The reluctance of young people to seek professional help for mental health problems is increasingly acknowledged as a challenge to effective early intervention approaches. Engaging in appropriate help is widely recognised as a generic protective factor, and early treatment and prevention are vital during adolescence and young adulthood (12–24 years) because of the high prevalence of mental health problems at this stage of life. A recent, large study from the United States reported that half of all life-long mental disorders start by 14 years of age, and three-quarters by 24 years of age.1 In Australia, the National Survey of Mental Health and Wellbeing (NSMHWB) found a prevalence of mental disorder of 27% for those in the 18–24-year age range.2 While young people have the greatest need for mental health interventions, they are the least likely to seek help.
A wide range of studies, nationally and internationally, attest to young people’s reluctance to seek professional mental health care. For example, a school-based survey of 11 154 Norwegian youth aged 15–16 years reported that, even at the highest symptom levels for anxiety and depression, only a third had sought professional help.3 Similarly, the most recent national survey data for Australia show that only 29% of children and adolescents with a mental health problem had been in contact with a professional service of any type in a 12-month period.2 In a Queensland study of 3092 young adults aged 15–24 years, 39% of the males and 22% of the females reported that they would not seek help from formal services for personal, emotional or distressing problems.4
Young men tend to be even more reluctant to seek help than young women. In the Queensland study mentioned above, 30% of males, compared with only 6% of females, reported they would not seek help from anyone.4 While the sex difference in help-seeking varies according to type of problem and source of help, greater unwillingness is shown by young men.5 This is of special concern partly because of the substantially higher rates of completed suicide in men.6
Young people who are Aboriginals or Torres Strait Islanders or from other cultural and linguistic minority groups may be even less likely to voluntarily seek professional help when needed. There are very few studies specifically of help-seeking for these population groups, and we have no knowledge of the process of help-seeking among young people from ethnic minority groups.7 This is a particular problem, given evidence of a very high level of unmet need for Aboriginal and Torres Strait Islander young people8 and of reluctance to voluntarily seek help from mental health services among people from some cultural and linguistic backgrounds.9,10
It has been argued that the key to increasing access to mental health services by Indigenous people is greater integration of cultural and clinical competencies at both a system and practitioner level.11 For example, at the engagement level, introductions between practitioners and Indigenous clients should recognise the importance of land, country and genealogy, along with potential barriers associated with language groups or tribal boundaries. Forms of questioning that are open-ended, positively phrased, and focus on narrative have also been suggested.11 However, better understanding of help-seeking processes and preferences of people from Aboriginal and Torres Strait Islander backgrounds is urgently needed.
Help-seeking is not a simple process of experiencing psychological distress and seeking help. Although awareness of a problem (by self or others) is a starting point, the symptoms of mental health problems and mental disorders play a smaller role than might be expected in prompting help-seeking.12 A wide range of other factors are involved, including appraisal of a problem as something to seek help for, willingness to seek help and social norms that encourage such behaviour, access to appropriate services, and choosing a source of help.
Recent reviews of studies about help-seeking emphasise the importance of distinguishing between individual and structural determinants of young people’s help-seeking behaviour.13 Individual determinants include factors such as mental health literacy, attitudes and perceived stigma. Structural determinants comprise family, school or community support systems, referral pathways, health system structures and payment systems. Individual and structural factors interact to determine when and how young people seek and access help for mental health problems.
Young people are more likely to seek help when they recognise that they have a mental health problem and have the knowledge, skills and encouragement to seek help (see Kelly et al, "Improving mental health literacy as a strategy to facilitate early intervention for mental disorders"). Mental health literacy comprises the ability to recognise mental health problems; knowledge and beliefs about risks, causes and effective treatments; and knowledge of how to seek mental health information and services.14 Lack of recognition of mental health problems among young people3 and their parents15 is a major “filter” to help-seeking. Poor mental health literacy is common among young Australians, particularly adolescent boys, and is a significant barrier to professional help-seeking.16,17
More specifically, a certain level of emotional competence is required to seek mental health help. When young people do not know how to identify and describe emotions, or manage their emotions in an effective and non-defensive manner, this impedes help-seeking.18 On average, this competence appears less developed in young men.19
For all types of health and mental health problems, if young people want to talk to anyone, it is generally someone they know and trust.20 Consequently, they are more likely to seek help from their friends and family for personal and emotional problems than from other sources, including mental health professionals.5,21 When young people do seek professional help, it is from the more familiar sources — family doctors and school-based counsellors.2
Suicidal thoughts are quite common during adolescence and have been shown to have a significant negating effect on help-seeking behaviour.2 In two Australian studies using non-clinical samples of university students22 and adolescents,23 young people’s intentions to seek help decreased as their level of suicidal ideation increased, and they became more likely to indicate that they would not seek help from anyone.
The mental health problems most commonly experienced by young people — depression, anxiety and substance use — similarly act to negate help-seeking by increasing social withdrawal and young people’s preference to keep their distress to themselves.5,24
As young people progress through adolescence they have a growing need for autonomy and independence, and increasingly believe they should be able to handle problems themselves.23 A large US study found that a third of adolescents with serious suicidal ideation, depression, or substance use problems believed that people should handle their own problems without outside help.24 Similar findings are apparent in Australia, with the Child and Adolescent component of the NSMHWB finding that 38% of adolescents endorsed a desire to solve their own problems as a barrier to seeking help.2
Stigma and negative attitudes toward seeking help from professionals are further barriers to professional help-seeking. Young people are particularly concerned about being seen as “mental” by their friends and others,25 and the stigma of mental illness is associated with less intention to seek help.17
Believing that seeking help won’t be useful also presents problems; “thinking that nothing could help” was the second most endorsed barrier (18%) in the NSMHWB.2 Young people are often unsure whether specific sources of help will actually make a difference. For example, while general practitioners are one of the most frequently accessed initial sources of professional help, young people often do not know whether seeing a GP for a mental health problem will be helpful.26 Furthermore, young people have been shown to prefer active treatment to watchful waiting, and counselling approaches to medication.27
Past experiences of seeking help that proved unhelpful also contribute to negative attitudes. This can include experiences in which the young person felt that they were not listened to or their problems were not taken seriously.5 Occasions when confidentiality was not kept, and fears about breaches of confidentiality, also contribute to negative attitudes toward mental health services, such as school counsellors.19,28
Friends and family are often consulted first and therefore have a significant role in the pathway to professional services. Parents are particularly important for younger adolescents. In childhood, parental perception of problems is the starting point for referral to professional services, and there is little evidence that children self-refer.29 The capacity for self-referral develops over adolescence, as independence and autonomy from parents increase, but parents continue to play a significant role, particularly until young people are financially independent.
In understanding pathways to care, it should be recognised that adolescents who are in their early to mid teens are still reliant on adults, particularly parents, to help them recognise the presence of a problem, facilitate access to appropriate help, and model appropriate help-seeking behaviour.15 Parents’ and other adults’ (eg, teachers’) perceptions of problems are critical to whether teenagers are identified and referred to mental health services. Interestingly, despite recent initiatives to encourage young people over 15 years to independently seek mental health care,30 there is some evidence that parents do not think their children should make their own appointments with doctors until about the age of 17 years.31
As young people progress through adolescence, the role of friends becomes more prominent, and peers increasingly have a role in the help-seeking process.5 For example, some visits to school counsellors are from young people seeking help for one of their peers.28
For young adults, intimate relationships become an important source of support; this applies particularly to men. Intimate partners have been shown to exert a strong influence on men who seek specialist psychological services.32
Schools are an ideal and opportunistic setting in which to reach out to young people.33 For those aged up to 16 years, the school setting is central, as school attendance is compulsory. Even for older adolescents, school is central, as most remain at school to complete Year 12.34 For adolescents aged 13–17 years, the child and adolescent component of the NSMHWB revealed that 16% of those identified with a mental health problem had received counselling in school.2
School-related problems themselves have been shown to play an important role in the help-seeking process for school-aged youth, as these can be important indicators of other mental health problems.35 Within schools, teachers, school counsellors, and other welfare and pastoral care staff have a major role in recognising mental health problems and referring young people to appropriate services.
A major initiative in Australia has been the development of partnerships between schools and general practice to improve young people’s access to mental health care. A resource kit has been released based on what has been learnt from the MindMatters Plus General Practice program to further encourage and support such initiatives.30 Importantly, ways to build referral pathways — a series of steps, shared understanding, and agreed ways of working together between services in a local area — are becoming better understood. To address the mental health needs of teenagers at school, schools need to be fully linked into referral pathways to local health, mental health and community-support services.
Another approach to increasing help-seeking has been to train GPs to conduct classroom lessons in high schools. These presentations cover a range of physical and mental health issues, and provide both encouragement and practical advice on how to seek help from a GP. This approach has shown encouraging results in preliminary feasibility studies in regional and rural locations, with adolescents reporting decreases in perceived barriers and increases in help-seeking intentions for mental health problems up to 10 weeks after the class presentations.36 Significant positive relationships were also found between help-seeking intentions and the frequency of actual consultations with GPs after the presentation.
General practice is essential to young people’s mental health and is often the point of initial contact with professional services. Importantly, the presence of medical problems increases help-seeking and provides an opportunity to investigate mental health issues.35
However, there is a need to improve the ability of GPs to recognise mental health problems in young people. For example, a recent review showed that, in the US, the median rate of recognition of mental health problems in children by GPs was only 18%, and was often dependent on parental expressions of concern.29 Older youth who visit GPs on their own are reluctant to mention their personal emotional problems, often because of concerns about confidentiality and being viewed as weak or abnormal.25
Recognition can be improved by GPs more frequently asking parents, or young people themselves, about stress or personal emotional difficulties. The process can be enhanced by providing a welcoming environment, and taking time to listen carefully and build rapport with young people. Also important is ensuring privacy and clearly explaining confidentiality. Finally, GPs can provide reassurance that it is common to feel distress at times, and that symptoms can be a normal response to stressful events. At the same time they can provide information and choices about treatment.19,25
Young people may also require additional support and follow-up from GPs as part of the referral process to specialist or other mental health services. For example, discussing issues of confidentiality, while explaining the need to share information and allowing the young person to specify the information they don’t want shared, can facilitate referral processes. Describing the potential benefits of receiving mental health services, and explaining the likely duration of therapy and what to expect in an initial mental health consultation, including any costs that might be incurred, are all reported to be helpful. GPs also need to explain how they will continue to support young people throughout this process.26
Barriers to seeking help early from specialist mental health services, and from alcohol and other drug services, can be particularly strong. Studies exploring how young people with psychosis access care highlight the highly variable pathways taken.37 Interviews with 62 people aged 16–30 years experiencing first-episode psychosis revealed a total of 307 previous contacts with various professionals, 52% with mental health professionals and 17% with GPs.37 In general, non-psychiatric contacts occurred first, followed by psychiatric consultations, and the single most frequent initial point of contact was with GPs (35.5%). The delay from the point of recognition of first symptoms to first service contact averaged 112 days (median, 31 days) and was even longer to initial treatment (mean, 273 days; median, 120 days). Reasons for such delays include lack of knowledge regarding the presence of a mental disorder, or inability to recognise it; stigma; uncertainty about treatment effectiveness; and service structures being focused on acute presentations.38
Focus groups with youth found the dominant barrier to help-seeking for substance use problems was a lack of self-motivation,39 highlighting the relevance of motivational interviewing skills for service providers. Other prominent themes were related to family dynamics (eg, poor communication), and societal concerns related to labelling and stigma. Young people’s perceptions of ideal responses to harmful alcohol and other drug use included improved relations with service staff, such as an initial compassionate and non-judgemental reception, and greater access and diversity of treatment options. These factors are consistent with other studies showing that the first contact between the therapist and youth is crucial and strongly determines the young person’s decision to continue.40 Confidentiality remains of utmost importance when engaging young people, and this is particularly important in the context of accessing alcohol and other drug services.
It is essential to recognise that many young people at high risk of mental health problems do not have links to work, school, or even a family doctor. For example, in 2004, 15.5% of teenagers and 22% of those aged 10–24 years were not in full-time study or work, and these young people are at greater risk of mental health problems.41 Extra effort must be put into reaching young people who are unemployed, homeless or otherwise marginalised from mainstream health and community services.
Youth workers, particularly those working in neighbourhood youth centres or shelters come in contact with young people who are disconnected from social supports and who might otherwise not be seen by other common gatekeepers, such as teachers, school counsellors, GPs, and community health. Youth workers are able to engage distressed young people by being highly accessible, “befriending” them, and acting as advocates.42 They potentially have a critical role in linking more marginalised youth with mental health services, but may need additional training to better identify mental health problems and to more effectively refer and collaborate with other services.43
It is worth mentioning that young people often use self-help and complementary treatments to deal with mental health problems. A recent review argues that incorporating this understanding into service delivery can enhance the therapeutic alliance, as well as discourage the use of potentially harmful treatments and encourage the use of helpful ones.44 Some particularly worthwhile adjuncts to treatment include Internet-based sources of help, such as MoodGym (http://moodgym.anu.edu.au/), which have been shown to be successful.45 Internet-based information and support are increasingly being taken up by young people.46
A final point to make about when and how young people seek mental health help is that it is essential for services to respect and build upon young people’s growing independence and mastery. This is acknowledged through the full and genuine participation of young people in developing and implementing services to meet their needs. Research evaluating programs that focus on young people with substance use problems confirms that limited results are achieved unless there is the opportunity for young people to be directly involved and have active roles in service development and delivery.47,48 To encourage and support adolescents and young adults to seek professional help early for emerging mental health problems, services must be informed and guided by the young people themselves.
- Debra J Rickwood1
- Frank P Deane2
- Coralie J Wilson2
- 1 School of Health Sciences, University of Canberra, Canberra, ACT.
- 2 University of Wollongong, Wollongong, NSW.
None identified.
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Abstract
Despite the high prevalence of mental health problems and disorders that develop in adolescence and early adulthood, young people tend to not seek professional help. Young men and young people from Indigenous and ethnic minority groups tend to be those most reluctant to seek help.
Young people are more inclined to seek help for mental health problems if they:
have some knowledge about mental health issues and sources of help;
feel emotionally competent to express their feelings; and
have established and trusted relationships with potential help providers.
Young people are less likely to seek help if they:
are experiencing suicidal thoughts and depressive symptoms;
hold negative attitudes toward seeking help or have had negative past experiences with sources of help; or
hold beliefs that they should be able to sort out their own mental health problems on their own.
Young people may seek help through talking to their family and friends, with family being more important for younger adolescents, and friends and partners becoming more influential later on.
The professionals most likely to act as gatekeepers to mental health services for young people are school counsellors, general practitioners, and youth workers.
Increasingly, Internet-based information and interventions are being used to engage young people in the help-seeking process.