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Do Help-Seeking Intentions During Early Adolescence Vary for Adolescents Experiencing Different Levels of Depressive Symptoms?
Journal of Adolescent Health 50 (2012) 236 –242
www.jahonline.org Original article
Do Help-Seeking Intentions During Early Adolescence Vary for Adolescents Experiencing Different Levels of Depressive Symptoms? Michael G. Sawyer, M.B.B.S., Ph.D.a,b,*, Nina Borojevic b, Kerry A. Ettridge, Ph.D.c, Susan H. Spence, Ph.D.d, Jeanie Sheffield, Ph.D.e, and John Lynch, Ph.D., M.P.H.f,g a
Discipline of Paediatrics, University of Adelaide, North Adelaide, South Australia, Australia Research and Evaluation Unit, Children, Youth and Women’s Health Service, North Adelaide, South Australia, Australia Behavioural Research and Evaluation Unit, Cancer Council SA, South Australia, Australia d Office of the Vice Chancellor, Griffith University, Queensland, Australia e School of Psychology, University of Queensland, Queensland, Australia f Discipline of Public Health, School of Population Health and Clinical Practice, University of Adelaide, Adelaide, Australia g School of Community and Social Medicine, University of Bristol, Bristol, United Kingdom b c
Article history: Received October 19, 2010; Accepted June 16, 2011 Keywords: Adolescents; Depression; Help-seeking; Social support
A B S T R A C T
Purpose: To investigate whether help-seeking intentions for depressive symptoms vary for adolescents experiencing low, mild-to-moderate, and high levels of depressive symptoms. Methods: A total of 5,362 participants aged 12–14 years had completed the baseline assessment for a randomized controlled trial evaluating the effectiveness of a universal intervention designed to reduce depressive symptoms among high school students. The participants reported their help-seeking intentions in response to a vignette describing an individual experiencing depressive symptoms consistent with a diagnosis of a minor depressive disorder. Standard measures were used to assess participants’ level of depressive symptoms and perceived level of social support. Results: Logistic regression models examined relationships between help-seeking intentions and levels of depression, after adjustment for demographic characteristics and perceived support. As compared with those with low levels of depressive symptoms, adolescents with high levels of symptoms reported less intention to seek help from friends (odds ratio [OR] ⫽ .42) or family members (OR ⫽ .29). They were also four times more likely to report that they would not seek help from anybody (OR ⫽ 4.55). A similar pattern was evident during comparisons of help-seeking intentions reported by adolescents with mild-to-moderate levels of depressive symptoms versus those with low levels of symptoms. Conclusions: Targeted and universal interventions need to encourage peers and family members to actively engage with young adolescents experiencing depressive symptoms rather than waiting for them to initiate help-seeking. This is particularly important for adolescents experiencing higher levels of depressive symptoms who may not initiate help-seeking themselves. 䉷 2012 Society for Adolescent Health and Medicine. All rights reserved.
At any time, 3%–5% of adolescents experience depressive disorders [1,2]. However, only a small proportion of these adolescents receive professional help [2,3]. For example, the
* Address correspondence to: Michael G. Sawyer, M.B.B.S., Ph.D., Research and Evaluation Unit, Children, Youth and Women’s Health Service, 72 King, William Road, North Adelaide, South Australia 5006, Australia. E-mail address: [email protected] (M.G. Sawyer).
Child and Adolescent Component of the Australian National Mental Health Survey reported that only 25% of young people with mental health problems in Australia had attended professional services [2]. Epidemiologic studies of adults and older adolescents have shown that females, younger age groups, and those with higher levels of mental health problems more frequently receive help from professional and informal sources [4 – 6]. In a
1054-139X/$ - see front matter 䉷 2012 Society for Adolescent Health and Medicine. All rights reserved. doi:10.1016/j.jadohealth.2011.06.009
M.G. Sawyer et al. / Journal of Adolescent Health 50 (2012) 236 –242
study of 2,419 adolescents enrolled in ninth through 12th grades in the United States, Gould et al [7] reported that adolescents with higher levels of suicidal ideation, substance abuse, and depressive symptoms made greater use of maladaptive help-seeking and coping strategies associated with isolative behaviors than those with fewer problems in these areas. However, a limitation of epidemiologic studies is that individuals who had attended professional services may have already received help for their problems. This has the potential to confound the relationship between level of mental health problems and service attendance in these studies. Furthermore, service attendance by adolescents may occur because parents or teachers consider that an adolescent should be referred to a professional service rather than help-seeking initiated by the adolescent. An alternative approach to study help-seeking intentions by adolescents makes use of vignettes in which the nature and level of mental health problems are specified. Level of need is controlled by the use of the vignette, which specifies the level of mental health problems for which help is being sought [8 –10]. This approach has increasingly been used to assess mental health literacy and identify factors that are associated with the intention to seek help from informal and professional sources [11–16]. The work is based on the theory of planned behavior, which suggests that intention is a good predictor of subsequent behavior if target behavior, time frame, and context are clearly specified [17–19]. Using this approach, previous studies have shown that female gender, greater social support, and more positive help-seeking attitudes are associated with a stronger intention to seek help for mental health problems [13,14,16,20]. For example, in a study of adolescents from predominantly middle- and upper-class backgrounds (n ⫽ 254, 15–17 years), Sheffield et al [16] reported a significant relationship between social support, adaptive functioning, psychological distress, and a willingness to seek help for mental health problems. Recently, in a study of young adults (n ⫽ 302, 18 –25 years), Wilson and Deane [15] found that higher levels of suicidal ideation were related to lower help-seeking intentions from family, friends, and professional services, and a higher intention to not seek help from anyone. The authors suggested that cognitive distortions experienced by participants with higher levels of suicidal ideation and/or their affective state may impede more rational help-seeking intentions [15]. This apparently paradoxical behavior has been called “help-negation” [21]. To date, studies of this pattern of help-seeking intentions have largely focused on a failure by individuals with high levels of suicidal ideation to seek help for their problems [21]. However, it has been suggested that the phenomenon may also occur among individuals with severe depression and/or anxiety, because such individuals lack motivation to seek help or because they believe that they should keep their feelings to themselves [15]. To date, little information is available about the extent to which help-seeking intentions vary in adolescents experiencing different levels of depressive symptoms (for brevity, the term “adolescent” is used to describe 12–14-year-olds in this study). This is a significant omission because a better understanding about this relationship has the potential to aid development and implementation of interventions designed to more effectively link adolescents experiencing depressive symptoms with potential sources of help. The principal aim of
237
Table 1 Demographic characteristics of study participants (N ⫽ 5,362) Characteristic Gender Male Age 12 years 13 years 14 years Parent marital status Living together Separated/divorced Other Language spoken at home English English and another language Another language Parent employment status Mother employed Father employed
Percentage
47 11 72 17 71 24 5 87 12 1 73 91
the present study was to examine whether help-seeking intentions of 12–14-year-olds in the community vary by levels of depressive symptoms, after adjusting for demographic characteristics and perceptions of social support. Methods Participants The demographic characteristics of participants in this study (N ⫽ 5,362) are shown in Table 1. All of them had participated in the baseline assessment for a randomized controlled trial evaluating the effectiveness of a school-wide intervention designed to reduce depressive symptoms among high school students [22]. Full details of the participants in the trial have been previously reported [22]. They were enrolled in year 8 in one of the 50 schools located in three Australian States, namely Queensland (n ⫽ 18), South Australia (n ⫽ 16), and Victoria (n ⫽ 16). Schools were recruited through an “expression of interest” process in both metropolitan and rural regions, and across different socioeconomic levels. The overall response rate for the trial was 64% (N ⫽ 5,634) [22]. For this study, we excluded 27 participants whose ages at enrollment were ⬍12 years or ⬎14 years. A small number of 12–14-year-olds (138 males, 107 females) were also excluded because of missing data, primarily on the Center for Epidemiologic Studies Depression Scale (CES-D) (n ⫽ 126) and/or one or more of the help-seeking questions (n ⫽ 204). As compared with 12–14-year-olds retained in the study, those excluded were more frequently male (56% vs. 47%, 2 ⫽ 8.98, p ⫽ .003), spoke “English and another language” or “another language” at home (18% vs. 13%, 2 ⫽ 6.29, p ⫽ .01), and had parents who were not in paid employment (mothers: 36% vs. 27%, 2 ⫽ 9.72, p ⫽ .002; fathers: 13% vs. 9%, 2 ⫽ 4.60, p ⫽ .03). However, there was no significant difference in the proportions with parents living together (66% vs. 71%, 2 ⫽ 2.58, p ⫽ .3). Informed consent was obtained from all participants and their parents before the baseline assessment. The questionnaire booklet for the assessment was completed by students in their classroom with appropriate arrangements to ensure privacy for individual students. Ethics approval was obtained from the De-
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partment of Education and Children’s Services South, Australia; Department of Education, Employment and Training, Victoria; and Queensland Government Department of Education and the Arts. Measures Help-seeking vignette. The questionnaire booklet contained a vignette that said, “You have a friend who has been sad for the past few weeks. They have stopped doing things they usually enjoy and say they feel tired all the time. Teachers keep telling them they have to concentrate more in class.” The depressive symptoms in the vignette were consistent with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnosis of minor depressive episode [23]. Its development was based on previous studies that have used vignettes to assess adolescents’ understanding of mental disorders with readability set at a level appropriate for 8th grade students [8 – 10]. The symptom content of the vignette was reviewed by clinical researchers for face validity and conformity with diagnostic criteria. After the participants read the vignette, they indicated whether, if they were experiencing the symptoms described in the vignette, they would seek help from any of several potential sources of help “in the next few days.” Adolescents responded using a three-point scale in which the answers were labeled “Yes,” “No,” and “Not Sure.” For the purpose of analyses in the present study responses were grouped into “Yes” and “No/Not Sure.” Potential sources of help in the questionnaire were identified from results of the Child and Adolescent Component of the Australian National Mental Health Survey [2]. It consisted of informal sources (“family,” “friends”), school services (“school counsellor or school nurse,” “teacher”), health services (“doctor”), and indirect services (“internet,” “telephone helplines”). The participants were also asked whether they would not seek help from anybody. Center for epidemiologic studies depression scale (CES-D). The CES-D consists of 20 items describing a wide range of depressive symptomatology. Summed scores can range from 0 to 60 with higher scores indicating more depressive symptoms. Recommended cut-off scores were used to group participants into low (0 –15), mild-to-moderate (16 –30), or high (31– 60) depressive symptom groups [24]. The scale has previously been used to
assess adolescent depressive symptoms in large-scale epidemiologic studies in Australia and it has a strong reliability and construct validity [2,25–27]. Multidimensional perceived social support scale. The multidimensional perceived support subscale (MPSS) was used to measure perceived social support [28]. The scale includes 12 items comprising three subscales: perceived social support from family (four items), friends (four items) and a significant other (four items). Participants respond using a seven-point scale with endpoints labeled “very strongly disagree” and “very strongly agree.” Subscale scores range from 4 to 28 with higher scores reflecting a higher level of perceived social support. The items comprising the scale are shown in the study by Zimet et al [28] and there is substantial information available about its psychometric properties [28 –31]. Data analysis Bivariate and multivariate logistic regression analyses were used to identify the strength of the relationship between adolescents’ help-seeking intentions and level of depressive symptoms. Bivariate analyses examined the strength of the relationship between help-seeking from each source (the outcome variable) and level of depressive symptoms (i.e., “mildmoderate” level of symptoms or “high” level of symptoms with “low” comprising the reference category in each case), gender, age, parent marital status, language spoken at home, parental employment, and each of the three MPSS subscale scores. As the distribution of MPSS subscale scores was not normal, the continuous scores were dichotomized, using the median score as the cut-off. Multivariate analyses examined the strength of the relationship between help-seeking from each potential source of help and level of depressive symptoms, with adjustment for gender, age, parent marital status, language spoken at home, parental employment, and the three MPSS subscale scores. In a separate analysis, we examined the strength of the relationship between help-seeking from friends and level of depression, while adjusting for the MPSS friends subscale score (that is, this statistical model did not include the MPSS family and significant other subscale scores). Similarly, we examined the strength
Table 2 Percentage of adolescents who intend to seek help in response to the vignette CES-D score Source Informal support Friends Family Health services Medical practitioner School services Counselor/nurse Teacher Indirect Telephone helpline Internet Nobody
All adolescents (n ⫽ 5,362)
Low (0 –15) (n ⫽ 3,532)
Mild-moderate (16 –30) (n ⫽ 1,287)
High (ⱖ31) (n ⫽ 543)
pa
80% 73%
83% 80%
77% 64%
70% 47%
⬍.001 ⬍.001
17%
16%
18%
17%
.61
29% 19%
28% 21%
29% 18%
33% 15%
.06 .003
24% 11% 8%
22% 9% 5%
26% 14% 10%
30% 15% 20%
⬍.001 ⬍.001 ⬍.001
CES-D ⫽ Center for Epidemiologic Studies Depression Scale. a Chi-square testing for the significance of differences across the low, mild-to-moderate, and high-depressive symptoms groups (based on CES-D scores).
M.G. Sawyer et al. / Journal of Adolescent Health 50 (2012) 236 –242
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Table 3 Odds ratios (ORs) and 95% confidence intervals (CIs) describing the bivariable relationship between help-seeking, gender, and perceived support Perceived supportb Help source Informal Friends Family Health services Medical practitioner School services Counselor/nurse Teacher Indirect Telephone helpline Internet Nobody a b
a
Gender
Family
Friends
Significant other
.31 (.27–.35) 1.13 (1.00–1.28)
1.70 (1.49–1.95) 5.68 (4.94–6.54)
5.92 (5.02–6.97) 1.40 (1.24–1.58)
2.76 (2.40–3.18) 2.41 (2.13–2.73)
1.47 (1.27–1.70)
1.26 (1.09–1.46)
.93 (.81–1.08)
1.08 (.93–1.24)
.72 (.64–.81) 1.31 (1.14–1.50)
1.27 (1.12–1.42) 1.95 (1.69–2.24)
1.31 (1.16–1.48) 1.23 (1.07–1.40)
1.57 (1.39–1.77) 1.49 (1.29–1.71)
.75 (.66–.85) 1.44 (1.21–1.72) 1.87 (1.52–2.30)
1.10 (.97–1.25) .58 (.49–.69) .30 (.24–.38)
1.22 (1.08–1.39) .72 (.60–.86) .37 (.29–.46)
1.24 (1.09–1.41) .73 (.61–.87) .29 (.23–.37)
For Gender, female coded 0 (reference category), male coded 1. For MPSS, scores at or below median coded 0 (reference category), scores above median coded 1.
of the relationship between help-seeking from family members and level of depression, while adjusting for the MPSS Family Subscale score. Results Overall, 80% of adolescents reported that they would seek help from friends and 73% from family members if they experienced the depressive symptoms described in the vignette (Table 2). A smaller percentage would seek help from other sources, ranging from 11% who would seek help from the Internet through to 29% from school counselors/nurses. Eight percent reported that they would not seek help from anyone if they experienced the symptoms in the vignette. Four other findings are evident in Table 2. First, friends and family were the most commonly identified source of help regardless of adolescents’ level of depressive symptoms. A somewhat smaller proportion of adolescents reported that they would seek help from school counselors/nurses, teachers, telephone helplines, and doctors. Second, compared with adolescents in the low-depression group, a smaller percentage of adolescents in the high-depression group reported that they would seek help from friends or family. For example, only 47% of adolescents with a high level of depressive symptoms reported that they would seek help from family members as
compared with 80% of adolescents with a low level of symptoms. Third, a larger percentage of adolescents with high levels of depressive symptoms reported that they would seek help from telephone helplines or the Internet than was reported by adolescents with lower levels of symptoms. For example, 15% of adolescents with a high level of symptoms reported that they would seek help from the Internet versus 9% of adolescents with a low level of symptoms. Finally, four times as many adolescents with a high level of symptoms reported that they would not seek help from anyone as compared with those with a low level of symptoms. Results from the bivariable logistic regression analyses examining the relationship between adolescents’ help-seeking intentions, gender, and perceived level of support are shown in Table 3. It can be seen that males were significantly less likely than females to seek help from friends, school counselors/nurses, or telephone helplines with ORs between .31 and .75 (95% confidence intervals [CIs] are shown in Tables 3–5). However, they were more likely to seek help from medical practitioners, teachers, and the Internet (odds ratios [ORs] ⫽ 1.31–1.47). They were also more likely than females to not seek help from anybody (OR ⫽ 1.87). Adolescents who perceived more support from family, friends, or a “significant other” were more likely to seek help from friends, family members, and school staff (ORs ⫽ 1.23–5.92) but were less
Table 4 Odds ratios (ORs) and 95% confidence intervals (CIs) describing the relationship between help-seeking and levels of depressiona Adjusted ORb
Unadjusted OR Help source Informal Friends Family Health services Medical practitioner School services Counselor/nurse Teacher Indirect Telephone helpline Internet Nobody a b
Mild-moderate (16 –30)
High (ⱖ31)
Mild-moderate (16 –30)
High (ⱖ31)
.68 (.58–.79) .44 (.38–.50)
.48 (.39–.58) .22 (.18–.26)
.67 (.56–.80) .54 (.46–.63)
.42 (.33–.54) .29 (.24–.36)
1.09 (.92–1.29)
1.05 (.82–1.33)
1.14 (.95–1.37)
1.15 (.88–1.49)
1.04 (.91–1.20) .82 (.69–.96)
1.27 (1.04–1.53) .70 (.55–.90)
1.07 (.92–1.24) 1.00 (.84–1.19)
1.29 (1.05–1.59) .92 (.71–1.20)
1.20 (1.03–1.39) 1.62 (1.33–1.97) 2.08 (1.63–2.64)
1.48 (1.21–1.81) 1.76 (1.36–2.29) 4.86 (3.75–6.30)
1.21 (1.03–1.42) 1.48 (1.20–1.82) 1.90 (1.47–2.46)
1.48 (1.20–1.84) 1.61 (1.22–2.14) 4.55 (3.41–6.08)
For CES-D scores, 0 –15 coded 0 (reference category), 16 –30 coded 1, ⱖ31 coded 2. Adjusted for gender, age, parent marital status, language spoken at home, parental employment, and MPSS friends, family, and significant other subscale scores; for gender, female coded 0 (reference category), male coded 1; for MPSS subscales, scores at or below median coded 0 (reference category), scores above median coded 1.
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Table 5 Odds ratios (ORs) and 95% confidence intervals (CIs) describing the relationship between help-seeking and levels of depressiona, adjusting for perceived support from friends or family OR (95% CI)b Mild-moderate High (ⱖ31) Help source (16 –30) Friends Family a
b
c
.80 (.68–.94) .57 (.49–.66)
OR (95% CI)c Mild-moderate High (16 –30) (ⱖ31)
.56 (.45–.70) .68 (.57–.81) .31 (.25–.37) .55 (.47–.65)
.42 (.33–.53) .30 (.25–.38)
For CES-D scores, 0 –15 coded 0 (reference category), 16 –30 coded 1, ⱖ31 coded 2. Adjusted for MPSS friends subscale score in the model predicting likelihood of help-seeking from friends, and MPSS family subscale score in the model predicting likelihood of help-seeking from family. Adjusted for MPSS friends or family subscale score and gender, age, parent marital status, language spoken at home, parental employment.
likely to seek help from the Internet (ORs .58 –.73). There was no consistent relationship between help-seeking intentions and adolescent age, parent marital status, language spoken at home, or parent employment (not shown in Table 3), with only 12 of the 40 ORs being statistically significant (p ⬍ .05). Results from bivariate and multivariate logistic regression analyses examining the relationship between help-seeking intentions and levels of depression are shown in Table 4. The adjusted ORs indicate that adolescents in the mild-to-moderate and high-depression groups were less likely to seek help from friends and family members than those in the low-depression group, with odds ratios ranging from .29 to .67. In contrast, adolescents in the mild-to-moderate and high-depression groups were more likely to seek help from telephone helplines and the Internet (ORs ⫽ 1.21–1.61). It can also be observed that adolescents with high levels of depressive symptoms were four times more likely to report that they would not seek help from anybody. In all areas, the size of the ORs changed little after adjustment for the effect of demographic characteristics and perceived level of support from friends, family members, and significant others (Table 4). The ORs in Table 5 show that help-seeking intentions from friends or family members were significantly lower among those with higher levels of depressive symptoms, after adjustment for perception of support from the source of help that was the focus of the help-seeking intention in each statistical model. Discussion In the present study, young adolescents most frequently identified friends and family members as sources of help for symptoms of depression. However, those with high levels of depressive symptoms less frequently reported that they would seek help from these sources than those with lower levels of symptoms. They were also four times more likely to report that they would not seek help from anybody. Across all sources of help, differences in help-seeking intentions remained evident after adjusting for adolescents’ demographic characteristics and their perceptions of social support. The results also showed that differences in relation to help-seeking intentions from friends and family members did not arise because of different perceptions of support available from these particular sources of help. The findings suggest that the phenomenon of help negation [15,21], previously described with suicidal ideation, may also occur among young adolescents experiencing higher levels of depres-
sive symptoms. As suggested by Wilson and Deane [15], perhaps lack of motivation or concerns about keeping feelings to themselves leads adolescents with higher levels of depressive symptoms to less frequently seek help for their problems. The pattern of findings is consistent with results from previous studies describing help-seeking intentions for suicidal ideation and depressive symptoms in older populations [5,11,14,15,21,32,33]. For example, males and females differed in the frequency with which they intended to seek help from several potential sources of help. Females more frequently identified than males that they would seek help from friends, school counselors/nurses, and telephone helplines. Males more frequently identified medical practitioners, teachers, and the Internet. Rickwood and Braithwaite [14] suggest that expressing emotion and confiding problems may have a different effect for males and females within their peer groups. For females, it may serve to consolidate friendships; however, among males, it may be interpreted as a sign of weakness and have a negative effect on peer relationships. Interventions designed to improve helpseeking intentions by young adolescents with depressive symptoms need to take into account these different patterns of helpseeking intentions reported by males and females. For example, males may prefer more “impersonal” forms of help with less emotional closeness, as evidenced in the different intentions expressed by males versus females for seeking help from teachers versus school counselors and the Internet versus telephone helplines. Of concern is the finding that 20% of adolescents with a high level of depressive symptoms stated that they would not seek help from anybody if they experienced symptoms consistent with minor depressive disorder. Similar findings have been reported in previous epidemiologic studies. For example, Rickwood and Braithwaite [14] reported that 23% of Australian 16 – 19-year-old high school students (n ⫽ 715) with General Health Questionnaire score ⬎4 (reflecting “moderate or severe psychological impairment,” p. 565) had not sought help from anyone in the previous 12 weeks, and only 175 of them had sought professional help. Oliver et al [5] reported that 22% of British 16 – 64year-olds (N ⫽ 10,842) with a General Health Questionnaire score ⱖ8 had not sought help from anyone. In the present study, a possible explanation for the greater frequency with which males reported that they would not seek help from anybody is that males less commonly recognize depressive symptoms than females [10]. Two recent studies support this explanation. In their study, Cotton et al [33] have shown that among 12–25year-olds (N ⫽ 1,207), males recognize depressive symptoms less frequently and are more likely to endorse the use of alcohol to deal with mental health problems. Similarly, Klineberg et al [11] have reported that female adolescents identify both mild and severe depressive symptoms more accurately than males. The authors suggested that this may delay help-seeking intentions among males. A challenge for studies using vignettes is knowing the extent to which help-seeking intentions reflect the behavior that would actually occur if individuals experienced the symptoms described in the vignette. Support for this approach is provided in a recent meta-analysis which found that in crosssectional studies the strength of the relationship between intentions and behavior was equivalent to a large effect size (d ⫽ 1.47) [19,33]. In more rigorous experimental prospective studies, medium-to-large changes in intention (d ⫽ .66) were associated with small-to-medium changes in behavior (d ⫽
M.G. Sawyer et al. / Journal of Adolescent Health 50 (2012) 236 –242
.36) [19]. The consistency of results found in the present study and in previous epidemiologic studies is also reassuring [5,11,14]. For example, in the present study, 33% of adolescents with a high level of depressive symptoms identified school counselors as a source of help and 25% of adolescents with depressive disorders in the Australian national survey [2] had actually attended school counseling during the 6 months before the study. Similarly, 17% of adolescents in the present study identified medical practitioners as a source of help and 24% had attended medical practitioners in the national survey. The general similarity of the findings suggests that the use of the vignette to assess behavioral intentions in the present study is providing a reasonable indication of the help-seeking behavior of adolescents when they experience a depressive episode. A limitation of the present study, which should be considered when interpreting results, is its use of a cross-sectional methodology. This limits the extent to which the direction of cause-and-effect relationships can be identified between variables showing a significant association. The study sample was also limited to younger adolescents, and a substantial number of potential participants did not enroll in the study. Finally, it is possible that there is no association between levels of depression and help-seeking intentions, and the associations identified in the present study represent chance findings among multiple comparisons. The strengths of the study include use of a large community sample of adolescents who described their help-seeking intentions in response to a standard description of depressive symptoms. This approach has the potential to avoid confounding between levels of depressive symptoms and service attendance, which can occur in studies using service attendance to assess the relationship between levels of mental health problems and help-seeking behavior. Four implications arise from the present study. First, it is important that universal and targeted interventions include a focus on improving the quality of the social support offered by peers and family members to young adolescents experiencing depressive symptoms. Second, interventions need to encourage peers and family members to actively engage with young adolescents experiencing depressive symptoms rather than waiting for them to initiate help-seeking. This is particularly important for adolescents experiencing higher levels of depressive symptoms who may not initiate help-seeking themselves. Third, the increasing availability of good quality interventions delivered on the Internet offers a potentially important avenue of help for young people who are reluctant to seek face-to-face counseling but who will seek help through the Internet. Finally, although not the focus of the present study, it is important that both peers and family members have sufficient knowledge to respond appropriately when trying to help young adolescents with depressive symptoms. A promising approach in this area is the use of mental health first aid programs being developed in Australia [12]. Acknowledgments The study was funded by beyondblue and the National Health and Medical Research Council. Linda Frost assisted with data analysis for the study.
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www.jahonline.org Original article
Do Help-Seeking Intentions During Early Adolescence Vary for Adolescents Experiencing Different Levels of Depressive Symptoms? Michael G. Sawyer, M.B.B.S., Ph.D.a,b,*, Nina Borojevic b, Kerry A. Ettridge, Ph.D.c, Susan H. Spence, Ph.D.d, Jeanie Sheffield, Ph.D.e, and John Lynch, Ph.D., M.P.H.f,g a
Discipline of Paediatrics, University of Adelaide, North Adelaide, South Australia, Australia Research and Evaluation Unit, Children, Youth and Women’s Health Service, North Adelaide, South Australia, Australia Behavioural Research and Evaluation Unit, Cancer Council SA, South Australia, Australia d Office of the Vice Chancellor, Griffith University, Queensland, Australia e School of Psychology, University of Queensland, Queensland, Australia f Discipline of Public Health, School of Population Health and Clinical Practice, University of Adelaide, Adelaide, Australia g School of Community and Social Medicine, University of Bristol, Bristol, United Kingdom b c
Article history: Received October 19, 2010; Accepted June 16, 2011 Keywords: Adolescents; Depression; Help-seeking; Social support
A B S T R A C T
Purpose: To investigate whether help-seeking intentions for depressive symptoms vary for adolescents experiencing low, mild-to-moderate, and high levels of depressive symptoms. Methods: A total of 5,362 participants aged 12–14 years had completed the baseline assessment for a randomized controlled trial evaluating the effectiveness of a universal intervention designed to reduce depressive symptoms among high school students. The participants reported their help-seeking intentions in response to a vignette describing an individual experiencing depressive symptoms consistent with a diagnosis of a minor depressive disorder. Standard measures were used to assess participants’ level of depressive symptoms and perceived level of social support. Results: Logistic regression models examined relationships between help-seeking intentions and levels of depression, after adjustment for demographic characteristics and perceived support. As compared with those with low levels of depressive symptoms, adolescents with high levels of symptoms reported less intention to seek help from friends (odds ratio [OR] ⫽ .42) or family members (OR ⫽ .29). They were also four times more likely to report that they would not seek help from anybody (OR ⫽ 4.55). A similar pattern was evident during comparisons of help-seeking intentions reported by adolescents with mild-to-moderate levels of depressive symptoms versus those with low levels of symptoms. Conclusions: Targeted and universal interventions need to encourage peers and family members to actively engage with young adolescents experiencing depressive symptoms rather than waiting for them to initiate help-seeking. This is particularly important for adolescents experiencing higher levels of depressive symptoms who may not initiate help-seeking themselves. 䉷 2012 Society for Adolescent Health and Medicine. All rights reserved.
At any time, 3%–5% of adolescents experience depressive disorders [1,2]. However, only a small proportion of these adolescents receive professional help [2,3]. For example, the
* Address correspondence to: Michael G. Sawyer, M.B.B.S., Ph.D., Research and Evaluation Unit, Children, Youth and Women’s Health Service, 72 King, William Road, North Adelaide, South Australia 5006, Australia. E-mail address: [email protected] (M.G. Sawyer).
Child and Adolescent Component of the Australian National Mental Health Survey reported that only 25% of young people with mental health problems in Australia had attended professional services [2]. Epidemiologic studies of adults and older adolescents have shown that females, younger age groups, and those with higher levels of mental health problems more frequently receive help from professional and informal sources [4 – 6]. In a
1054-139X/$ - see front matter 䉷 2012 Society for Adolescent Health and Medicine. All rights reserved. doi:10.1016/j.jadohealth.2011.06.009
M.G. Sawyer et al. / Journal of Adolescent Health 50 (2012) 236 –242
study of 2,419 adolescents enrolled in ninth through 12th grades in the United States, Gould et al [7] reported that adolescents with higher levels of suicidal ideation, substance abuse, and depressive symptoms made greater use of maladaptive help-seeking and coping strategies associated with isolative behaviors than those with fewer problems in these areas. However, a limitation of epidemiologic studies is that individuals who had attended professional services may have already received help for their problems. This has the potential to confound the relationship between level of mental health problems and service attendance in these studies. Furthermore, service attendance by adolescents may occur because parents or teachers consider that an adolescent should be referred to a professional service rather than help-seeking initiated by the adolescent. An alternative approach to study help-seeking intentions by adolescents makes use of vignettes in which the nature and level of mental health problems are specified. Level of need is controlled by the use of the vignette, which specifies the level of mental health problems for which help is being sought [8 –10]. This approach has increasingly been used to assess mental health literacy and identify factors that are associated with the intention to seek help from informal and professional sources [11–16]. The work is based on the theory of planned behavior, which suggests that intention is a good predictor of subsequent behavior if target behavior, time frame, and context are clearly specified [17–19]. Using this approach, previous studies have shown that female gender, greater social support, and more positive help-seeking attitudes are associated with a stronger intention to seek help for mental health problems [13,14,16,20]. For example, in a study of adolescents from predominantly middle- and upper-class backgrounds (n ⫽ 254, 15–17 years), Sheffield et al [16] reported a significant relationship between social support, adaptive functioning, psychological distress, and a willingness to seek help for mental health problems. Recently, in a study of young adults (n ⫽ 302, 18 –25 years), Wilson and Deane [15] found that higher levels of suicidal ideation were related to lower help-seeking intentions from family, friends, and professional services, and a higher intention to not seek help from anyone. The authors suggested that cognitive distortions experienced by participants with higher levels of suicidal ideation and/or their affective state may impede more rational help-seeking intentions [15]. This apparently paradoxical behavior has been called “help-negation” [21]. To date, studies of this pattern of help-seeking intentions have largely focused on a failure by individuals with high levels of suicidal ideation to seek help for their problems [21]. However, it has been suggested that the phenomenon may also occur among individuals with severe depression and/or anxiety, because such individuals lack motivation to seek help or because they believe that they should keep their feelings to themselves [15]. To date, little information is available about the extent to which help-seeking intentions vary in adolescents experiencing different levels of depressive symptoms (for brevity, the term “adolescent” is used to describe 12–14-year-olds in this study). This is a significant omission because a better understanding about this relationship has the potential to aid development and implementation of interventions designed to more effectively link adolescents experiencing depressive symptoms with potential sources of help. The principal aim of
237
Table 1 Demographic characteristics of study participants (N ⫽ 5,362) Characteristic Gender Male Age 12 years 13 years 14 years Parent marital status Living together Separated/divorced Other Language spoken at home English English and another language Another language Parent employment status Mother employed Father employed
Percentage
47 11 72 17 71 24 5 87 12 1 73 91
the present study was to examine whether help-seeking intentions of 12–14-year-olds in the community vary by levels of depressive symptoms, after adjusting for demographic characteristics and perceptions of social support. Methods Participants The demographic characteristics of participants in this study (N ⫽ 5,362) are shown in Table 1. All of them had participated in the baseline assessment for a randomized controlled trial evaluating the effectiveness of a school-wide intervention designed to reduce depressive symptoms among high school students [22]. Full details of the participants in the trial have been previously reported [22]. They were enrolled in year 8 in one of the 50 schools located in three Australian States, namely Queensland (n ⫽ 18), South Australia (n ⫽ 16), and Victoria (n ⫽ 16). Schools were recruited through an “expression of interest” process in both metropolitan and rural regions, and across different socioeconomic levels. The overall response rate for the trial was 64% (N ⫽ 5,634) [22]. For this study, we excluded 27 participants whose ages at enrollment were ⬍12 years or ⬎14 years. A small number of 12–14-year-olds (138 males, 107 females) were also excluded because of missing data, primarily on the Center for Epidemiologic Studies Depression Scale (CES-D) (n ⫽ 126) and/or one or more of the help-seeking questions (n ⫽ 204). As compared with 12–14-year-olds retained in the study, those excluded were more frequently male (56% vs. 47%, 2 ⫽ 8.98, p ⫽ .003), spoke “English and another language” or “another language” at home (18% vs. 13%, 2 ⫽ 6.29, p ⫽ .01), and had parents who were not in paid employment (mothers: 36% vs. 27%, 2 ⫽ 9.72, p ⫽ .002; fathers: 13% vs. 9%, 2 ⫽ 4.60, p ⫽ .03). However, there was no significant difference in the proportions with parents living together (66% vs. 71%, 2 ⫽ 2.58, p ⫽ .3). Informed consent was obtained from all participants and their parents before the baseline assessment. The questionnaire booklet for the assessment was completed by students in their classroom with appropriate arrangements to ensure privacy for individual students. Ethics approval was obtained from the De-
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partment of Education and Children’s Services South, Australia; Department of Education, Employment and Training, Victoria; and Queensland Government Department of Education and the Arts. Measures Help-seeking vignette. The questionnaire booklet contained a vignette that said, “You have a friend who has been sad for the past few weeks. They have stopped doing things they usually enjoy and say they feel tired all the time. Teachers keep telling them they have to concentrate more in class.” The depressive symptoms in the vignette were consistent with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision diagnosis of minor depressive episode [23]. Its development was based on previous studies that have used vignettes to assess adolescents’ understanding of mental disorders with readability set at a level appropriate for 8th grade students [8 – 10]. The symptom content of the vignette was reviewed by clinical researchers for face validity and conformity with diagnostic criteria. After the participants read the vignette, they indicated whether, if they were experiencing the symptoms described in the vignette, they would seek help from any of several potential sources of help “in the next few days.” Adolescents responded using a three-point scale in which the answers were labeled “Yes,” “No,” and “Not Sure.” For the purpose of analyses in the present study responses were grouped into “Yes” and “No/Not Sure.” Potential sources of help in the questionnaire were identified from results of the Child and Adolescent Component of the Australian National Mental Health Survey [2]. It consisted of informal sources (“family,” “friends”), school services (“school counsellor or school nurse,” “teacher”), health services (“doctor”), and indirect services (“internet,” “telephone helplines”). The participants were also asked whether they would not seek help from anybody. Center for epidemiologic studies depression scale (CES-D). The CES-D consists of 20 items describing a wide range of depressive symptomatology. Summed scores can range from 0 to 60 with higher scores indicating more depressive symptoms. Recommended cut-off scores were used to group participants into low (0 –15), mild-to-moderate (16 –30), or high (31– 60) depressive symptom groups [24]. The scale has previously been used to
assess adolescent depressive symptoms in large-scale epidemiologic studies in Australia and it has a strong reliability and construct validity [2,25–27]. Multidimensional perceived social support scale. The multidimensional perceived support subscale (MPSS) was used to measure perceived social support [28]. The scale includes 12 items comprising three subscales: perceived social support from family (four items), friends (four items) and a significant other (four items). Participants respond using a seven-point scale with endpoints labeled “very strongly disagree” and “very strongly agree.” Subscale scores range from 4 to 28 with higher scores reflecting a higher level of perceived social support. The items comprising the scale are shown in the study by Zimet et al [28] and there is substantial information available about its psychometric properties [28 –31]. Data analysis Bivariate and multivariate logistic regression analyses were used to identify the strength of the relationship between adolescents’ help-seeking intentions and level of depressive symptoms. Bivariate analyses examined the strength of the relationship between help-seeking from each source (the outcome variable) and level of depressive symptoms (i.e., “mildmoderate” level of symptoms or “high” level of symptoms with “low” comprising the reference category in each case), gender, age, parent marital status, language spoken at home, parental employment, and each of the three MPSS subscale scores. As the distribution of MPSS subscale scores was not normal, the continuous scores were dichotomized, using the median score as the cut-off. Multivariate analyses examined the strength of the relationship between help-seeking from each potential source of help and level of depressive symptoms, with adjustment for gender, age, parent marital status, language spoken at home, parental employment, and the three MPSS subscale scores. In a separate analysis, we examined the strength of the relationship between help-seeking from friends and level of depression, while adjusting for the MPSS friends subscale score (that is, this statistical model did not include the MPSS family and significant other subscale scores). Similarly, we examined the strength
Table 2 Percentage of adolescents who intend to seek help in response to the vignette CES-D score Source Informal support Friends Family Health services Medical practitioner School services Counselor/nurse Teacher Indirect Telephone helpline Internet Nobody
All adolescents (n ⫽ 5,362)
Low (0 –15) (n ⫽ 3,532)
Mild-moderate (16 –30) (n ⫽ 1,287)
High (ⱖ31) (n ⫽ 543)
pa
80% 73%
83% 80%
77% 64%
70% 47%
⬍.001 ⬍.001
17%
16%
18%
17%
.61
29% 19%
28% 21%
29% 18%
33% 15%
.06 .003
24% 11% 8%
22% 9% 5%
26% 14% 10%
30% 15% 20%
⬍.001 ⬍.001 ⬍.001
CES-D ⫽ Center for Epidemiologic Studies Depression Scale. a Chi-square testing for the significance of differences across the low, mild-to-moderate, and high-depressive symptoms groups (based on CES-D scores).
M.G. Sawyer et al. / Journal of Adolescent Health 50 (2012) 236 –242
239
Table 3 Odds ratios (ORs) and 95% confidence intervals (CIs) describing the bivariable relationship between help-seeking, gender, and perceived support Perceived supportb Help source Informal Friends Family Health services Medical practitioner School services Counselor/nurse Teacher Indirect Telephone helpline Internet Nobody a b
a
Gender
Family
Friends
Significant other
.31 (.27–.35) 1.13 (1.00–1.28)
1.70 (1.49–1.95) 5.68 (4.94–6.54)
5.92 (5.02–6.97) 1.40 (1.24–1.58)
2.76 (2.40–3.18) 2.41 (2.13–2.73)
1.47 (1.27–1.70)
1.26 (1.09–1.46)
.93 (.81–1.08)
1.08 (.93–1.24)
.72 (.64–.81) 1.31 (1.14–1.50)
1.27 (1.12–1.42) 1.95 (1.69–2.24)
1.31 (1.16–1.48) 1.23 (1.07–1.40)
1.57 (1.39–1.77) 1.49 (1.29–1.71)
.75 (.66–.85) 1.44 (1.21–1.72) 1.87 (1.52–2.30)
1.10 (.97–1.25) .58 (.49–.69) .30 (.24–.38)
1.22 (1.08–1.39) .72 (.60–.86) .37 (.29–.46)
1.24 (1.09–1.41) .73 (.61–.87) .29 (.23–.37)
For Gender, female coded 0 (reference category), male coded 1. For MPSS, scores at or below median coded 0 (reference category), scores above median coded 1.
of the relationship between help-seeking from family members and level of depression, while adjusting for the MPSS Family Subscale score. Results Overall, 80% of adolescents reported that they would seek help from friends and 73% from family members if they experienced the depressive symptoms described in the vignette (Table 2). A smaller percentage would seek help from other sources, ranging from 11% who would seek help from the Internet through to 29% from school counselors/nurses. Eight percent reported that they would not seek help from anyone if they experienced the symptoms in the vignette. Four other findings are evident in Table 2. First, friends and family were the most commonly identified source of help regardless of adolescents’ level of depressive symptoms. A somewhat smaller proportion of adolescents reported that they would seek help from school counselors/nurses, teachers, telephone helplines, and doctors. Second, compared with adolescents in the low-depression group, a smaller percentage of adolescents in the high-depression group reported that they would seek help from friends or family. For example, only 47% of adolescents with a high level of depressive symptoms reported that they would seek help from family members as
compared with 80% of adolescents with a low level of symptoms. Third, a larger percentage of adolescents with high levels of depressive symptoms reported that they would seek help from telephone helplines or the Internet than was reported by adolescents with lower levels of symptoms. For example, 15% of adolescents with a high level of symptoms reported that they would seek help from the Internet versus 9% of adolescents with a low level of symptoms. Finally, four times as many adolescents with a high level of symptoms reported that they would not seek help from anyone as compared with those with a low level of symptoms. Results from the bivariable logistic regression analyses examining the relationship between adolescents’ help-seeking intentions, gender, and perceived level of support are shown in Table 3. It can be seen that males were significantly less likely than females to seek help from friends, school counselors/nurses, or telephone helplines with ORs between .31 and .75 (95% confidence intervals [CIs] are shown in Tables 3–5). However, they were more likely to seek help from medical practitioners, teachers, and the Internet (odds ratios [ORs] ⫽ 1.31–1.47). They were also more likely than females to not seek help from anybody (OR ⫽ 1.87). Adolescents who perceived more support from family, friends, or a “significant other” were more likely to seek help from friends, family members, and school staff (ORs ⫽ 1.23–5.92) but were less
Table 4 Odds ratios (ORs) and 95% confidence intervals (CIs) describing the relationship between help-seeking and levels of depressiona Adjusted ORb
Unadjusted OR Help source Informal Friends Family Health services Medical practitioner School services Counselor/nurse Teacher Indirect Telephone helpline Internet Nobody a b
Mild-moderate (16 –30)
High (ⱖ31)
Mild-moderate (16 –30)
High (ⱖ31)
.68 (.58–.79) .44 (.38–.50)
.48 (.39–.58) .22 (.18–.26)
.67 (.56–.80) .54 (.46–.63)
.42 (.33–.54) .29 (.24–.36)
1.09 (.92–1.29)
1.05 (.82–1.33)
1.14 (.95–1.37)
1.15 (.88–1.49)
1.04 (.91–1.20) .82 (.69–.96)
1.27 (1.04–1.53) .70 (.55–.90)
1.07 (.92–1.24) 1.00 (.84–1.19)
1.29 (1.05–1.59) .92 (.71–1.20)
1.20 (1.03–1.39) 1.62 (1.33–1.97) 2.08 (1.63–2.64)
1.48 (1.21–1.81) 1.76 (1.36–2.29) 4.86 (3.75–6.30)
1.21 (1.03–1.42) 1.48 (1.20–1.82) 1.90 (1.47–2.46)
1.48 (1.20–1.84) 1.61 (1.22–2.14) 4.55 (3.41–6.08)
For CES-D scores, 0 –15 coded 0 (reference category), 16 –30 coded 1, ⱖ31 coded 2. Adjusted for gender, age, parent marital status, language spoken at home, parental employment, and MPSS friends, family, and significant other subscale scores; for gender, female coded 0 (reference category), male coded 1; for MPSS subscales, scores at or below median coded 0 (reference category), scores above median coded 1.
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Table 5 Odds ratios (ORs) and 95% confidence intervals (CIs) describing the relationship between help-seeking and levels of depressiona, adjusting for perceived support from friends or family OR (95% CI)b Mild-moderate High (ⱖ31) Help source (16 –30) Friends Family a
b
c
.80 (.68–.94) .57 (.49–.66)
OR (95% CI)c Mild-moderate High (16 –30) (ⱖ31)
.56 (.45–.70) .68 (.57–.81) .31 (.25–.37) .55 (.47–.65)
.42 (.33–.53) .30 (.25–.38)
For CES-D scores, 0 –15 coded 0 (reference category), 16 –30 coded 1, ⱖ31 coded 2. Adjusted for MPSS friends subscale score in the model predicting likelihood of help-seeking from friends, and MPSS family subscale score in the model predicting likelihood of help-seeking from family. Adjusted for MPSS friends or family subscale score and gender, age, parent marital status, language spoken at home, parental employment.
likely to seek help from the Internet (ORs .58 –.73). There was no consistent relationship between help-seeking intentions and adolescent age, parent marital status, language spoken at home, or parent employment (not shown in Table 3), with only 12 of the 40 ORs being statistically significant (p ⬍ .05). Results from bivariate and multivariate logistic regression analyses examining the relationship between help-seeking intentions and levels of depression are shown in Table 4. The adjusted ORs indicate that adolescents in the mild-to-moderate and high-depression groups were less likely to seek help from friends and family members than those in the low-depression group, with odds ratios ranging from .29 to .67. In contrast, adolescents in the mild-to-moderate and high-depression groups were more likely to seek help from telephone helplines and the Internet (ORs ⫽ 1.21–1.61). It can also be observed that adolescents with high levels of depressive symptoms were four times more likely to report that they would not seek help from anybody. In all areas, the size of the ORs changed little after adjustment for the effect of demographic characteristics and perceived level of support from friends, family members, and significant others (Table 4). The ORs in Table 5 show that help-seeking intentions from friends or family members were significantly lower among those with higher levels of depressive symptoms, after adjustment for perception of support from the source of help that was the focus of the help-seeking intention in each statistical model. Discussion In the present study, young adolescents most frequently identified friends and family members as sources of help for symptoms of depression. However, those with high levels of depressive symptoms less frequently reported that they would seek help from these sources than those with lower levels of symptoms. They were also four times more likely to report that they would not seek help from anybody. Across all sources of help, differences in help-seeking intentions remained evident after adjusting for adolescents’ demographic characteristics and their perceptions of social support. The results also showed that differences in relation to help-seeking intentions from friends and family members did not arise because of different perceptions of support available from these particular sources of help. The findings suggest that the phenomenon of help negation [15,21], previously described with suicidal ideation, may also occur among young adolescents experiencing higher levels of depres-
sive symptoms. As suggested by Wilson and Deane [15], perhaps lack of motivation or concerns about keeping feelings to themselves leads adolescents with higher levels of depressive symptoms to less frequently seek help for their problems. The pattern of findings is consistent with results from previous studies describing help-seeking intentions for suicidal ideation and depressive symptoms in older populations [5,11,14,15,21,32,33]. For example, males and females differed in the frequency with which they intended to seek help from several potential sources of help. Females more frequently identified than males that they would seek help from friends, school counselors/nurses, and telephone helplines. Males more frequently identified medical practitioners, teachers, and the Internet. Rickwood and Braithwaite [14] suggest that expressing emotion and confiding problems may have a different effect for males and females within their peer groups. For females, it may serve to consolidate friendships; however, among males, it may be interpreted as a sign of weakness and have a negative effect on peer relationships. Interventions designed to improve helpseeking intentions by young adolescents with depressive symptoms need to take into account these different patterns of helpseeking intentions reported by males and females. For example, males may prefer more “impersonal” forms of help with less emotional closeness, as evidenced in the different intentions expressed by males versus females for seeking help from teachers versus school counselors and the Internet versus telephone helplines. Of concern is the finding that 20% of adolescents with a high level of depressive symptoms stated that they would not seek help from anybody if they experienced symptoms consistent with minor depressive disorder. Similar findings have been reported in previous epidemiologic studies. For example, Rickwood and Braithwaite [14] reported that 23% of Australian 16 – 19-year-old high school students (n ⫽ 715) with General Health Questionnaire score ⬎4 (reflecting “moderate or severe psychological impairment,” p. 565) had not sought help from anyone in the previous 12 weeks, and only 175 of them had sought professional help. Oliver et al [5] reported that 22% of British 16 – 64year-olds (N ⫽ 10,842) with a General Health Questionnaire score ⱖ8 had not sought help from anyone. In the present study, a possible explanation for the greater frequency with which males reported that they would not seek help from anybody is that males less commonly recognize depressive symptoms than females [10]. Two recent studies support this explanation. In their study, Cotton et al [33] have shown that among 12–25year-olds (N ⫽ 1,207), males recognize depressive symptoms less frequently and are more likely to endorse the use of alcohol to deal with mental health problems. Similarly, Klineberg et al [11] have reported that female adolescents identify both mild and severe depressive symptoms more accurately than males. The authors suggested that this may delay help-seeking intentions among males. A challenge for studies using vignettes is knowing the extent to which help-seeking intentions reflect the behavior that would actually occur if individuals experienced the symptoms described in the vignette. Support for this approach is provided in a recent meta-analysis which found that in crosssectional studies the strength of the relationship between intentions and behavior was equivalent to a large effect size (d ⫽ 1.47) [19,33]. In more rigorous experimental prospective studies, medium-to-large changes in intention (d ⫽ .66) were associated with small-to-medium changes in behavior (d ⫽
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.36) [19]. The consistency of results found in the present study and in previous epidemiologic studies is also reassuring [5,11,14]. For example, in the present study, 33% of adolescents with a high level of depressive symptoms identified school counselors as a source of help and 25% of adolescents with depressive disorders in the Australian national survey [2] had actually attended school counseling during the 6 months before the study. Similarly, 17% of adolescents in the present study identified medical practitioners as a source of help and 24% had attended medical practitioners in the national survey. The general similarity of the findings suggests that the use of the vignette to assess behavioral intentions in the present study is providing a reasonable indication of the help-seeking behavior of adolescents when they experience a depressive episode. A limitation of the present study, which should be considered when interpreting results, is its use of a cross-sectional methodology. This limits the extent to which the direction of cause-and-effect relationships can be identified between variables showing a significant association. The study sample was also limited to younger adolescents, and a substantial number of potential participants did not enroll in the study. Finally, it is possible that there is no association between levels of depression and help-seeking intentions, and the associations identified in the present study represent chance findings among multiple comparisons. The strengths of the study include use of a large community sample of adolescents who described their help-seeking intentions in response to a standard description of depressive symptoms. This approach has the potential to avoid confounding between levels of depressive symptoms and service attendance, which can occur in studies using service attendance to assess the relationship between levels of mental health problems and help-seeking behavior. Four implications arise from the present study. First, it is important that universal and targeted interventions include a focus on improving the quality of the social support offered by peers and family members to young adolescents experiencing depressive symptoms. Second, interventions need to encourage peers and family members to actively engage with young adolescents experiencing depressive symptoms rather than waiting for them to initiate help-seeking. This is particularly important for adolescents experiencing higher levels of depressive symptoms who may not initiate help-seeking themselves. Third, the increasing availability of good quality interventions delivered on the Internet offers a potentially important avenue of help for young people who are reluctant to seek face-to-face counseling but who will seek help through the Internet. Finally, although not the focus of the present study, it is important that both peers and family members have sufficient knowledge to respond appropriately when trying to help young adolescents with depressive symptoms. A promising approach in this area is the use of mental health first aid programs being developed in Australia [12]. Acknowledgments The study was funded by beyondblue and the National Health and Medical Research Council. Linda Frost assisted with data analysis for the study.
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