a male researcher. Against the background of interactionism, male participants might answer in a specific way depending on the gender of the interviewer (for e.g., to stage themselves as “real men” who never lost control in coping depression). To try to control this bias a qualitative research group with several perspectives (men and women, different professions etc.) discussed this issue critically. We used MAXQDA 12 for data analysis.

Characteristics of Participants

Interviewees' characteristics ( n = 12) are presented in Table 2 . The mean age was 52 (range from 30 to 62). Three participants had a general qualification for university entrance, five an advanced technical college entrance qualification, three an intermediate school-leaving certificate, and one participant had a certificate of secondary education. The mean household income was 3,917€ (range from 2,500€ to 6,000€). Interviewees were employed in technical professions, public administration, marketing, social profession, or transportation. Five participants were unemployed, on sick leave, or participating in occupational rehabilitation. Before being on sick leave, in rehabilitation or unemployed these interviewees were employed in manufacturing and construction, human services, and marketing. One participant was single, two were divorced and nine were married. Seven participants had children and two lived together with them. At the time of the interviews, eleven out of twelve participants were utilizing mental health services by a GP, psychologist and/or a psychiatrist.

Table 2 . Characteristics of the clinical sample of participants ( n = 12).

Based on the qualitative analysis, we summarized themes which refer to men's (i) attitudes toward depression; (ii) perception of societal views on depression; (iii) Family environment: between role expectations and social support; and (iv) experiences with mental health services ( Table 3 ). These main themes contained 20 categories with 58 subcategories and will be presented in more detail in the following section, using pseudonyms and participant's age range to preserve confidentiality.

Table 3 . Core themes, categories, and subcategories, n = number of quotations.

Men's Attitudes Toward Coping With Depression: Critical Stance Toward Masculine Norms

The majority of interviewees reported that masculine norms influenced their attitudes toward depression as well as their decision to seek help. Some of them reported having “trivialized” their symptoms in terms of a “temporary” condition, which was expected to return quickly to a normal state of health: “It's a bit difficult at the moment, but it'll be fine again soon” (Luke, 55–59 y). Most participants reported having tried to solve mental health problems on their own instead of seeking mental health services. Along these lines, some interviewees described their own as well as men's socialization in general as having an emphasis on avoiding feelings, appearing strong and never crying. One participant reflected masculine norms meant that he never disclosed mental health problems, saying that “[…] it doesn't exist among men. Men are the breadwinners, the problem solvers, the doers” (Luke, 55–59 y). In order to meet traditional masculine norms concerning societal roles, respondents decided not to disclose their mental health problems and to post-pone their own needs:

You have to play your part in the world of business. This means you can rarely be honest anywhere. That's the main thing, not to actually show how you're really doing (Steve, 50–54 y).

Interviewees explained low levels of help-seeking behavior as being a means of maintaining their employability as well as to safeguard career options. Therefore, one respondent reported that shortly after being admitted to a psychiatric ward due to a mental breakdown, he asked to be discharged “in order to go to work” (Jack, 50–54 y). In line with a critical stance toward masculine norms, the analysis indicates a change in attitudes toward mental health problems during recovery processes. Interviewees emphasized a salutogenic perspective on depression and help-seeking. Respondents perceived having depression as an important “life experience” (Alex, 55–59 y) or a “necessary wake-up call” (Harry, 45–49 y). This perspective awakened them to the need to change harmful attitudes toward work and life: “Before my illness, work came first. And now I have to say I'm the top priority and I only do what is good for me” (Luke, 55–59 y). Some participants viewed their depression primarily as a chance to reflect on their attitudes, which led to positive coping strategies in everyday life (Alex, 55–59 y). Due to their critical stances toward masculine norms, interviewees recommended being “more sensitive to looking after oneself and noticing these warning signs earlier” (Luke, 55–59 y). Others suggested detaching oneself from traditional masculine norms that inhibit help-seeking and service use for depression: “This kind of thing, of ‘I cannot show weakness, I cannot be sick’ should be avoided” (Jack, 50–54 y).

Men's Perception of Societal Views on Depression: The Stigma of Being Depressed and “Unmanly”

Participants referred to a variety of gender-related stigma experiences which could be classified into two categories: firstly, participants reported being assessed as incapable to adequately cope with mental distress. Depressive symptoms were not taken seriously by others who alleged that mental disorders are a result of an inability to deal with distress: “I've often heard people say ‘Get a grip! Don't make such a fuss’” (Luke, 55–59 y). Secondly, stigma experiences were related to the failure to fulfill norms relating to work. One respondent reported that he had been shunned by workmates and management due to his failure to cope with mental health problems: “They said I didn't appear to be sick and that they had never been sick in their lives” (Luke, 55–59 y). The analysis revealed that “not being sick” was associated with attributes of being strong, successful and self-reliant conveyed by the employment environment. In contrast, mental health problems in the workplace left interviewees feeling weak and vulnerable. Thus, they reported that their depression-related incapacity to work made them feel stigmatized by other colleagues. Participants were labeled “loser,” “lazy,” or “incapable” (James, 55–59 y). Along with these experiences, respondents on sick leave reported being afraid that “outside my house somebody could ask me ‘What are you doing for work these days?’” (Jack, 50–54 y) Some participants developed strategies in order to meet work-related norms, e.g., by telling people “I'm a freelancer. I'm working from home at the moment” (Jack, 50–54 y). Against this background, respondents stated that seeking help continues to be viewed negatively as it is connected with the inability to cope with mental distress: “It's certainly still the case that people say, ‘Oh, he needed help, he can't do it himself’” (Oliver, 55–59 y). Interviewees perceived little understanding of what it means to have a depressive disorder and seek help within different social and job-related contexts. Some respondents reported fears of being stigmatized, which led to them rejecting inpatient services:

The goal is under no circumstances to check into a clinic, because then the stigma is even bigger. That means you can't hide it any more, either at work or in your private life (Oliver, 55–59 y).

However, some participants perceived a slowly growing societal acceptance for professional help-seeking. One respondent noted that “People used to be locked up. All psychiatric institutions used to be completely closed off, and in the last 15 years they've become much more open” (Daniel, 50–54 y).

Family Environment: Between Role Expectations and Social Support

Participants reported both negative and positive experiences within their familial context during the help-seeking process. Some men perceived a loss of empathy that might be related to the duration of mental health problems: “I feel like I can't really mention my depressive symptoms at home anymore, because obviously it's annoying [for my family]” (Oliver, 55–59 y). Participants described a lack of understanding regarding their depression and their “inability” to recover:

The worst thing is my environment: “You've been to the hospital twice now, you are taking the medication and you have been on holiday, you must be healthy now” (Jack, 50–54 y).

Others reported that the diagnosis of “depression” was not taken seriously by family members but seen as a pseudo-problem (Daniel, 50–54 y). Within the familial context, paternal role expectations were an important issue for some participants: “My family couldn't understand that I, a father, didn't go to the hardware store today, because I didn't feel good. It was never really recognized” (James, 55–59 y). In contrast, an open-minded and appreciative family environment was seen as assisting in the seeking of professional help (Harry, 45–49 y). Further findings underlined the supportive role of the partner as the “rock” (Jack, 50–54 y) in the help-seeking process: “Without my wife, I wouldn't still be sitting here. I wouldn't have accepted any help, and I would be sitting somewhere in a clinic where I wouldn't be able to open the door by myself” (Jack, 50–54 y).

(Mental) Health Service Use: Between Obstacles and Enablers

Participants described both negative and positive experiences with (mental) health service use. Some respondents reported a lack of interest as well as a downplaying of depressive symptoms by GPs which led to them no longer seeking help:

The GP said, “Yeah, my God, I'm seeing you again? So, what have you got? Problems at work? So, a lot of people have problems. Don't get so upset!” (Oliver, 55–59 y).

In some men's views, GPs tended to relativize depressive symptoms and recommended calming oneself down. In contrast, other interviewees reported the role of GPs as being a gateway to mental health services and being generally supportive and encouraging as well: “I told him everything. And then he pressed a note into my hand and said I had to go to the clinic immediately” (Alex, 55–59 y). Alongside structures of formal service use, interviewees pointed out the positive role of other informal service users' social support during and after inpatient services. They reported the key role of a face-to-face exchange with fellow service users, especially those with a similar illness-related background, which was described as a supportive feature during the help-seeking process. Respondents felt accepted without being questioned by others: “There was no question of why… just this listening and sympathy and being there for you” (Luke, 55–59 y). In particular, group counseling for men with depression was perceived as facilitating the disclosure of weaknesses. For this reason, interviewees preferred approaches that enabled them to address anxieties in a group of fellow service users who identify with the same gender. Relatedly, participants highlighted the familiarity of men-only groups in the context of inpatient services: “You can really show your true self. You can show weakness and it won't be interpreted negatively. Nobody laughs at you” (Steve, 50–54 y). Because of societal expectations due to masculine norms as well as perceived stigma of being “unmanly,” some participants defined inpatient services as a sheltered space: “You're in a kind of cocoon, where you're protected, where you feel really comfortable. Where you're doing well” (Luke, 55–59 y). Others described inpatient services as being their first opportunity to open up to someone else: “That was the first time I was able to be open about my problems like that” (James, 55–59 y). These interviewees perceived inpatient services as being a protection against external expectations which they were unable to meet due to mental health problems. Instead of having to meet the expectation of being active and responsible, service users are allowed to be “passive” recipients:

I really appreciate the clinic. To be free of my responsibilities for a while. In a clinic, you're completely relieved of it. You're given a plan to work through (George, 45–49 y).

Consistent with the change in attitudes toward mental health-related help-seeking, interviewees described their experiences of inpatient services as an “educational resource”, where they could benefit from fellow patients' life experiences and learn how to cope with depressive symptoms: “I learned a lot through meeting people with the same problems. That makes you smarter, when you know how to deal with it” (Alex, 55–59 y).

The objective of our study was to explore experiences and attitudes toward depression, help-seeking and service use in a sample of men undergoing treatment for depression. Our findings suggest that men with depression retrospectively give both negative and positive experiences of help-seeking and service use. On the one hand, they report the adverse impact of masculine norms as well as stigma experiences. On the other hand, results indicate a transformation of their attitudes toward traditional masculine norms by critically reflecting on non-help-seeking behavior as well as maladaptive work patterns. In this regard, peer-led men-only groups were seen as assisting the disclosure of anxieties.

Adverse Impact of Masculine Norms

Retrospectively, the interviewees perceived that they trivialized and downplayed their symptoms, which they justified using the societal role of caring for their family or to meet career-related expectations. This is in line with previous studies showing that men who suffer from depression have difficulties disclosing their mental health problems, reasoning that traditional masculine norms such as being strong, successful, and self-reliant inhibit help-seeking behavior ( 2 ). Furthermore, attitudes toward depression can be discussed following the concept of hegemonic masculinity ( 19 ). Hegemonic masculinity is defined as the dominant cultural ideal in Western countries serving as a normative orientation for men concerning heterosexuality, rationality, success, strength, or control, although only a small group of men might conform to these ideals ( 19 ). Therefore, the sociological concept describes a cultural ideal of masculinity in a given society, including being strongly work-oriented, having breadwinner mentality and a reluctance to talk about mental health issues. Results of qualitative studies support this assumption by showing that men's decision not to seek help is accompanied by the concern that they would be making fools of themselves and expect social isolation as a consequence of not matching masculine role norms ( 20 ).

Male Stigma Surrounding Depression and Help-Seeking

Additionally, our findings also report on stigma experiences, which relate to the inability to cope with mental distress as well as to perform expected job- and family-related roles. The concept of mental illness stigma describes a process that involves labeling, stereotypes, separation, loss of status, and discrimination ( 21 , 22 ). Two forms of stigma may be of relevance to our findings: public stigma, which involves processes that represent stereotypes, prejudice and discrimination among members of the general public (e.g., “all men with depression are weak and unmanly”) and self-stigmatization, where people with mental illness agree with negative stereotypes and turn them against themselves (e.g., “I am a man with depression and need help, so I must be weak”). Men with depressive symptoms may avoid treatment in order not to be labeled “mentally ill” or “unmanly” by others, and self-stigmatization or shame can undermine motivation to seek help ( 23 ). However, while much of the literature shows how masculinity creates stigma around men seeking help for depression, our findings may provide insight into how men were able to cope with stigma experiences by accessing (mental) health services. Analysis of our findings underlined the role of peer support, especially in men-only groups, which allowed men to disclose weaknesses without being questioned by others.

GPs Role in Men's Help-Seeking Decisions

Some interviewees indicated negative experiences in seeking GPs' help for depression, whereas other participants pointed out the importance of GPs as gateways to mental health services. This discrepancy is in line with results from a qualitative study that identified positive factors that may assist men's help-seeking decisions ( 8 ). These findings suggest that men consulted a GP prior to counseling, which led to both negative and positive experiences. For some interviewees, the GP provided immediate assistance, while others reported the initial consultation as being a deterrent ( 8 ) to further help-seeking. Previous studies have identified a number of reasons for men's varying experiences when consulting a GP. Findings also referred to GPs' diagnostic errors in evaluating symptoms of depression in men, which can also lead to differing diagnoses ( 24 ). Others pointed out time restrictions that undermine GPs' capacity to effectively diagnose and treat depression ( 25 ). However, findings across different studies have been inconsistent, with previous research also finding that men emphasized GPs' supportive role and stressed that a positive relationship between patient and GP facilitates mental health service use ( 26 ). Therefore, more in-depth education of GPs in terms of handling psychosocial issues in their male patients in particular is recommended. Moreover, results indicate that some male GPs tended to play down symptoms of depression and primarily recommended reducing occupational stress making it more difficult for patients to seek help. In order to reduce this factor impairing the patients' ability to seek help, health professionals should be trained to reflect their own gender stereotypes, e.g., by participating in advanced gender trainings.

Transformation of Attitudes During Recovery Processes

Contrary to the power of traditional masculine norms as an obstacle to seeking help, our findings indicate a change of attitudes toward service use during the participants' recovery processes. Our qualitative analysis pinpointed a critical stance toward masculine norms as well as a salutogenic perspective on depressive illness and service use experiences among interviewees after seeking help. In contrast to the assumption that psychiatric service use contradicts masculinity ( 27 ), our results show that depression and service use were retrospectively perceived as a resource to assist in changing harmful attitudes, e.g., toward internalized maladaptive work patterns. This is in line with recent systematic reviews of studies on the role of masculinity in men's mental health service use ( 4 , 7 ). Qualitative studies have also explored the characteristics of positive attitudes during and after the mental help-seeking process ( 28 , 29 ). Research has found that men developed positive coping strategies after utilizing mental health services by gaining a greater personal awareness during the recovery process. These strategies provided a new perspective on their situation, and they stopped striving for perfection in work and life ( 13 ). Alongside the hypothesis of a transformation of attitudes toward maladaptive work patterns among men with depression, our findings could also be discussed in the light of changing attitudes toward work in the general population. Results of a study about work values across generations suggests that workers from the generation of traditionalists placed more importance on status and autonomy than baby boomers or Generation X workers ( 30 ).

Limitations and Future Research

Because study participants had used mental health care services prior to the study, results only refer to participants who had successfully sought help. Therefore, our findings are not able to explain reasoning processes in men who have never sought help for mental health problems. Another limitation is the small sample size as well as participants' high age (mean = 52), which means it is not possible to reveal age-related differences in help-seeking attitudes and behavior. However, there may be variances of dealing with depression in the light of society's expectations, e.g., relating to the male “breadwinner” role. Alongside the need for age-differentiated analyses, future studies could focus on fathers with depression to explore the meaning of fatherhood for coping with depression. While most of the reviewed literature demonstrated how masculine norms create barriers in seeking help for depression, more evidence on preferred types of service use is needed, e.g., in terms of the role of GPs as a potential point of contact for further information about mental health services. Furthermore, other findings suggest that the educational level is associated with the rigidity of gender roles, i.e., that a low level of education corresponds to rigid gender roles. Future research could focus on differences between milieus and along socio-demographic factors (i.e., education) to examine these hypotheses. Finally, our results show that it would be of great interest to conduct quantitative studies examining mental health needs among men with depression in a broader population. Although our study did not reveal any impact of socioeconomic status (SES) to masculinity orientations and service use behavior quantitative studies should include measurement of SES.

Implications for Improving Help-Seeking Among Men With Depression

Despite its limitations, our study calls for interventions to improve help-seeking among men with depression. Findings highlight the need to consider perceived discrimination against men with depression. Interventions to reduce the stigma of being “unmanly” and to improve men's capacity to cope with being unable to work should be developed. Peer-led men-only groups may increase participants' self-esteem and assist in disclosing weaknesses. In the context of GPs' mediating role, training for health professionals concerning the impact of masculine norms on mental health is recommended. GPs competent in recognizing depressive symptoms may be able to play a key role in helping men by acting as a mediator for further psychiatric services. Finally, public campaigns are needed to change society's negative view of mental illnesses, help-seeking and service use among men as well as women with depression. One example approach that could be used to target the male population is the “ Real Men. Real Depression.” campaign that aimed to increase public awareness and help other men recognize depression ( 31 ).

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s.

Ethics Statement

The studies involving human participants were reviewed and approved by the ethics committee of Ulm University, Germany (Ref. Nr. 202/15). The patients/participants provided their written informed consent to participate in this study.

Author Contributions

SK, RK, HG, TB, and PB proposed the project idea. SK supervised the project. KF, MP, MSc, HG, and PB helped with participant recruitment. TS, AM-S, MSt, and SK undertook literature research and conducted and analyzed the interviews. TS drafted the manuscript. All authors contributed to and approved the final manuscript.

This work was supported by the German Research Foundation under Grant No. 288917560.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We are grateful to clinical providers for their support with participant recruitment as well as to all participants.

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Keywords: masculinity, depression, help-seeking, service use, qualitative study

Citation: Staiger T, Stiawa M, Mueller-Stierlin AS, Kilian R, Beschoner P, Gündel H, Becker T, Frasch K, Panzirsch M, Schmauß M and Krumm S (2020) Masculinity and Help-Seeking Among Men With Depression: A Qualitative Study. Front. Psychiatry 11:599039. doi: 10.3389/fpsyt.2020.599039

Received: 26 August 2020; Accepted: 29 October 2020; Published: 24 November 2020.

Reviewed by:

Copyright © 2020 Staiger, Stiawa, Mueller-Stierlin, Kilian, Beschoner, Gündel, Becker, Frasch, Panzirsch, Schmauß and Krumm. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Tobias Staiger, tobias.staiger@dhbw-vs.de

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Help-seeking for mental health concerns: review of Indian research and emergent insights

Journal of Health Research

ISSN : 2586-940X

Article publication date: 10 March 2021

Issue publication date: 27 April 2022

The purpose of this review was to examine Indian research on help-seeking for mental health problems in adults.

Design/methodology/approach

Original Indian research studies on help-seeking for mental health, published from the year 2001−2019 were searched on PubMed, EBSCO, ProQuest and OVID using a set of relevant keywords. After applying exclusion criteria, 52 relevant research studies were identified.

The reviewed studies spanned a variety of themes such as barriers and facilitators to help-seeking, sources of help-seeking, causal attributions as well as other correlates of help-seeking, process of help-seeking and interventions to increase help-seeking. The majority of these studies were carried out in general community samples or treatment-seeking samples. Very few studies incorporated non-treatment seeking distressed samples. There is a severe dearth of studies on interventions to improve help-seeking. Studies indicate multiple barriers to seeking professional help and highlight that mere knowledge about illness and availability of professional services may be insufficient to minimize delays in professional help-seeking.

Originality/value

Help-seeking in the Indian context is often a family-based decision-making process. Multi-pronged help-seeking interventions that include components aimed at reducing barriers experienced by non-treatment seeking distressed persons and empowering informal support providers with knowledge and skills for encouraging professional help-seeking in their significant others may be useful.

• Help-seeking
• Help-seeking intervention
• Mental health

Sanghvi, P.B. and Mehrotra, S. (2022), "Help-seeking for mental health concerns: review of Indian research and emergent insights", Journal of Health Research , Vol. 36 No. 3, pp. 428-441. https://doi.org/10.1108/JHR-02-2020-0040

Emerald Publishing Limited

Copyright © 2021, Prachi Bhavesh Sanghvi and Seema Mehrotra

Published in Journal of Health Research . Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Introduction

Despite the availability of evidence-based cost-effective interventions, the treatment gap for mental disorders is very high, leading to increased burden and disability. The widespread treatment gap has been attributed to various demand- and supply-related barriers. According to the National Mental Health Survey 2015–16 conducted in India, the main demand-side barriers consisted of low help-seeking inclination, low perceived need, inadequate awareness and socio-cultural beliefs and stigma, whereas, the supply-side barriers included inadequate, unevenly disseminated and inefficiently used resources [ 1 ]. In the past, the focus on increasing access to mental health care to reduce the treatment gap has been more on the supply-side, while the demand-side factors, such as help-seeking inclinations and behaviors have been given less important due to their complex nature [ 2 ].

In the context of mental health, help-seeking has been defined as, “an adaptive coping process that is the attempt to obtain external assistance to deal with a mental health concern” [ 3 ]. Appropriate help-seeking has the potential to reduce psychological distress and improve mental health [ 4 ]. It involves communication with various help-seeking sources including professional ones to understand, seek advice, inform, treat and support for one’s disturbing life events [ 5 ]. Various theories have been introduced to understand help-seeking. The health-belief model [ 6 ] helps to understand how beliefs about health problems explain health-related behaviors. The theory of planned behavior [ 7 ] suggests that behavior is influenced by the intention to perform which is in turn dependent on one’s attitude toward the behavior, perceived subjective norms and behavior control. Cramer’s help-seeking model [ 8 ] proposed that help-seeking behavior is associated with attitudes toward seeking counseling in addition to factors such as social support, level of distress and the tendency toward concealing personally distressing information. While there are several generic models of help-seeking, a few have focused on youth, and the factors likely to be of the highest relevance in this segment of the population [ 9, 10 ]. Across theories, attitudes toward seeking help and perceived norms regarding help-seeking in one’s community or peers emerge as some of the most common factors that influence help-seeking intention and behaviors.

Among the empirical studies conducted across the globe on help-seeking, a high prevalence and wide treatment gap for common mental health problems have been noted [ 11 ] along with negative attitudes and low inclination to seek professional help [ 12 ]. Among those who do seek help, informal sources are preferred more than the professionals [ 13 ]. Systematic reviews have identified cognitive, affective and structural barriers that hinder professional help-seeking [ 14 ]. The facilitators of help-seeking identified in various studies include mental health literacy, positive past experiences, social support and encouragement from significant others in the help-seeking process [ 15 ]. Interventions have been developed to reduce these barriers to help-seeking and increase the uptake of health services, using various health behavior models including those specific to mental health-related help-seeking. These focus on changing help-seeking attitudes, inclinations and behaviors. Interventions targeted at behavior change have been most successful in altering health behavior [ 16 ]. Examples of help-seeking interventions include mental health literacy and de-stigmatization programs [ 17 ], screening and linkage [ 18 ], contact with the researcher and gatekeeper and peer training [ 19 ] among others. Both universal and targeted interventions have been tried out. Universal interventions directed at everyone in a given population have not shown consistent improvements in help-seeking behaviors. Therefore, the need to take into consideration those populations which are at risk or are already suffering from mental health problems (targeted interventions) has been highlighted [ 15 ].

This study aimed to provide a review of Indian research on the factors and processes related to help-seeking for mental health problems in adults, utilization and experiences of services during the help-seeking process as well as interventions that aim to enhance professional help-seeking for mental health issues in the Indian context.

Methodology

The databases used to search for studies included PubMed, EBSCO, ProQuest and OVID. Google Scholar was used as a supplementary tool to aid the search. The search was initially carried out in March 2019 using the following combination of keywords: “Help-seeking AND mental AND India; Help-seeking AND Inclination AND India; Mental Health AND Help-seeking AND India; Help-seeking AND Intervention AND India,” anywhere in the text from 2001 to 2019. Only those studies focusing on original research articles that assessed or documented help-seeking variables (e.g. attitude, inclination, behaviors, pattern, pathways, process, facilitators and barriers) in the adult samples were included. The following types of articles were excluded: general and conceptual articles, editorials, letters to the editor, review articles, case studies, monographs, commentaries, poster presentations and research proposals. The studies that did not assess mental health-related help-seeking and studies using non-Indian samples were also excluded. A repeat search was also subsequently carried out in March 2020 for additional articles published between March and December 2019. After applying exclusion criteria and removal of duplicate studies, 52 relevant primary research studies were identified ( Figure 1 ). The studies during the review period spanned a variety of themes related to help-seeking such as barriers and facilitators to help-seeking, sources of help-seeking, causal attributions for mental illness as well as other correlates to help-seeking, the process of help-seeking, service utilization and interventions to increase help-seeking. The following sections present the summary findings from these studies. The sections have been organized based on the nature of the target population focused upon studies on general community samples, treatment-seeking samples and those on non-treatment seeking distressed samples. The last section summarizes the intervention studies on help-seeking in the Indian context. There is no ethical consideration for this review paper.

Studies on community samples

Various segments of the community population have been studied concerning help-seeking including college-going adolescents, medical students, community health workers and adults in the general community [ 20 – 23 ]. Several studies have highlighted poor identification of mental illness, even in young adults pursuing higher education. For example, only 15% of the college-going youth were able to identify depression correctly in a vignette when depressive symptoms were described as preceded by a negative life event. Thirty-three percent correctly identified depression only if it was not preceded by a negative life event [ 24 ]. Similarly, another study found that only 13% of medical students identified depression correctly [ 25 ]. Not being able to correctly identify the signs of depression indicates low mental health literacy leading to hesitation in seeking professional help. Also, not being able to identify depression correctly when preceded by a life event again points to the distress being normalized and being considered as a passing phase instead of a mental health condition, resulting in a delay in help-seeking.

The decision to seek professional help is likely to be influenced by perceived causal factors. Depressive symptoms preceded by negative life events may be normalized as a life event that would pass in due course and therefore not necessitate professional help [ 24 ]. Similarly, when mental illness is believed to be caused by black magic or evil spirits, this may lead to the belief that medical help would not be beneficial [ 26 ].

Barriers to professional help-seeking that delay early identification and treatment have been the focus of multiple studies. Some of the common barriers found across these community samples were negative attitudes and poor knowledge of mental health, social- and self-stigma, confidentiality concerns, misconceptions and perceived ineffectiveness of mental health services, apprehension of unwanted intervention, lack of time and finances, worries about risking a future in academics by seeking professional help and lack of availability of mental health services in the vicinity [ 18 , 21 – 24 , 27 ]. Beliefs about the causal factors and barriers to professional help-seeking may lead to a preference for informal sources of help like family and faith healers for conditions such as depression and schizophrenia and to consider professional consultation only if traditional healing did not improve the condition [ 17 , 21 – 24 ].

A few studies have also reported enabling factors for higher inclination to seek professional help. Parasocial interaction has been considered as a facilitator with regard to intentions and efficacy perceptions to seek professional help [ 20 ]. Parasocial interaction refers to “an illusion of a ‘face-to-face’ relationship with a media celebrity where the conditions of response to the performer are similar to those in a primary group” [ 28 ]. Individuals also report preferring professional help if they felt out of control [ 29 ] or if the problem was correctly identified as a mental health condition when symptoms were not preceded by a negative life event [ 24 ]. In a study that elicited perceptions of the participants themselves on improving help-seeking, members of a rural community recommended creating awareness regarding mental illness and the need to receive support and treatment through the use of social networking and group meetings, door-to-door campaigns and involvement of various stakeholders in the treatment process [ 30 ].

To summarize, the studies on community samples highlight the role of poor mental health literacy, perceived causal attributions, barriers and facilitators of professional help-seeking and the preference for informal sources to seek help for mental health concerns.

Studies on treatment-seeking samples

This section consists of studies on individuals and their caregivers who were already seeking mental health services. These studies have been mostly conducted among newly registered patients with various psychiatric disorders and their caregivers. Several of these were conducted in tertiary care settings and mainly on persons with severe mental illnesses (SMIs). The average duration of an untreated illness varied widely, e.g. from 21 days for bipolar disorder-I (BPD-I) [ 31 ] to two years for Dhat syndrome [ 32 ]. For psychoses, it ranged from six months to around four years [ 33, 34 ]. These data highlight variable levels of delays in help-seeking across mental health conditions.

Delay in help-seeking as a variable was extensively examined in a study among persons with psychosis and their caregivers [ 35 ]. The authors categorized the reasons into (1) illness-related (stigma, poor awareness, attributions to supernatural and physical causes); (2) patient-related (pre-morbid personality, negative symptoms, significant life events, poor insight, uncooperativeness and impaired functioning); (3) treatment-related (poor knowledge of general practitioners about the disorders, delayed referrals and misconceptions regarding medication side-effects) and (4) family-related (shared societal beliefs, magico-religious attributions, cultural and financial restraints and poor social support). Some of these factors have also been noted in other studies [ 36 ].

The utilization of mental health services has been linked not just to patients’ but also to caregivers’ causal attributions. In almost all the studies reviewed, patients and their caregivers reported a combination of psychological, biological and sociocultural factors as perceived causation of mental illness [ 37 ]. Attribution to supernatural forces or patient’s traits was commonly seen in cases of SMIs among individuals from lower socioeconomic statuses [ 38 ], rural background and lower education [ 39 ]. Choosing traditional or faith healers as the first contact to seek help were noted across several studies that mainly sampled persons with SMIs or their caregivers and rural backgrounds [ 32 , 35 – 37 , 40 ]. These causal attributions were culturally meaningful and seemed to propel help-seeking from non-professional sources, delayed identification and timely management of SMIs.

In cases of BPD-I [ 31 ] and neurotic disorders [ 41, 42 ], patients and caregivers emphasized external or biopsychosocial factors as causal attributions and were likely to seek help from sources such as general practitioners or psychiatric services. Also, a significant proportion of patients and their caregivers hailing from an urban background and having formal education up to intermediate level and higher reported psychiatrists as their first contact for treatment [ 43 – 47 ]. This shows that awareness about the causality as well as treatment options for mental illnesses and sociodemographic factors play an important role in the decision-making process for help-seeking. This decision is also heavily influenced by significant others. Studies have shown that recommendations to seek help mostly came from relatives or friends ranging from 26% to 87% [ 31 , 42 , 46 – 48 ] or other patients and their families [ 45, 49 ]. The reasons related to preference for a particular source ranged from the ease of accessibility, causal match, belief in a particular medicine system, the reputation of the source, recommendations from significant others, time given for consultation and awareness about the appropriateness of a treatment to cost and distance factors [ 45, 46, 48, 50 ]. Although some patients and caregivers had less conviction in faith healing, initial help was still sought from these sources owing to their significant others’ wishes and fear of stigma and isolation in their society. This highlights that help-seeking is not a purely individual decision, but is often a shared decision or a decision influenced by the perspectives of significant others [ 43 ].

Past professional help-seeking was negatively linked to illness-related stigma, whereas previous informal help-seeking was positively related. Informal help-seeking signaled an unwillingness to disclose symptoms of the illness, whereas positive encounters during professional help-seeking were likely to reduce such hesitations [ 51 ]. Similarly, stigma interfered significantly with the treatment and utilization of the available facilities [ 48, 52 ]. On the other hand, support from family and well-wishers proved beneficial in sustaining engagement with professional help-seeking [ 53 ]. Education of the decision-maker significantly influenced help-seeking behaviors [ 54 ]. Patients and caregivers having higher awareness about mental illness sought help from mental health professionals sooner, whereas, those with lower awareness contacted faith healers first [ 49 ].

Persons with schizophrenia who believed in supernatural explanations of the illness had poor insight, whereas those with an awareness of the consequences of illness showed higher levels of insight and early help-seeking. A pattern suggesting self-serving bias and the role of stigma was also observed in this sample, wherein the hypothetical person in the vignette was readily recognized as suffering from a mental illness, but such identification was rarely used by patients for themselves [ 55 ]. The reviewed studies indicate that when faith healing did not provide any improvement or provided only short-term improvement, patients and their caregivers progressed to medical management as a last resort [ 37, 39, 48 ]. On an average, two to four transitions from one source to another ensued before finally reaching a mental health professional [ 32, 47, 50 ]. On ultimately reaching the tertiary care setup, patients and their caregivers reported being satisfied with the illness-related information and with the management of symptoms [ 36 ]. Treatment was continued for a longer duration with more visits than other sources of help [ 46 ]. Caregivers experienced a wide range of feelings from despair, frustration, lost opportunities and loneliness to hope of recovery and fear of the future while seeking professional help. They also had expectations for understanding and acceptance of their situation from their community. They helped others by guiding them into treatments by mental health professionals, expressed interest in increasing awareness and reducing stigma related to mental illness [ 38 ]. However, the continuation of faith healing alongside medical treatment has also been noted in a few studies highlighting the significance of culturally approved ways of dealing with mental illness [ 31, 56 ]. Despite availability of mental health services and awareness about the same, urban context and higher education levels, sources of help other than mental health services may be initially chosen due to multiple factors such as apprehensions and misconceptions about treatment as well as stigma [ 39, 47 ].

In sum, there is an abundance of studies on treatment-seeking samples that have examined variables such as duration of untreated illness, reasons for the delay in help-seeking, causal attributions associated with different sources of help, pathways to psychiatric care, factors influencing help-seeking behaviors and caregiving experiences. Recommendation of significant others plays an important role in help-seeking often resulting in a shared decision-making process. Furthermore, the review reiterates that pathways to care are complex and multifaceted without a fixed direction [ 49 ].

Studies on non-treatment seeking distressed samples

There is a dearth of studies conducted exclusively on non-treatment seeking distressed individuals in the community. However, the majority of the studies in this section have identified a sub-sample of distressed participants using screening or diagnostic instruments for conditions like problem alcohol use [ 57 ], suicidality [ 58 ], depression [ 59, 60 ], severe and stress or distress [ 61, 62 ]. These studies have used diverse samples such as adults in the general community, college-going youth, or trainee resident doctors and identified a significant proportion of their sampled participants with elevated levels of distress/symptoms.

Experience of subjective distress may not go hand-in-hand with the identification of the same as a mental health concern as noted in the previous section. Similarly, elevated symptoms/distress does not necessarily result in professional help-seeking. As part of the National Mental Health Survey, a 91% treatment gap was found for mental health conditions in the community sample of Madhya Pradesh [ 50 ]. Out of approximately 60% of pre-university students who reported significant emotional problems, only 3 to 9% had undertaken professional consultation [ 58 ]. Also, a few studies highlight that even when professional services are accessed, this may not necessarily reflect access to all kinds of interventions. For example, those who were screened positive for depression, 79% had visited either a private or a government general medical practitioner in the past three months. But, only 3.3% were prescribed medications and none of them were offered counseling or psychotherapy [ 59 ]. Similarly, a World Health Organization-World Mental Health (WHO-WMH) survey found that only 17% from lower middle-income countries including India received treatment for suicidality mostly from general practitioners (22%), followed by a psychiatrist (15%) [ 63 ].

Among 25% of the pre-university students who reported suicidal ideation or attempts in the past three months, only 13% expressed a need for seeking help and only a minimal proportion had sought professional help [ 58 ]. Even though around half of the stressed trainee medical residents felt the need to consult a mental health professional, only 13% did so indicating a large disparity [ 62 ]. Similar results were obtained in other studies [ 60 ]. This demonstrates that recognition of a mental health concern alone is not enough to seek help and even when the need is high, individuals may not seek professional help. Instead, their preferences may often center around informal sources like friends [ 61, 62 ].

Various internal and external barriers to help-seeking in distressed non-treatment seeking sub-samples have been observed in these studies. For example, although students with moderate to severe self-reported depression had a higher need for psychological help, they were least likely to do so due to stigma-related beliefs. They believed that help-seeking would imply inadequacy to deal with stress, inadequate coping and reflect poorly on one’s intelligence [ 60 ]. Similarly, the stigma of being labeled as mentally ill, being perceived as weak among peers and a lack of time were also found to be some of the barriers to seeking professional help among trainee resident doctors [ 62 ]. Most of the problem alcohol users reported shame (27%) and perceived ineffectiveness of treatment (23%) as barriers for not seeking professional help [ 57 ]. In another study, among suicidal individuals who had not sought treatment, stigma was not found to be an important barrier (7%). Instead, it was a low perceived need (58%), followed by a preference for self-reliance (40%) and financial constraints (15%) [ 63 ].

In a large-scale study to understand the barriers to mental health treatment, WHO-WMH surveys were conducted in 24 countries including India, where household representative samples were recruited ( N  = 2992). Barriers were analyzed separately in a sub-sample of participants who acknowledged the need for treatment based on the severity of the problem. Women, young and middle-aged adults with moderate-to-severe disorders had a higher likelihood of acknowledging the need for treatment as well as reported more structural barriers to seeking help. Among persons with mild-to-moderate severity, the low perceived need for treatment was the commonest barrier followed by attitudinal barriers. Self-reliance was another important barrier identified among those who recognized a need for treatment. Structural barriers and negative experiences with the professionals played a key role in persons with severe problems. The most common reasons for drop-out from professional services included perceived ineffectiveness of treatment and negative experiences with treatment providers [ 64 ]. Negative experiences with healthcare providers, exorbitant costs of services in private settings, loss of hope and resultant discontinuation of help-seeking have also been described in another study among persons with disabling mental stress in rural Uttar Pradesh [ 65 ].

In a nutshell, studies focusing solely on non-treatment seeking distressed samples are scarce. The available studies have focused on the treatment gap along with the needs and barriers to seeking professional help.

Interventions promoting help-seeking

While there are multiple studies on help-seeking processes and related factors, only a handful of Indian studies have described the development or evaluation of interventions to improve help-seeking inclinations and/or behaviors for mental health concerns (help-seeking interventions). For instance, the impact of a 24-h telephonic helpline set up by the psychiatry department in a government medical college hospital in delivering mental health care for the prevention of suicide was examined in a study [ 66 ]. Almost 73% of the callers had not contacted any kind of mental health service earlier. They were unaware if they had any mental illness, where to seek treatment and if the disorder was treatable. Interventions carried out by the helpline varied based on the need in a given case ranging from counseling, referral to psychiatric outpatient services, other healthcare facility or crisis intervention team and hospital admissions to home visits. Only 16% of the callers who were referred to psychiatric outpatient services visited the concerned department for consultation.

Another study examined the effects of a structured educational intervention on explanatory models of illness and help-seeking behavior among family members of patients with schizophrenia using a randomized controlled design [ 67 ]. The baseline assessment elucidated that the relatives of patients held multiple, diverse and contradictory explanatory models of the illness. The intervention explored participants’ explanations for illness, provided psychoeducation without challenging the indigenous beliefs and focused on coping methods. At a two-week follow-up, some reduction in non-medical explanations was seen in the intervention group as compared to the control; however, several indigenous beliefs models persisted.

Systematic medical appraisal referral and treatment mental health project provided mental health care for common mental disorders in a rural community of Andhra Pradesh. It employed a task-shifting approach through training accredited social health activists and primary healthcare center doctors for screening, diagnosis and management using an electronic decision support system and conducting an anti-stigma campaign to raise awareness for mental health and help-seeking which included printed information, education and communication materials, indirect social contact and a promotional video and drama. Indirect social contact and drama were found to be most helpful [ 68 ]. Information obtained through the intervention helped the participants to approach the activists, share their concerns and increased their perceived need for help-seeking [ 69 ]. Participants became aware of the available services and utilization increased from 0.8% to 12.6%. Mobile-based technology for mental health service delivery using government resources was found to be feasible [ 70 ]. The longitudinal assessment showed improvement in knowledge, attitude and behaviors related to mental health along with a tenfold drop in perception of stigma related to help-seeking and service use [ 71 ].

Similarly, VISHRAM (the Vidarbha Stress and Health ProgRAM), a multi-component grass-root community-based mental health program was developed to tackle risk factors for suicide and increase contact coverage for depression among rural community members by improving mental health literacy and increasing the provision of evidence-based interventions by community workers and lay counselors and teaming up with the general practitioners and psychiatrists. There was a significant increase in mental health literacy and help-seeking inclination post-intervention and contact coverage increased from 4.3% to 27.2% [ 72 ].

A handful of studies conducted on help-seeking interventions have shown that significant improvement could be achieved in knowledge, attitude and behaviors related to help-seeking and utilization of services along with a reduction in perceived barriers and stigma. However, there is a need for more studies in this area.

Implications

There is a need for large-scale studies, particularly on samples of distressed non-treatment seekers from varied backgrounds that comprehensively assess the role of various barriers to help-seeking and examine mediators and moderators in the professional help-seeking process. There is a need for further studies that can help in a systematic examination of any differences in factors related to help-seeking between different psychiatric disorders as well as between psychiatric disorders and non-communicable diseases in general. Findings from such studies can provide important leads for fine-tuning the interventions to promote help-seeking for various disorders. There have been very few studies in India that have explored preferences for medical and psychological interventions for various common mental disorders. The paucity of studies on interventions to improve help-seeking inclinations and behaviors highlights that addressing demand-side barriers requires as much attention as managing supply-side barriers for reducing the treatment gap for mental health problems in the Indian context.

Less than a handful of studies have demonstrated the potential utility of integrating technology in healthcare delivery systems, but its role in improving help-seeking remains to be sufficiently explored. The available studies on correlates of help-seeking also provide several leads in developing help-seeking interventions. There is a need for developing and testing the utility of help-seeking intervention components that target and enable informal sources of support such as family and friends and equip them with knowledge and skills to motivate professional help-seeking to someone in their family or social circle as and when appropriate. Rather than a mere focus on improving knowledge and attitudes toward mental illnesses, an emphasis on the complementary roles of informal and formal sources of support may be helpful during mass campaigns. Multi-pronged help-seeking interventions that are theoretically grounded and address awareness and attitudinal shifts in the larger community while simultaneously targeting distressed non-treatment seekers, and their significant others can aid in negotiating barriers to appropriate help-seeking and go a long way in addressing the mental health treatment gap.

While there are several Indian studies on variables related to help-seeking, most of these pertain to individuals who are currently utilizing professional help (treatment seekers) or to general community samples. Fewer studies have focused on distressed persons in the community who are not availing professional services for their mental health concerns. Among the studies on treatment-seeking samples, severe mental illnesses have been taken into consideration. There is a serious dearth of Indian studies on interventions to improve help-seeking. Studies across sections reveal that help-seeking is a complex process, influenced by multiple interacting factors ranging from education, socioeconomic status and background, to perceived causal attributions, beliefs related to treatment effectiveness along with a preference for self-reliance and informal sources, perceptions of the severity of one’s problem and perceived social consequences of seeking professional help. Such factors are in addition to instrumental barriers such as cost and ease of access. Across studies, it repeatedly emerges that mere knowledge about the illness and availability of professional services is insufficient to minimize the delays in professional help-seeking. Moreover, the review suggests that the help-seeking often involves a shared family-based decision-making process or that the process of help-seeking is often influenced by the recommendations of one’s social networks [ 47 ]. This seems to be a reflection of a predominantly collectivistic orientation that characterizes the Indian culture and places a higher value on interdependence and social harmony [ 73 ]. These patterns are in line with the previous observations that cultural differences in professional help-seeking exist and may be partially mediated by the use of support-seeking among close others that are prominent in more collectivistic cultures [ 74 ]. The review has highlighted several implications for further studies in India on interventions to promote help-seeking and thereby reducing the treatment gap for psychiatric disorders.

Conflict of Interest: None

Study selection flow diagram

1 Gururaj G , Varghese M , Benegal V , Rao GN , Pathak K , Singh LK , et al. National mental health survey of India, 2015-16: prevalence, pattern and outcomes . Bengaluru : National Institute of Mental Health and Neuro Sciences ; 2016 .

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36 Hossien SA , Loganathan S , Kolar Sridara Murthy M , Palanimuthu Thangaraju S , Bharath S , Varghese M . Pathways to care among persons with dementia: study from a tertiary care center . Asian J Psychiatr . 2017 ; 30 : 59 - 64 . doi: 10.1016/j.ajp.2017.07.002 .

37 Cohen A , Padmavati R , Hibben M , Oyewusi S , John S , Esan O , et al. Concepts of madness in diverse settings: a qualitative study from the INTREPID project . BMC Psychiatry . 2016 ; 16 ( 1 ): 388 . doi: 10.1186/s12888-016-1090-4 .

38 Dijkxhoorn MA , Padmakar A , Jude N , Bunders J , Regeer B . Understanding caregiver burden from a long-term perspective: the Banyan model of caregiver experiences . Perspect Psychiatr Care . 2019 ; 55 ( 1 ): 61 - 71 . doi: 10.1111/ppc.12299 .

39 Naik SK , Pattanayak S , Gupta CS , Pattanayak RD . Help-seeking behaviors among caregivers of schizophrenia and other psychotic patients: a hospital-based study in two geographically and culturally distinct Indian cities . Indian J Psychol Med . 2012 ; 34 ( 4 ): 338 - 45 . doi: 10.4103/0253-7176.108214 .

40 Kumar V , Kiran M . Pathways of psychiatric treatmentin rural patients with psychosis . East J Psychiatry . 2019 ; 22 : 11 - 24 .

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42 Hashimoto N , Fujisawa D , Giasuddin NA , Kenchaiah BK , Narmandakh A , Dugerragchaa K , et al. Pathways to mental health care in Bangladesh, India, Japan, Mongolia, and Nepal . Asia-Pacific J Public Heal . 2015 ; 27 ( 2 ): NP1847 - 57 .

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45 Behari M , Gupta DK , Singh V , Verma K , Sengupta S , Sidana R , et al. Help seeking behaviour and pathways to care among patients seeking care at a community mental health clinic and psychiatry outpatient department of a medical college: a study from North Rajasthan . J Ment Health Hum Behav . 2013 ; 18 ( 1 ): 18 - 33 .

46 Mishra N , Nagpal SS , Chadda RK , Sood M . Help-seeking behavior of patients with mental health problems visiting a tertiary care center in north India . Indian J Psychiatry . 2011 ; 53 ( 3 ): 234 - 8 . doi: 10.4103/0019-5545.86814 .

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50 Kokane A , Pakhare A , Gururaj G , Varghese M , Benegal V , Rao GN , et al. Mental health issues in Madhya Pradesh: insights from national mental health survey of India 2016 . Healthcare (Basel) . 2019 ; 7 ( 2 ): 53 . doi: 10.3390/healthcare7020053 .

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52 Chadda RK , Agarwal V , Singh MC , Raheja D . Help seeking behaviour of psychiatric patients before seeking care at a mental hospital . Int J Soc Psychiatry . 2001 ; 47 ( 4 ): 71 - 8 . doi: 10.1177/002076400104700406 .

53 Yamarthi P , Kannuri NK . Enabling factors for behavior change among people with alcohol dependency: an exploratory study in a mental health-care facility . Indian J Public Health . 2019 ; 63 ( 3 ): 233 - 8 . doi: 10.4103/ijph.IJPH_364_18 .

54 Upadhyaya SK , Raval CM , Sharma DK . The sociocultural factors and patterns of help-seeking among patients with mental illness in the sub-Himalayan region . Ind Psychiatry J . 2018 ; 27 ( 2 ): 279 - 84 . doi: 10.4103/ipj.ipj_95_14 .

55 Saravanan B , Jacob KS , Johnson S , Prince M , Bhugra D , David AS . Assessing insight in schizophrenia: East meets West . Br J Psychiatry . 2007 ; 190 : 243 - 7 . doi: 10.1192/bjp.bp.106.029363 .

56 Housen T , Ara S , Shah A , Shah S , Lenglet A , Pintaldi G . Dua Ti Dawa Ti: understanding psychological distress in the ten districts of the Kashmir Valley and community mental health service needs . Confl Health . 2019 ; 13 : 59 . doi: 10.1186/s13031-019-0243-8 .

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58 Bhola P , Rekha DP , Sathyanarayanan V , Daniel S , Thomas T . Self-reported suicidality and its predictors among adolescents from a pre-university college in Bangalore, India . Asian J Psychiatr . 2014 ; 7 ( 1 ): 38 - 45 . doi: 10.1016/j.ajp.2013.10.003 .

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60 Vankar JR , Prabhakaran A , Sharma H . Depression and stigma in medical students at a private medical college . Indian J Psychol Med . 2014 ; 36 ( 3 ): 246 - 54 . doi: 10.4103/0253-7176.135372 .

61 Fathima M . Help seeking for psychological distress and its correlates in college going youth . Bangalore : National Institute of Mental Health and Neuro Sciences ; 2017 .

62 Grover S , Dua D , Shouan A , Nehra R , Avasthi A . Perceived stress and barriers to seeking help from mental health professionals among trainee doctors at a tertiary care centre in North India . Asian J Psychiatr . 2019 ; 39 : 143 - 9 . doi: 10.1016/j.ajp.2018.12.020 .

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65 Mathias K , Jacob KS , Shukla A . “We sold the buffalo to pay for a brain scan” - a qualitative study of rural experiences with private mental healthcare providers in Uttar Pradesh, India . Indian J Med Ethics . 2019 ; 4 ( 4 ): 282 - 7 . doi: 10.20529/IJME.2019.057 .

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68 Maulik PK , Devarapalli S , Kallakuri S , Tewari A , Chilappagari S , Koschorke M , et al. Evaluation of an anti-stigma campaign related to common mental disorders in rural India: a mixed methods approach . Psychol Med . 2017 ; 47 ( 3 ): 565 - 75 . doi: 10.1017/S0033291716002804 .

69 Tewari A , Kallakuri S , Devarapalli S , Jha V , Patel A , Maulik PK . Process evaluation of the systematic medical appraisal, referral and treatment (SMART) mental health project in rural India . BMC Psychiatry . 2017 ; 17 ( 1 ): 385 . doi: 10.1186/s12888-017-1525-6 .

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Acknowledgements

The author gratefully acknowledges support from the Indian Council of Medical Research, Delhi, India for the fellowship support for her doctoral research on help-seeking among young adults.

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Mohave County asking for help solving 1979 murder of Yellow Pages heiress

The Mohave County Sheriff's Office is asking for help solving a decades-old Arizona cold case. A woman, now being called the Yellow Pages heiress, was found dead off a highway in Mohave County back in 1979. The lead investigator sat down with ABC15 Wednesday to share how people can help as they work to solve the mystery.

The case of Marion Berry Ouma is full of unexpected twists that all began on January 3, 1979.

"Hoover Dam security thought they saw something, you know, off on the embankment," said Mohave County Sheriff's Office Investigator Lori Miller.

The 25-year-old, identified as Marion Berry Fox Ouma, was found off Highway 93. Ouma had been shot multiple times and was originally known as "New Year's Nancy." It would be years until investigators would find out Ouma's identity.

"Until a private investigator from Ohio, where the family's from, put two and two together," said Miller.

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Pictures, fingerprints, and dental records were used to confirm Ouma's identity. Information led Mohave County detectives from Ohio to Las Vegas, where they learned Ouma had been renting an apartment at the Sierra Vista Apartments. She even withdrew money at a bank in Las Vegas, not far from those apartments, weeks before she was found dead in Arizona.

"She left her bank book there, and it was mailed back to the mother," said Miller. "And that's where the private investigator started his investigation."

But another twist in the case emerged after Ouma was identified. Her grandpa, Loren Berry, was the founder of "Yellow Pages" and passed away just after his granddaughter in 1980. After his death, Ouma would have been set to inherit $40 million.

ABC15 asked Miller if Ouma's family ties or money could have played a role in the case, but she doesn't believe it was a motive.

"If you looked at her, you certainly wouldn't know," said Miller. "I mean, she had sweatpants on and a shirt. I mean, she didn't conduct herself as an heiress."

Miller said there hasn't been any evidence of a ransom note or any way someone else could have tried to benefit monetarily.

Miller told ABC15 that before Ouma moved to Las Vegas, she got married while working with a program in Africa. According to her family, the marriage ended, and detectives confirmed her former husband stayed behind.

One major clue was called in about 24 hours after Ouma was found. A driver told law enforcement he and his wife were on that same highway early in the morning of January 3, when he noticed a specific car backed up to the guardrail.

"A powder blue 76 to 77 Chevy Blazer or Ford Bronco, with a hard top, and then with the chrome push bars, the oversized tires, the large antenna," described Miller.

The same driver also reported there was a rag over the front plate and no one standing by the car. But decades later, Miller needs new leads.

"Anything at this point that anybody could provide would be valuable," said Miller.

The Mohave County Sheriff’s Office posted this case to social media this week and spoke with ABC15 hoping to get help with the case.

"She deserves my time and my efforts to go out there and try to find somebody that might know something. That's why I'm here," said Miller.

Forty five years later, Miller hasn't given up help that someone will come forward with the information that will help solve this mystery.

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Kansas game wardens seek information in deer poaching case

WICHITA, Kan. (KWCH) - The Kansas Department of Wildlife and Parks is asking for the public’s help in an investigation involving the theft and shooting of a whitetail deer in Barber County Kansas.

On August 11, a local landowner reported a deer had been shot on his property and left.

Game wardens responded and found a large whitetail buck with its velvet antlers cut from the skull. The rest of the deer was left to waste.

Anyone who saw suspicious activity along HWY 281 north of Medicine Lodge between Aug 7-11, or if anyone has information regarding suspects or of those individuals in possession of these antlers is asked to call or text 620-770-9035 or call 1-877-426-3843(Operation Game Thief Hotline) or complete an online OGT form from the KDWP website below. You can remain anonymous.

Copyright 2024 KWCH. All rights reserved. To report a correction or typo, please email [email protected]

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Why I recommend the Line manager Induction Programme

Senior Finance Business Partner Marc Fitchett says the Line manager Induction Programme’s bite-size learning can be fitted into the busiest schedule.

Marc Fitchett, Department for Business and Trade

Marc Fitchett believes he’s got his dream job, thanks to the line managers he’s had since he joined the Civil Service five years ago. 

He started with a degree in chemical engineering, but soon realised that his heart was not in it and he wanted a different challenge. He applied to the Civil Service and was offered a job in the Ministry of Housing, Communities and Local Government (formerly  Department for Levelling Up, Housing and Communities). He arrived in Whitehall with the goal to contribute to positive change within the Homelessness and Rough Sleeping (HRS) Programme.

The impact of a great line manager

He was lucky to have a great line manager from his first day as an HEO, then rising to SEO and now Grade 7, heading up their Finance Division for HRS with his own team of seven. 

He said: “It was my first line manager that saw that I was ready to move on and encouraged me to look beyond the work that I was doing, to other opportunities to expand my knowledge and skills. He was hugely supportive and that advice gave me the confidence to really develop in roles that I loved.”

Marc has recently moved to the Department for Trade and Business. Because he has benefitted so directly from great line management he says he wants to foster great line management within the teams he leads. 

Benefits of the Line manager Induction Programme

That’s why he made a point of doing the Civil Service Line manager Induction Programme which helps new and developing managers better understand the requirements of their roles. 

It also provides a useful refresher for all line managers in how best to support their teams and is a valuable introduction to the new Line Management Standards .

“I found the programme really easy to access on Civil Service Learning,” said Marc.

“The bite-sized learning was easy to go through in your own time and come back to where you left. I was able to fit it in around my busy schedule and I’d really recommend for everyone to carve out a bit of their time to complete it. I’m going to recommend the training to all my team and then I’d like to look and compare our own management styles to understand how we can work together better. I think it’s important to do this and recognise differences and how you can all learn from each other”.

The two-hour course Civil Service Line manager Induction Programme can be completed in 20 minute chunks and participants can log out and return to complete it later. 

Marc said: “The best compliment that a line manager can have is a team member that loves what they do, who feels that their work is important, and that they are valued in the team and want to stay in it. Good line managers make all the difference. I want to be the best leader and manager for my team.”

Full details of the Line manager Induction Programme can be found here .

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F.D.A. Declines to Approve MDMA Therapy, Seeking More Study

The agency said there was insufficient data to allow the use of a treatment for PTSD that involves the drug known as Ecstasy.

By Andrew Jacobs

The Food and Drug Administration on Friday declined to approve MDMA-assisted therapy for the treatment of post-traumatic stress disorder, dealing a serious blow to the nascent field of psychedelic medicine and dashing the hopes of many Americans who are desperate for new treatments.

The F.D.A. said there was insufficient data to allow its use, and it asked the company seeking approval for the treatment, Lykos Therapeutics, to conduct an additional clinical trial to assess whether the drug, commonly known as Ecstasy or molly, would be safe and effective.

An additional clinical trial could add years, and millions of dollars, to the approval process.

If approved, MDMA would have become the first psychedelic compound to be regulated by federal health authorities. Supporters of psychedelic medicine were deeply disappointed, and some said they were stunned, having assumed the therapy’s promising data would overcome flaws in the company’s clinical trials, which had been designed in consultation with F.D.A. scientists.

“This is an earthquake for those in the field who thought F.D.A. approval would be a cinch,” said Michael Pollan, the best-selling author and co-founder of the UC Berkeley Center for the Science of Psychedelics . His book, “How to Change Your Mind,” helped catalyze public interest in the therapeutic potential of psychoactive compounds, demonized during the nation’s long war on drugs.

But the agency’s decision had not been entirely unexpected, after a group of independent experts convened by the F.D.A. to evaluate Lykos’s data met in June and did not recommend the treatment. On two central questions, the experts voted overwhelmingly that the company had not proven the treatment was effective, and that the drug therapy’s benefits did not outweigh the risks.

The agency generally follows the recommendations of its outside panels. Critics, however, have questioned the panel’s expertise, noting that only one of its 11 members had experience in psychedelic medicine.

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Historic barn vandalized at Gettysburg Battlefield, officials seek public help

Only a day after requesting the public's assistance with unnamed missing artifacts, the Gettysburg National Military Park is again asking for the public's help, this time in regards to vandalism at a historic barn.

According to a release by the park, between Feb. 13 and Feb. 19, 2024, law enforcement rangers are investigating vandalism that occurred to the Benner barn, located at the Josiah Benner farm, in the northern section of the battlefield

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No description of the damage done by the vandalism was provided.

The release did not share when the park service was made aware of the vandalism, or how investigators came to that timeframe.

The release follows just a day after the park issued a release regarding the theft of artifacts from the historic Timbers farm on the southern end of the battlefield between Dec. 2023 and Jan. 2024. Officials did not share what those artifacts were.

Jason Martz, spokesperson for the park, said in an email that releasing further details would be detrimental to the investigations.

More: Artifacts taken from Gettysburg battlefield: Officials offering reward for information

Anyone with any information regarding the vandalism, or missing artifacts, is asked to contact the Adams County Crimestoppers hotline at 717-334-8057. A reward for information is being offered in regards to both the vandalism and the missing artifacts, separately.

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The impact of non-dysentery shigella infection on the growth and health of children over time (insight)—a prospective case–control study protocol.

1. Introduction

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Chakraborty, S.; Dash, S.; Antara, N.A.; Roy, B.R.; Mamun, S.A.; Ali, M.; Naz, F.; Johura, F.-T.; Lewis, J.; Afroze, F.; et al. The Impact of Non-Dysentery Shigella Infection on the Growth and Health of Children over Time (INSIGHT)—A Prospective Case–Control Study Protocol. Microorganisms 2024 , 12 , 1677. https://doi.org/10.3390/microorganisms12081677

Chakraborty S, Dash S, Antara NA, Roy BR, Mamun SA, Ali M, Naz F, Johura F-T, Lewis J, Afroze F, et al. The Impact of Non-Dysentery Shigella Infection on the Growth and Health of Children over Time (INSIGHT)—A Prospective Case–Control Study Protocol. Microorganisms . 2024; 12(8):1677. https://doi.org/10.3390/microorganisms12081677

Chakraborty, Subhra, Sampa Dash, Nowrin Akbar Antara, Bharati Rani Roy, Shamim Al Mamun, Mohammad Ali, Farina Naz, Fatema-Tuz Johura, Jade Lewis, Farzana Afroze, and et al. 2024. "The Impact of Non-Dysentery Shigella Infection on the Growth and Health of Children over Time (INSIGHT)—A Prospective Case–Control Study Protocol" Microorganisms 12, no. 8: 1677. https://doi.org/10.3390/microorganisms12081677

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Cultural Determinants of Help Seeking: A model for research and practice

Denise saint arnault.

Michigan State University, B510-B West Fee Hall, Nursing Research Center, East Lansing, Michigan 48824, 517-355-3332 (Office), 517-353-9553 (Fax), ude.usm@nratnias

Increasing access to, and use of, health promotion strategies and health care services for diverse cultural groups is a National priority. While theories about the structural determinants of help seeking have received empirical testing, studies about cultural determinants have been primarily descriptive, making theoretical and empirical analysis difficult. This article synthesizes concepts and research by the author and others from diverse disciplines to develop the mid-range theoretical model called the Cultural Determinants of Help Seeking (CDHS). The multidimensional construct of culture, which defines the iterative dimensions of ideology, political-economy, practice and the body, is outlined. The notion of cultural models of wellness and illness as cognitive guides for perception, emotion and behavior; as well as the synthesized concept of idioms of wellness and distress, are introduced. Next, the CDHS theory proposes that sign and symptom perception, the interpretation of their meaning and the dynamics of the social distribution of resources, are all shaped by cultural models. Then, the CDHS model is applied to practice using research with Asians. Lastly, implications for research and practice are discussed.

The analysis and elimination of health disparities has reached the National priority level. Calls for multilevel, multidisciplinary studies that integrate biological, small group and system-level processes are common across the National Institutes of Health ( National Institutes of Health, 2000 ; OBSSR, 2001 ). Research such as this is challenging because it is difficult to grasp the mechanisms by which the phenomenon of culture (which is system-level processes) becomes incorporated into community, family and individual-level patterning of illness experience and help seeking. To further complicate this integration, these multiple levels are examined from different fields of study. One recent initiative has suggested a new field called Clinical Social Science ( Kleinman, Eisenberg & Good, 2006 ), that synthesizes and translates social science concepts into clinical strategies with direct application in practice and teaching. Until that time, nursing science can synthesize developed concepts from diverse literatures, identify their linkages, and assemble them into theory that can guide research and practice in health care.

In this article, theoretical concepts are synthesized from divergent disciplines to formulate the Cultural Determinants of Help Seeking (CDHS) theoretical model. Help seeking is an appropriate outcome variable for this mid-range theory because the adoption of health promotion strategies and the effective and satisfying use of health care services by culturally-diverse peoples are critical to reducing and eliminating health disparities. The theoretical model proposed in this article explores the cultural determinants of help seeking to maintain wellness and relieve distress. The model does not attempt to include the structural barriers that affect access to care for diverse cultural groups, such as poverty, social class or education. This is an extremely important research focus, and readers interested in these are urged to examine literature in medical sociology and critical medical anthropology, both lines of inquiry that operationalize race, gender, social class and culture from a political and economical vantage point. Culture in this paper is understood to be a system-level, multidimensional construct that describes the social processes of beliefs and values, rules about social behavior, and social practice.

Culture affects all aspects of health and illness, including the perception of it, the explanations for it, and the behavioral options to promote health or relieve suffering. Anthropologists and transcultural nurses have demonstrated that people from all cultural groups seek help for their suffering based on the meaning that culture assigns to the suffering. Medical anthropology has used the phrase “idioms of distress” to describe the culturally specific experience of psychosocial and physical suffering. However, nursing is also interested in health promotion activities; our interests extend equally to those processes by which people experience health, understand the sources of it, and act to optimize or promote it for themselves and others. Therefore, in this theory, the concept of idioms of distress is expanded into the concept of “ idioms of wellness or distress .” An idiom of wellness or distress is a collection of physical, emotional and interpersonal sensations and experiences labeled by the individual as optimal or abnormal, and identified as important. Using this new concept allows for the recognition of culturally distinct patterns of health promotion, wellness and illness experience, meaning interpretation and help seeking, avoiding the premature and/or possibly erroneous conclusion that specific signs of wellness and symptoms of distress or illness are identified and interpreted the same way across cultures. Help seeking in this theory is defined as attempts to maximize wellness or to ameliorate, mitigate, or eliminate distress.

Understanding the ways that people experience and respond to wellness and distress has been a challenging endeavor. Defining the theoretical underpinnings of this theory have involved a journey to study diverse bodies of literature including philosophy, social psychology, medical and psychological anthropology, and transcultural psychiatry and nursing. Each body of work has strengths and limitations. However, this search for culturally relevant practice guidelines has revealed that there has been little integration of social science theories into practice models. This CDHS theory was developed first by examining the literature from these diverse fields to identify concepts that might have practical clinical relevance. Next, these theoretical concepts were synthesized into a model based on their predictive assumptions. In this article, research with the Asian population conducted by the author and others supports these proposed linkages and demonstrates how this theory can guide practice with a given cultural group. However, the author has also made use these concepts for similar analyses with other cultural groups, especially Native Americans and Mexicans. This theory is presented, not as a finished product, but as a stimulus for discussion, elaboration, testing and application.

Conceptual Definitions

Culture is a set of interacting, system-level, social processes that include four interrelated dimensions (Saint Arnault, 2001) (see Figure 1 ). Cultural ideology is the beliefs and values held by a people are about what is good, right and normal. The ideology of a culture refers to the available symbols, meanings, and values about what is important and what behaviors are right and correct. Of course, ideologies are about ideals, and are only behavioral guides; the average person rarely achieves these ideals in practice ( D'Andrade, 1995 ; Geertz, 1977 ; Hodder, 1986 ; Lutz, 1988 ; Schneider, 1980 ; Turner, 1969 ). Another important and often overlooked element of culture is the political/economic dimension. The political/economic dimension of culture includes the social structures of the society; how families, groups and institutions distribute resources, divide labor, and acquire and distribute wealth. The political/economic dimension of culture also includes how those in power define proper social conduct, as well as how public behavior will be regulated. The political/economic dimension is informed by the cultural ideology, because it is the cultural beliefs and values about “good” and “right” that justify positions about who will hold power over whom ( Dirks, Eley & Ortner, 1993 ; Grimasi, 1992 ; Harris, 1979 ; Lindenbaum & Lock, 1993 ). The final dimension of culture is practice , which includes the traditional behaviors, spatial organization, and interpersonal behaviors. The practice aspect of culture includes both power and ideals—these two forces are acted out in even the smallest gestures, speech patterns, manners of dress, social distances, food choices, and health behaviors. Practice is the embodiment of “tradition.” Thus, cultural practices are the enactments of both cultural ideology and political/economy at the small group or personal level ( Berger & Luckmann, 1967 ; Bourdieu, 1977 ; Foucault, 1982 ).

Overlapping Dimensions of Culture

While the social forces of ideology, political-economy and practice shape belief and behavior, and are enacted by groups and individuals, the body remains crucial in understanding cross-cultural health and illness. As a forth dimension of culture, Scheper-Hughes and Lock (1987) propose that the body is cultural in three important ways: individuals experience the body as the “individual body-self” based on cultural prescriptions and templates; each person experiences themselves as having as a social body, which is a natural symbol for culturally-based thinking about relationships among nature, society and culture; and finally, the body is political, in that it is an artifact of, and is subject to, culturally-based social and political control.

In Figure 1 , culture is depicted as mutually iterative dimensions. The body is situated in the middle of the overlapping cultural dimensions, showing how they exert their effects upon the body, and how they are enacted or lived out through the body. Finally, all of these cultural forces occur within, and are shaped, by the geographic ecosystem in which people live, including interacting plants, animals, and physical components such as sunlight, soil, air and water.

The collection of social patterns of interpretation and expectations that are provided for people by their prevailing, local cultural milieu are referred to as cultural models ( Holland & Quinn, 1987 ; Markus, Kitayama & Heiman, 1996 ; Moscovici, 1988 ). Cultural models provide specific and consensual guidelines about ideals, values, motivations, goals, social roles and preferred social behaviors. While people may have several cultural models available to guide their perception, thinking, emotions and behavior, unconscious and conscious processes operate that create a coherent cognitive map that is shared by small groups such as families and reference groups. Also, individuals within any given cultural model vary in countless personality dimensions, temperaments, life histories and a host of other variables; future research is needed to illuminate the impact of these personality variables on individual help seeking. In the discussion that follows, the system-level processes of culture relevant to health and help seeking are understood as operationalized at the small-group and individual levels as cultural models of health and illness .

Cultural Determinants of Help Seeking Model

Cultural models direct cognition, emotion and action ( Holland & Quinn, 1987 ; Markus et al., 1996 ; Moscovici, 1988 ; Nisbett & Norenzayan, 2002 ). Perceptions of salient physical or emotional sensations, or relevant aspects of the social environment, are encouraged in individuals in early infancy through the processes of enculturation. The cultural model “tells” the person to attend to certain aspects of his or her experience, what to ignore, what things mean and what should be done about them. Understanding how a given cultural model might direct attention is a starting point for making predictions about how the sensations within the body, emotions and social situations will be perceived, and therefore how health is maintained, or distress is experienced.

Perception and labeling

Studies about how people experience, interpret and label internal sensations and their environment have been conducted within a number of interrelated fields. Ethnobiology is the study of how people of any cultural tradition interpret, conceptualize, represent, cope with, utilize, and generally manage their knowledge of their environmental experience ( Ellen, 2006 ). Interpretative medical anthropology focuses on metaphorical conceptions of the body and shows the social, political, and individual uses to which these conceptions are applied ( Waldstein and Adams, 2006 ). Ethnophysiological theory proposes that, once a sensation is noticed, individuals evaluate them in terms of their normalcy and severity ( Hinton and Hinton, 2002 ).

In short, the attention people give to any given physical or emotional sensation is “filtered through” cultural models. To provide a more complete understanding, cultural models provide a complex set of templates for arousal, attention, and expectation. Cultural models guide attentional amplification of physiological shifts. A person exists as an experiential agent of the cultural model, such that processes of sensation amplification alter their perception and awareness of arousal sensations; this amplification and elaboration are affected by numerous variables, including local ethnophysiology, cultural metaphor, and culturally-based cognitive templates. These, in turn, affect self-surveillance, sensation amplification, and experience labeling ( Hinton and Hinton, 2002 ). For example, some cultures have a rich and varied understanding of subtle changes in the body, such as skin sensitivity, digestive patterns, and tongue characteristics; other cultures have less sophisticated attention to the body, but have a rich and varied emotional awareness.

The CDHS theory proposes that physical or emotional sensations are labeled “ signs of wellness ” when they are interpreted as desired, valued, ideal or optimal states. Physical sensations or emotions are labeled “ symptoms ” when they are interpreted as a sign of an abnormal state, a disturbance, pathology or an illness. Along with labeling, individuals and groups evaluate the level of importance or severity of the sign or symptom. Often signs and symptoms are experienced as a collection, constellation or cluster ( Kirmayer, 2001 ).

Interpretations of Meaning

Once wellness signs or distress symptoms are experienced and labeled, people consider the meanings of what they have noticed in terms of what the cultural model “tells” them might have caused the signs or symptoms. People also consider what this means about them as a person based on the ideals of the culture, and about themselves as a member of the group.

Causal attributions

Cultural models influence shared conceptualizations about the body, the nature of the healthy self, and what symptoms signify a condition outside the range of normal. In addition, cultural models provide explanations about the cause of wellness and distress, referred to as explanatory models ( Kleinman, 1988 , 1995 ). Explanatory models provide culturally-specific explanations about how health and wellness are achieved, as well as the causes of distress and illness. In addition, explanatory models allow groups to develop shared and meaningful patterns of health promotion, need and care that are natural and predictable within the larger cultural model.

Individuals make three types of interpretations of causes of signs or symptom clusters that affect help seeking ( Kirmayer, Dao and Smith, 1998 ). A somatic interpretation is the attribution of a physical sources of wellness or distress; a psychological interpretation is about emotional sources; and an environmental interpretation posits social or physical environment sources (Robbins and Kirmayer, 2001). In general, we can predict that people will attempt to match their help seeking behavior to their interpretations about the sources of wellness or causes of distress ( Chrisman & Kleinman, 1993 ).

Social significance

Individuals also make estimations about the positive or negative social significance of their signs of wellness and distress symptoms based on cultural models ( Kleinman and Good, 1986 ; Corrigan, 2005 ). Signs of wellness may be positively evaluated and may be a source of pride because they are evaluated as meaning that the person is good, or happy, or in some way, socially desirable. Wellness may be interpreted as an indication that one has achieved individual, group or social goals. Symptoms of distress or illness can be interpreted as indicating signs of moral weakness, physical frailty, or failure to carry out important social roles. Illnesses may be evaluated negatively when they signify that a person (or a family member) has failed in some important social role. When people evaluate their distress or illness as negative, they will have emotional responses of shame, humiliation, anxiety or fear. These people will avoid disclosing it out of fear of the social consequences.

Social Context Dynamics

The interpretation of the meaning of an experience of wellness or distress occurs within an individual with reference to the cultural model. However, help seeking requires the engagement of the social network. These networks include relationships of power that operate to exchange social resources, including division of the labor of care and support. Cultural models differ in terms of whether they emphasize the group or the individual. Therefore, the next step in the help seeking process involves an analysis of the rules that regulate resource exchange.

Availability of resources

The emphasis of a cultural model on the group or the individual can greatly impact the availability of social resources ( Bruner, 1991 ; Fiske, Kitayama, Markus & Nisbett, 1998 ; Geertz, 1993 ; Lawson & McCauley, 1990 ; Markus, Mullally & Kitayama, 1997 ; Shweder, 1991 ). Within a group-oriented system, there is a cultural emphasis on behaviors that foster group harmony and solidarity. Within a group-oriented cultural model, the focus is on the family as the primary vehicle of support and nurturance of the individual. Resources are understood to be available to group members for the benefit of the group as a whole. In a group-oriented model, health is considered the result of, and a resource of, the well-functioning group, rather than a solely an individual asset. Also, illness can be seen as the result of a poorly functioning group, and a detriment to the group as a whole.

Individually-oriented cultural models have a cultural emphasis on the needs, feelings and attributes of the individual. Within these individually-oriented cultural models, the focus is on the individual as an agent of his or her own circumstances. Resources are distributed by the group to the individual, and while gratitude is expected, the resource is primarily for the benefit of the individual, thereby promoting his or her success. Wellness in an individually-oriented cultural model is an individual achievement based on moral character, daily habits or personal success. Alternately, while illness affects others, it is primarily an individual failure. The responsibility for health falls upon the individual.

Exchange rules

Cultural models also include guidelines about the exchange of support and help within the perceived social resources. Reciprocity refers to expectations about the give and take of instrumental, social and emotional support, and rules about who should engage in these exchanges, and under what circumstances. Because group-oriented cultural models believe that health and illness arise from, and are the responsibility of, the group, they may expect their members to seek help only from known, intimate or in-group members. These cultural models also have edicts that each favor incurs a reciprocal exchange, but that reciprocity may be repaid to other people within the in-group. In addition, some group-oriented cultural models have specific rules about the situations in which reciprocity between people who are not members of the same family or in-group is appropriate, and what the exchange should be ( Backnik, 1994 ; Hendry, 1992 ; Saint Arnault, 1998 , 2002 , 2004 ). Experiences of wellness are a group-level asset that may be seen as a situational factor that can be considered when reciprocity is expected. For example, someone old, frail or ill who needs help might not be expected to repay based on social exchange rules. Rather, other members of the group, who are healthy, are responsible to repay those favors.

Individually-oriented cultural models foster individual autonomy, and have contractual exchange rules, in which autonomous individual agents repay debts in-kind within a proximate span of time. These individually-oriented cultural models may expect that people will only ask for assistance when they cannot do for themselves and will repay the favor within a short time frame ( Antonucci, 1990 ; Gouldner, 1960 ; Klein Ikkink, 1999; Neufeld & Harrison, 1995 ; Rusbult, 1993). The expectation for repayment might be suspended or lifted until the individual regains health and strength.

Model Description

In summary, the CDHS model ( figure 2 ) proposes that the processes of perception, meaning interpretation, as well as resource exchange, are filtered through cultural models of wellness and distress. The help seeking process begins when there is a perception of physical or emotional sensations. In the model, wellness or distress perceptions are identified and labeled as important, optimal or abnormal, beginning of a series of interpretations and evaluations used by people to determine if (and what) additional help is needed (perception and labeling).

Once wellness signs or distress symptoms are experienced and labeled, people interpret the meaning of them. When a person deems the wellness signs or distress symptoms to be significant, the person then determines what the possible source or cause might be (causal attribution). Sometimes individuals may determine that their experiences are caused by their ways of thinking, and reinforce them or institute internal adjustments to eliminate them. Alternatively, individuals may interpret their wellness or distress to be caused by personal habits or behaviors. In this case, people will try to strengthen them to maintain or support their wellness, or alter daily habits to try to eliminate symptoms. The causes for these signs or symptoms are related to the interpretation of the social significance (social significance). People may decide that their wellness is a sign that they are living the good life, are moral and right, and believe that they can be examples to others. Sometimes people may decide that their symptoms suggest that they have committed a social failure, and choose to hide them. A person may decide that their condition is not amenable to help, or that it is simply too shameful to acknowledge their needs.

After this interpretation of the cause and social significance of wellness signs or distress symptoms, people begin evaluating the rules that govern the resources available within their social network. The person may be in a social network that sees wellness as a group asset and may therefore expect that resource to be shared for the benefit of all members. Others may be in a social network in which wellness represents a personal achievement (availability of resources).

Next, the social network has rules about the exchange of the resources they posses. People assess their relationships to determine who will support their wellness, or from whom they can ask for help; determining what type of help they can request, and at what cost (reciprocity rules). They consider the forms and strategies they should use to access support. They may find that closeness and supports regarding their distress are unavailable, or decide that asking for help creates too many social complications, deciding to keep quiet. When people suffer from symptoms that they have deemed to be of negative social significance, social rules may dictate that they can only share those feelings with people who are in a reciprocal helping relationship with them, such as immediate or extended family. Other cultures prohibit burdening ones family with problems and prescribe that one should seek a paid professional for troubles and needs, leaving the family as the place where good feelings are shared.

CDHS Theory and Practice with Asians

For over 20 years, the health care community has struggled to respond to the mandate for cultural sensitivity in their provision of care. Mastery of all of the relevant cultural variants demonstrated by a diverse population makes this task overwhelming for busy practitioners. This CDHS is one response to this need, providing health care providers the assessment categories that they can use regardless of the cultural group, and by providing suggestions about how these might operate to affect help seeking. Most practices are based in communities with established cultural groups. Using these assessment categories, health care providers can begin to discover themes within commonly contacted groups, and develop strategies to address them. Therefore, it is helpful to look at research data from one group to demonstrate how the CDHS can be used to understand the relationships among the theoretical concepts and the implications of these for practice. It should be clear, however, that these cultural concepts and processes could be used to analyze any cultural group.

Of course, most clinical cultural research focuses on distress and illness. However, assessment of symptoms of distress requires understanding of what conceptions of normalcy and health are for that group. In general, people enculturated within many Asian countries share the belief that health is part of a holistic system of experience in which the spiritual realm (including ancestors and gods), society, the body, thinking activities and emotions are intertwined. In a system such as this, experiences of health are understood to be the result of a person who has respectful and appropriate relationships with the spirits, with others, especially those in ones family, whose diet is appropriate for the season and ones constitution, and whose thoughts and emotions are balanced and harmonious. In this system, physical sensations are closely monitored because they are understood as signs of emerging disharmony in one of more of these areas. For many Asians, attending to disharmony and restoration of harmony or balance is the key to health. Therefore, attention to subtle physical sensations, diet patterns, sleep patterns, social rules and spiritual activities are attended to daily ( Association of Asian Pacific Community Health Organizations, 1995 ; Kleinman, 1982 , 1983 , 1988 ; Lock, 1987; Ohnuki-Tierney, 1984 ; Sue, 1999 ).

Somatic symptoms in Asians

Complaints of physical symptoms can be seen in any population; however Asian groups from many countries describe their distress in somatic forms ( Draguns, Phillips, Broverman & Caudill, 1970 ; Gureje, Simon, Ustun & Goldberg, 1997 ; Hinton & Hinton, 2002 ; Hong, Lee & Lorenzo, 1995 ; N. Iwata & Roberts, 1996 ; Kanno, 1981 ; Kawanishi, 1992 ; Kirmayer, Dao & Smith, 1998 ; Kirmayer & Groleau, 2001 ; Lock, 1987a ; Maeno et al., 2002 ; Pang, 1998 ; Parsons & Wakeley, 1991 ; Simon et al., 1999 ). In Japanese clinics, 13% to 15% of patients had both depression and co-occurring physical symptoms ( Maeno et al., 2002 ; Mino, Aoyama & Froom, 1994 ).

Ethnographic and ethnophysiological studies have explored this somatic distress in Asians in more detail. In a review of interactions between Chinese physicians and their patients, Ots found that both physicians and patients related internal organs with emotions, and carefully examined bodily perceptions ( Ots, 1990 ). For example, the liver was believed to be the cause of headaches, epigastric pain, hypertension and anger, while the heart was thought to cause anxiety, uncertainty and fear. In a sample of Koreans with depression, Pang found that people connected internal organs, emotions and bodily sensations. These patients described depression as a symptom cluster that included anger, physical pain and social discord ( Pang, 1998 ). Finally, Lock (1987b) explains that futeishūso (non-specific physical complaints) includes symptoms such as coldness, shoulder pain, palpitations and nervousness. Both the physicians and patients in her study related these symptoms with social discontent, problems with the autonomic nervous system, pelvic inflammatory disease, and general personality sensitivity.

Saint Arnault, Sakamoto and Moriwaki (2006) tested whether the symptoms found in ethnographic studies might be seen in a larger sample of 50 female Japanese college students using standardized measures. Using a broad physical symptom inventory ( Pennebaker, 1982 ), as well as a Japanese version of the Beck Depression Inventory, the authors found that the Japanese women who scored above 15 on the Beck had significantly higher mean scores for the neurological (weakness, faintness, dizziness, lightheadedness, numbness), gastrointestinal (abdominal pain, stomachache, abdominal cramps), neuromuscular (pain in the shoulders, stiff joints), and cardiac symptoms (inability to breathe, and palpitations) (p < .03) than their non-depressed counterparts ( Saint Arnault, Sakamoto & Moriwaki, 2006 ). They also found that the Japanese had higher somatic distress means than Americans, which they interpreted this finding as related to a culturally-patterned perceptual focus on the body rather than a difference in levels of distress.

Causal Interpretation as Social and Environmental

As stated above, many people enculturated in Asian cultures tend to have a holistic view of the body as in balance with natural, social and spiritual forces. Experiences of wellness are believed to be caused by this harmonious integration. Research has shown that Asians may attribute their somatic experiences, whether wellness or distress, to environmental and somatic causes. In situations of distress, this causal attribution may explain the tendency for Asians to primarily use medical care and social support ( Guarnaccia, Rivera, Franco & Neighbors, 1996 ; Hinton, Um & Ba, 2001 ; Jenkins, Kleinman & Good, 1991 ; Kirmayer, 1993 ; Kirmayer et al., 1998 ; Kirmayer & Young, 1999 ; Kleinman, 1988 , 1996 , 2003 ; Pang, 1998 ).

The Symptom Interpretation Questionnaire ( Robbins & Kirmayer, 1991 ) measures whether people attribute commonly occurring physical symptoms to somatic, psychological, or environmental causes. There have been very few studies that examine the relationship between symptom interpretation and service use. An example of such a study was conducted by Parker & Parker (2003), examined symptom interpretation and use of mental health services for 698 patients in Sydney, Australia. They found that psychological interpretation for somatic symptoms was related to both a history of depression and use of mental health services (unfortunately, ethnicity was not reported). However, we do not know whether those Asians who seek help from primary care clinics are more likely to hold physical interpretations about their distress, while those who do not use such services believe that their distress is somatic or environmental. This is a challenging area for nursing research.

Social Evaluation as Shameful

Research about Asian philosophy has shown that people from many Asians countries share Confucian collectivist values. These values foster a focus on the in-group, especially ones family. In a philosophical system such as this, wellness is attributed to fulfillment of ones social roles, the existence of mutually supportive relationships within the family, as well as proper respect and conduct with ancestors.

Research has suggested that these shared beliefs also cast shame onto the families of those who experience mental illness because the experience of distress signifies a lack of a supportive network, inability to fulfill social roles or improper relationships with family or ancestors ( Association of Asian Pacific Community Health Organizations, 1995 ; Iwamasa & Hilliard, 1999 ; Lin & Cheung, 1999 ; Ma, 1999 ). While this negative evaluation is assumed to inhibit the use of mental health care, very few studies have examined specifically how this relates to cultural models. One effort to systematize the assessment of the social evaluation of distress is the development of the Beliefs toward Mental Illness Scale (BMI) ( Hirai & Clum, 2000 ). These authors operationalize the socially significant cultural beliefs about mental illness to be beliefs about dangerousness, incurability and poor social skills. For one Asian sample, high scores for beliefs about dangerousness were positively correlated with seeking medical care instead of psychological care; high scores for beliefs about incurability were negatively correlated with seeking medical care; and scores for beliefs about poor social skills were positively correlated with use of folk medicine ( Hirai & Clum, 2000 ). Furthermore, while many studies have made assumptions about how the social evaluation of distress affects help seeking, no published studies have documented the relationship between symptom perceptions, interpretation, resource-related social dynamics, and help seeking.

Perception of Social Resources: In-group and Hierarchical Social Networks

As noted earlier, a core aspect of the Confucian philosophy is the prescriptions about the nature of interpersonal relationships, especially the belief that the individual's primary or ideal concern is with their family ( Kim, Atkinson & Yang, 1999 ; Rozman, 1991 ; Sue, 1999 ). Confucian philosophy also specifically structures society along hierarchal-status lines. Within this social system, the individual knows that smooth functioning within the group requires sensitively to one's role within the group. For these Asian cultures, the primary social unit is the family and the primary reference group. A reference group is the group that the person feels identification with, and may include a peer group or ones co-workers. Wellness signifies that an Asian person is engaged in mutually interdependent relationships with the people in their primary reference group and their family, sharing responsibility for the support and security with all of the other members. A well person understands and respects their obligations both to family, and to the harmony within his or her primary reference group. Research has shown that many Japanese favor reliance on the primary family or group for emotional support ( Fetters, 1998 ) and that they simultaneously fear stigmatizing or shaming the family if they use professional mental health care ( Alem et al., 1999 ; Atkinson & Gim, 1989 ; Bekker, Hentschel & Fujita, 1996 ; Flum, 1998 ; Hom, 1998 ; Kagawa-Singer, Wellisch & Durvasula, 1997 ; Kim, 1998 ; W. Kim, 2003 ; Narikiyo & Kameoka, 1992 ; Ono et al., 2001 ; Suan & Tyler, 1990 ; Yeh, Inose, Kobori & Chang, 2001 ).

One effort to measure ideas about ones relations is the Asian Values Scale ( Kim, Atkinson and Yang, 1999 ). Studies that examine adherence to Asian values find that high adherence is negatively associated with the actual use of counseling. In general, research has found that low levels of acculturation, however it is defined, is related to a tendency not to use psychological services ( Atkinson & Gim, 1989 ; Hom, 1998 ; H. H. W. Kim, 1998 ; Le, 1996 ; Lee, 2002 ; Schwartz, 1998 ; Zhang & Dixon, 2003 )

Social exchange rules and norms

Above, research was presented that illuminated the relationship between some Asian values and the social resources relevant to health and distress. In addition to these interpretations, these cultural values also relate to rules regarding social exchange of those resources. The values described above foster group harmony by encouraging social exchange within the family and the primary reference group. A well person is one who understands and engages in this mutual exchange of resources. Autonomy is fostered in the sense that one cares for ones own needs to avoid over tapping these limited reserves. Therefore, a well person is one who handles their own needs and who works with others to benefit the strength and capabilities of everyone in the group.

In contrast, within that same system, group harmony rules may also discourage the open display of emotions, and may sanction the expression of negative emotion because they may disrupt the harmony and solidarity of the group. Research has also shown that Asians may deny the experience and expression of emotions, or may conform to social emotion display rules that favor showing somatic rather than emotional or interpersonal distress ( Kirmayer, 2001 ; Kleinman, 1982 , 1983 , 1988 ; Lin, 1996 ; Lock, 1987; Ohnuki-Tierney, 1984 ).

The social structure described above serves to modify and inhibit support-giving and help seeking. A reciprocity norm for the Japanese is to ask for help only within one's intimate social group ( Backnik, 1994 ; Hendry, 1992 ; Saint Arnault, 1998 , 2002 , 2004 ). Therefore, people need to be self-reliant to avoid overtaxing limited support reserves. Appropriate role behavior includes indirect communication of personal needs, and limited negative and positive emotional expression outside of ones intimate social circle. Behaviors that foster conflict or indicate deviance are frowned upon, and may result in ostracism (Bestor, 1996; Johnson, 1995; Lebra, 1976; Saint Arnault, 1998 , 2002 ; Smith, 1961). Very little research has been done to examine the effects of reciprocity rules on help seeking (See Klein Ikkink, 1999; Neufeld & Harrison, 1995 ; and Rusbult, 1993 for examples of such work on care giving and receiving). However, Saint Arnault found that Japanese expatriate spouses felt unable to freely express emotional distress within their general social network, as well as cultural rules dictating reciprocity in the exchange of social support ( Saint Arnault, 2002 ).

Implications for Research and Practice

The CDHS model has implications for cross-cultural health promotion, primary health care and psychiatry. First, the model illustrates how and why we must integrate ethnographic, epidemiological, survey and clinical methods and data to understand these complex cultural questions. One example seen here is the need for identification of culturally relevant symptom sets in large groups. Perhaps we can discover symptom clusters in large populations that can improve the sensitivity of our assessments, thereby increasing the accuracy of our community-based screening efforts. Improved assessments will also lead to more appropriate referrals and interventions for our culturally diverse clients. In order to do this, we must move systematically between the small-scale interviews common in ethnophysiological research toward the use of surveys that can examine these in wider populations, enabling us to compare symptom sets across cultural groups. These surveys, however, must be based on the logic of cultural system in question, instead of using the western cultural system as a norm.

Second, understanding the interaction among culturally based intra- and inter-personal factors may help researchers and practitioners target their efforts toward the forces that inhibit help seeking. General notions about stigma and language issues in health care utilization have yielded little in the way of removing the interacting obstacles that prevent service utilization, especially in the areas of mental health and other socially significant diseases. We need to identify how symptom perceptions, meaning interpretations and the exchange of social resources interact to fully understand and predict culturally-related help seeking strategies. This detailed knowledge will help service providers identify risk groups and develop culturally relevant services for them.

We have seen that the symptoms that warrant help seeking from a health care professional will not be experienced, understood and/or communicated in the same way across cultural groups. Health care providers must understand the cultural groups that they serve. Most clinics service people from predictable cultural groups. Groundwork outside of clinic time is time well spent when the providers can be conversant in the experiences and interpretations of important symptom sets. In addition, securing the services of cultural translators that can help providers learn more within the clinic setting can also be extremely helpful. A cultural translator is someone who understands and can articulate the dominant idioms of wellness and distress of their cultural group. Often, volunteers from communities can serve in this capacity. However, the cultural model presented here also illustrates how understandings and social evaluations will vary by gender, class and religion, so that the careful choice of cultural translators is essential.

The symptom sets used in American and international assessments to evaluate distress have relied on somatic indicators such as sleep, appetite and fatigue, which may have been based on the idioms of distress for western samples. As we have seen, focusing on these symptoms may be systematically overlooking symptoms that may be important for members of other groups—symptoms such as headache, neurological symptoms, muscular and joint pain and abdominal distress. The construct validity of western derived notion that the important emotions in depression are exclusively happiness, sadness, hopeless and guilt are vigorously critiqued in both Native American and Asian studies (See Iwata & Buka, 2002 , Iwata, Roberts & Norito, 1995 and Manson & Kleinman, 1998 for examples of this critique).

The nature of culture lends itself to multidisciplinary and mixed-method research strategies. Only by working across disciplinary lines can we succeed in creating synthesized theories that can guide practice. As we have seen, while culture is a system-level phenomenon, it becomes part of an individual's cognition, and is therefore enacted at the small group and individual levels. Culture necessarily affects health and distress perceptions, interpretation, communication and social support, and ultimately all help seeking behaviors. Within each of these domains, one can use qualitative and quantitative methods to document mechanisms and explicate dynamics ( Office of Behavioral and Social Sciences Research, 2001 ). Readers are encouraged to take up this challenge to deepen our nursing research about the complexity of culture and help seeking.

Acknowledgments

This research was supported by the Office of Behavioral and Social Sciences Research and the National Institute of Mental Health MH071307).

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