Where to seek help for a mental disorder?

Despite the availability of a range of effective treatments, mental disorders are often either not treated, or there are considerable delays in obtaining treatment.1 Recognition that many people do not receive appropriate treatment has led to considerable investment by the Australian Government in improving mental health care, particularly at the primary care level. In recent years, there have been programs to improve the training of general practitioners in mental health care and to increase access to psychological, allied mental health, and psychiatric services (ie, the Better Outcomes in Mental Health Care initiative and the Better Access to Mental Health Care initiative). The success of these initiatives depends on the willingness of the public to use them, but the public do not always have a positive view of interventions and services for mental disorders.2

An additional consideration is that, unlike many physical disorders which begin in older age, mental disorders often first appear in adolescence or early adulthood.3,4 Because the risk of developing a mental disorder is relatively high, young people and their supporters need to know about appropriate sources of help. If their beliefs are not concordant with the provisions made by the health system, they are unlikely to use available services.

Primary care services are potentially very important for mental health care for young people, but existing service models do not always appeal to this age group.5 There have been international recommendations for developing more youth-friendly services,6 but these have not been fully taken up in Australia.7 Recently, the federal government has funded headspace, the National Youth Mental Health Foundation, to improve mental health services for young people.8

In this study, we examined the help-seeking intentions of young people and their parents for four types of mental disorders: depression, depression with comorbid alcohol misuse, social phobia and psychosis. We sought to identify intended sources of help for these problems, and perceived barriers to obtaining help from these sources.

A survey company (The Social Research Centre) performed a national computer-assisted telephone survey of young Australians aged 12–25 years. Participants were contacted by random-digit dialling, covering the whole country, from 1 June to 24 August 2006. Eligible members within a household were selected by the nearest-birthday method. If the young person lived with a parent, then one parent (the one with the nearest birthday) was also invited to be interviewed.

The interview was based on a vignette of a young person with a mental disorder. On a random basis, respondents were read one of four vignettes depicting depression, depression with alcohol misuse, social phobia or psychosis (schizophrenia). Vignettes described either “John” or “Jenny” with the sex of the character chosen to match that of the respondent. Respondents aged 12–17 years were read a version of the vignette portraying a person aged 15 years, while those aged 18–25 years were read a version portraying a person aged 21 years. The details of the vignettes were altered slightly to be age-appropriate. Parents who were interviewed were read the same vignette as their children. The actual vignettes are described elsewhere.9

After being presented with the vignette, respondents were asked a series of questions to assess: their recognition of the disorder in the vignette; what they would do to seek help if they had the problem; their beliefs and intentions about first aid; beliefs about interventions; beliefs about prevention, stigmatising attitudes and social distance; exposure to mental disorders; symptoms of psychological distress via the K6 screening scale;10 exposure to campaigns and media items about mental health; and sociodemographic characteristics. Parents were asked a subset of the same questions as their children, with changes in the wording to reflect the parent’s perspective.

Here, we report only on help-seeking intentions and perceived barriers. Young people were asked: “If you had a problem right now like (John/Jenny), would you go for help? Where would you go? How confident would you be in your ability to ask this (person/service) for help? Would you say: very confident, fairly confident, slightly confident, or not confident at all? What might stop you from seeking help from this (person/service)?”.

Parents were asked to imagine that John/Jenny was their child, and then: “If you had to get help from someone for (John/Jenny), where would you go? What might stop you from seeking help from this (person/service)?”

Responses to where participants would go for help were coded based on categories identified from an earlier study of mental health first aid responses of the public,11 with additional categories relevant to the younger population and different mental disorders studied. Responses were coded with a “yes” or “no” in each category, so that multiple categories were possible. Categories included: a health professional or service such as a GP/doctor, community health centre or hospital; a mental health professional or service, including psychologist, psychiatrist, counsellor, or helpline; other professionals including teacher/lecturer, naturopath, police or religious authority; another organisation, such as a youth centre, rehabilitation facility, support group or Centrelink; another person, such as family, friends, spouse, neighbour, or work colleague; and other sources, such as the Internet or phonebook. Categories of barriers to seeking help were informed by barriers identified in previous research in adolescents,12-15 and included:

• structural barriers such as cost, distance to travel, and difficulty in getting an appointment;

• stigma-related barriers such as concern that the person might feel negatively about you, concern about what other people might think of you seeking help from the person, being too embarrassed/shy, and denial/pride;

• barriers related to treatment or support offered, such as concern that what the person might say is wrong, concern about treatment side effects, not liking the type of treatment expected to be offered, thinking that nothing can help, and lack of confidence in the helper; and

• other barriers such as negative feelings/self-perceptions, confidentiality/privacy, the illness or symptoms themselves, resistance from the young person, and wanting to deal with it themselves.

Ethical approval was given by the University of Melbourne Human Research Ethics Committee.

The response rate was 61.5%, defined as the number of completed interviews (3746) of the number of sample members who could be contacted and were confirmed as being in the 12–25-year age group (6087). There were 835 males and 798 females in the 12–17-year-old group, and 958 males and 1155 females in the 18–25-year-old group. There were 2925 youth respondents with a parent in the household, and 2005 parents completed interviews, to give a response rate of 68.5%.

Box 1 shows the most frequently mentioned help-seeking intentions for young people. For adolescents, family was by far the most commonly mentioned source of help. For young adults, there was no predominant source, with GP/doctor/medical, family and friend being the most commonly mentioned.

The help-seeking intentions of young people were broadly similar across vignettes. The exception was the social phobia vignette, for which counsellors were relatively more preferred and GP/doctor/medical, family and friend relatively less so.

When predictors of help-seeking intentions were examined, young people mentioning help from GP/doctor/medical were more likely to be older (odds ratio [OR], 1.16; P < 0.001), female (OR, 1.40; P < 0.001), of English-speaking background (OR, 1.28; P = 0.043), have previously sought help (OR, 1.36; P = 0.019), know someone else who had (OR, 1.42; P < 0.001), and be aware of beyondblue (OR, 1.20; P = 0.038). Intention to seek help from a counsellor was predicted by younger age (OR, 0.94; P < 0.001), being female (OR, 1.57; P < 0.001), personal experience of help (OR, 1.70; P < 0.001), awareness of beyondblue (OR, 1.33; P = 0.003), and having received mental health information (OR, 1.38; P = 0.001). Intention to seek help from a mental health specialist/service was predicted by older age (OR, 1.07; P = 0.005), personal experience of help (OR, 1.68; P = 0.008), and having received mental health information (OR, 1.38; P = 0.029). Intention to seek help from family was predicted by younger age (OR, 0.86; P < 0.001), living with a parent (OR, 1.49; P < 0.001), and not having personal experience of help (OR, 0.69; P = 0.006). Intention to seek help from a friend was predicted by being female (OR, 1.52; P < 0.001), living with a parent (OR, 1.36; P = 0.021), and having received mental health information (OR, 1.23; P = 0.032).

Box 2 shows the help-seeking intentions of parents for their children. The pattern was quite different from the young people, with GP/doctor/medical being the predominant source of help. Mental health specialists/services were also mentioned much more often by the parents, while informal sources of help (family/friend) were mentioned much less often.

As for the young people, the help-seeking intentions of parents were broadly similar across vignettes, with the exception of social phobia, for which GP/doctor/medical was relatively less favoured, and counsellors and teachers relatively more favoured.

Box 3 shows the main barriers perceived by young people to receiving each type of help. As the barriers differed little between vignettes, findings are pooled. The barriers were similar across all types of help, with the main ones being: feeling too embarrassed/shy, and concern that the person being approached for help might feel negatively about the young person.

Box 4 shows the main barriers perceived by parents. The parents perceived fewer barriers overall, and quite different barriers from those identified by the young people. The main one was resistance from the child, and cost was also sometimes mentioned for counsellors and mental health specialist/services.

When adolescents are asked where they would seek help for a range of mental disorders, they mainly nominate family, and GPs (“GP/doctor/medical”) are only mentioned by a small minority. For young adults, family is less important and GPs relatively more so, but they are still only mentioned by a minority. By contrast, when co-resident parents are asked what help they would seek for their child, GPs are mentioned by a large majority.

Our findings about GPs can be compared with an earlier regional Australian survey covering the same age group.16 This survey used a depression or a psychosis vignette and asked the participants how they thought the person in the vignette could best be helped. The question used in this survey differed from ours, which asked where respondents would go if they wanted help. Nevertheless, the findings are similar in showing that GPs are not seen as a major source of potential help. For adolescents, 15% mentioned family doctor/GP for the depression vignette and 9% for the psychosis vignette. For young adults, this response was given by 22% for depression and 15% for psychosis. The survey did not cover parents.

These findings have some implications for Australia’ s system of primary care for mental disorders, which is based around GPs as the point of first contact, with referral to mental health specialists where necessary. Recent reforms to the funding of mental health care through the Better Outcomes in Mental Health Care initiative and the Better Access to Mental Health Care initiative have reinforced the central role of GPs, with referral to psychologists and other allied mental health professionals being based around a GP Mental Health Care Plan. This system makes a lot of sense for adults who are regular patients of GPs and are familiar with their role. However, for young people who may be having a first-onset mental disorder, GPs are not such a familiar path to getting help. When young people seek help from their families, the parents may act as a conduit to GP care, but this will not always be the case.

It is noteworthy that the perceived barriers to receiving care do not relate to the organisation or financing of the health system, but to personal factors. For young people, it is embarrassment or concern about what others think, whereas for parents it is the resistance of their child to receiving the help. The only structural health system barrier identified (by some parents) in this study was the cost of counsellors and mental health specialists. This is a barrier that has been reduced by recent government initiatives.

How might young people who develop a mental disorder be encouraged to seek help from GPs? There are several things that could be done, none of which are mutually exclusive. First, it would be possible to promote the role of GPs as a first point of contact with young people. We found that exposure to mental health information and awareness of beyondblue are associated with preferences for seeking professional help, showing that successful intervention is possible. There is other evidence showing that campaigns can improve mental health literacy.17,18 Any new intervention would have to address the barriers that young people perceive, specifically, embarrassment and concern about what the GP would think.

Second, the role of parents in facilitating appropriate help-seeking, particularly with adolescents, could be enhanced. Parents require greater skill in how to identify emerging disorders and to help their child get professional help.9

Finally, primary services could be improved to be more attractive to young people. The World Health Organization has proposed a framework for development of youth-friendly health services.6 Some of the components, such as equity and accessibility, are already provided by the Australian health system. The major deficit appears to be in acceptability. One focus of the National Youth Mental Health Foundation, headspace, will be “the creation of a service platform that will bring together youth friendly doctors, psychologists, drug and alcohol clinicians, vocational and educational counsellors, and complemented by a broader network of youth oriented agencies”.8 It is planned to have such a service platform in place in up to 30 sites nationally over the next few years. For these new services to be successful, they will have to become prominent in the minds of young people and their parents as a potential source of help. Promoting greater mental health literacy, including knowledge of help-seeking options,18 needs to go hand-in-hand with this new service development. In addition, direct contact with service providers through outreach activities with youth may be necessary to reduce the stigma barriers identified in our study.