Factors affecting help-seeking during depression in a community sample

Journal Elsevier

ofAffectiveDisorders,

223

14 (1988) 223-234

JAD 00531

Factors

Mary Amanda

affecting help-seeking during depression in a community sample

Dew’, Leslie 0. Dunn’, Evelyn J. Bromet2

and Herbert

C. Schulberg’

’ Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, U.S.A. and 2 Department of Psychiatty and Behavioral Saence, State University of New York at Stony Brook, Stony Brook, NY,

U.S.A.

(Received 12 August 1987) (Accepted 2 November 1987)

Summary Little is known about factors that influence community residents to seek professional help while experiencing diagnosable episodes of depression. The present study utilized longitudinal data from 96 female subjects to examine whether clinical and psychosocial features of a recent depressive episode, as well as preexisting psychiatric and psychosocial characteristics, could distinguish between individuals who (a) did and did not seek help during their episode and (b) chose to consult one professional source rather than another. Results showed that less than half of the sample sought professional help. Few variables could distinguish subjects who sought help from those who did not. Instead, subjects consulting mental health specialists were more clinically impaired and had fewer psychosocial assets than both those consulting nonpsychiatric physicians and those seeking no help. Subjects in the latter two groups were indistinguishable from one another on the assessed variables. Results were cross-validated with a smaller sample of male community residents.

Key words: Help-seeking;

Depression;

Distinguishing

Introduction Mentally ill persons in the U.S.A. are considerably more likely to consult health care professionals than are persons without a diagnosable disorder (Weissman et al., 1981; Roberts and Vernon, 1982; Shapiro et al., 1984; Leaf et al., 1985; Leaf and Bruce, 1987). Even so, the major-

Address for correspondence: Dr. M.A. Dew, Psychiatric Epidemiology Program, Department of Psychiatry, University of Pittsburgh, 3811 O’Hara Street, Pittsburgh, PA 15213, U.S.A. 0165~0327/88/$03.50

0 1988 Elsevier Science Publishers

characteristics

ity of clinically diagnosable individuals, 58-69%, seek no professional help for their distress (Weissman et al., 1981; Vernon and Roberts, 1982). What characteristics distinguish clinically diagnosable individuals who seek treatment from those who do not? Among those seeking treatment, what determines whether help is sought from a mental health or another type of helping professional? Researchers in two areas - medical sociology and health services utilization - have identified correlates of help-seeking in the general population (M&inlay, 1972; Andersen and New-

B.V. (Biomedical

Division)

224

man, 1973; Mechanic. 1982; Frank and McGuire. 1986). However, it remains unclear whether the types of characteristics identified in previous studies, e.g., gender. education, and income, actually influence individuals to seek help during diagnosable episodes of psychiatric illness. Examination of this issue is difficult and costly because of low prevalence rates for psychiatric disorders. In addition, even when sufficiently large samples could be identified, investigators rarely have collected data on psychosocial functioning or clinical history prior to the onset of clinical impairment. These baseline data are essential for distinguishing the effects on help-seeking behavior of current clinical status from other variables which may antedate the current impairment. Earlier studies in this area identified individuals who either were currently diagnosable (Weissman et al.. 1981). or had experienced a diagnosable episode of psychiatric illness during the prior 6-12 months (Roberts and Vernon, 1982; Vernon and Roberts, 1982; Shapiro et al., 1984; Leaf and Bruce. 1987). The investigators then determined whether these individuals had sought professional help for emotional problems at any time during the last 6-12 months. Findings that, for example, women, Whites (as compared to Blacks and Mexican Americans) and older persons were more likely to have sought recent professional help are difficult to interpret, however. because the investigators did not ascertain whether individuals were (a) in fact psychiatrically impaired at the time help was sought or (b) at the very least. impaired at some point prior to recent help-seeking. Most recently. Bucholz and Robins (1987) advanced work in this area by temporally linking help-seeking from a physician to a specific depressive episode. They found that symptom configuration significantly influenced physician help-seeking, with poor appetite or substantial weight loss being critical precipitants of a medical consultation. This suggests the need to examine the impact on help-seeking of additional clinical features, such severity and episode duration. as symptom Evaluation is also needed of the extent to which clinical variables contribute to help-seeking specifically from mental health professionals as opposed to other professional caregivers (Mechanic. 1982). Such information would clarify service

utilization concerns regarding which clinically distressed persons are most likely to use mental health services. In countries like the U.K., administrative policy about referral practices virtually guarantees that mental health professionals only assess and treat relatively disturbed individuals; less severe psychiatric illness is treated by the general practitioner (Fahy, 1974; Goldberg and Huxley, 1980; Sireling et al.. 1985). In the U.S.A., however, it is unclear whether individuals who are, for example, depressed and who consult a mental health professional have the same or a more serious illness pattern than those who consult only a primary care physician. We had the unusual opportunity of examining the predictive effects of clinical and psychosocial variables on the nature of help-seeking during a depressive episode. utilizing longitudinal data collected from a sample of community residents. As in most prior studies of help-seeking among psychiatrically impaired individuals, we focus on depression since it is one of the most prevalent psychiatric disorders (Weissman and Myers, 1980: Myers et al., 1984) and is one for which failure to seek care is particularly troubling given (a) the disorder’s attendant suicide risk (Wetzel. 1976; Miles, 197’7) and (b) the present availability of efficacious treatments for many depressive conditions (Klerman, 1986). The present investigation conceptually and methodologically extends previous work in several ways. First, we evaluate more thoroughly the contribution of an individual’s current clinical profile. as well as psychiatric history. to the decision to seek help from numerous professional sources. Second. in addition to analyzing standard demographic variables such as education, we examine pre-episode data about other psychosocial characteristics potentially predicting the choice of help sought, independent of subsequent clinical status. Finally. we attempt to validate our derived model of predictors of help-seeking with data from a second smaller sample of community residents. Method Suhjrcts

Panel data were gathered from fall, 1981 and fall. 1982 home interviews with 741 women resid-

225

ing in three semi-rural, demographically similar regions of Pennsylvania. The present analyses focus on the 96 subjects who met criteria described below for definite major depression (n = 56) or probable major depression (n = 40) during the 12-month interim between interviews. The prevalence rate of 13.0% for major depression (7.6% for definite major depression) among this cohort during the 12-month study period was at the expected level applying appropriate normative 6-month rates for women in the Epidemiologic Catchment Area Study (Myers et al., 1984). Subjects had originally been recruited in a longitudinal investigation of the mental health effects of the 1979 Three Mile Island (TMI) accident (Bromet et al., 1982; Dew et al., 1987). Each had delivered a child between January, 1978 and March, 1979. Since Pennsylvania law prohibited access to vital statistics records, women were randomly drawn from area newspaper birth announcements. Hospitals routinely reported birth delivery data to the local newspapers and virtually all local women delivered in a hospital, thus minimizing sample bias. The refusal rate at initial interview was 20%, and the rate of attrition was 6%.

Meusures Clinical characteristics of the index depressive episode. The Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SADS-L; Endicott and Spitzer, 1978) was administered at the second interview to determine whether subjects met Research Diagnostic Criteria (RDC; Spitzer et al., 1978) for either definite or probable major depression during the preceding 12 months. Criteria for diagnosis include having (a) a period of at least 1 week characterized by feelings of dysphoria (definite major depression if 2 or more weeks, probable major depression if less than 2 weeks), (b) at least four of eight cardinal symptoms for the worst episode, and (c) evidence of treatment, referral for treatment, or impairment of functioning during the episode. The worst episode during the 12-month period is hereafter referred to as the index episode, and its length (in weeks) was ascertained. To examine symptom severity during this episode, the SADS-L

was modified to assess each symptom on the 6-point severity rating scale from Part I of the instrument (1 = symptom absent, 2 = present but not clinically significant, 3-4 = mild to moderate range, 5-6 = severe to extreme range). For analytic purposes, four symptom factors were derived based on a principal components analysis of the eight symptoms: factor A averaged guilt/worthlessness and suicidal intent ratings; factor B averaged loss of interest, concentration difficulties, and psychomotor agitation/retardation ratings; factor C averaged sleep difficulty and lack of energy ratings; and factor D denoted the rating for appetite/weight change. Within Help-seeking during the index episode. the SADS-L Depression section, subjects were asked whether they sought any professional help during their worst episode. They were then assigned to one of four help-seeking groups, depending on whether they (a) consulted a mental health professional (e.g., psychiatrist, psychologist, social worker, counselor); (b) consulted a nonpsychiatric physician (e.g., internist, obstetriciangynecologist); (c) consulted another professional (e.g., clergy, lawyers); or (d) did not seek professional help. The few subjects who consulted more than one source (n = 9) were classified according to a hierarchical system wherein consultation with any mental health professional produced assignment to the Mental Health Professional group. Those who did not consult a mental health professional but who visited a nonpsychiatric physician as well as other caregivers were assigned to the Nonpsychiatric Physician group. Psychiatric characteristics preceding the index episode. Lifetime episodes of definite and/or probable major depression prior to the index episode were determined at the first interview with the SADS-L (1 = history of depression, 0 = no history). Lifetime professional help-seeking for mental health problems prior to the index episode was also determined at the first interview, using an expanded section of the SADS-L concerning such behavior (1 = ever sought treatment, 0 = did not). History of any psychiatric disorder among the subject’s parents, siblings. or children was derived from an adaptation of the family history section of the Renard Diagnostic Interview administered at the first interview (1 = family history of

226

disorder, 0 = no history of disorder; Helzer et al., 1981). Psychosocial characteristics related to the index episode. Three such variables pertaining to the index episode were assessed at the second interview. These were whether (a) subjects sought support from friends or relatives, including spouse, during the episode (1 = yes, 0 = no), (b) friends or relatives suggested during the episode that they needed professional help (1 = yes, 0 = no), and (c) the event that subjects reported as having precipitated the episode was, in the investigators’ consensus opinion, an external event over which a subject was likely to have no control, e.g., a family member’s physical illness (1 = external, 0 = not; Brown and Harris, 1978). Psychosocial characteristics preceding the index episode. Psychosocial variables potentially predisposing subjects to seek help were assessed at the first interview. First, a complete demographic profile was obtained on each subject. Although the sample was homogeneous on many variables (e.g., 98% of the women were Caucasian and all were of childbearing age (M = 28.42 years, SD = 4.74)) subjects differed on level of education and family income. Thus, these two variables were included as potential predictors since previous community studies have found them related to help-seeking (McGuire, 1981; Veroff et al., 1981) (education: 1 = grammar school, 7 = graduate or professional training, after Hollingshead and Redlich, 1958; family income: 1 < $5,000. 8 > $50,000). Second, pre-existing social support from two sources was determined. Support from friends was assessed with an item concerning whether the subject had anyone to turn to in times of emotional or practical need (0 = no one to turn to, 3 = can turn to all of friends; adapted from Moos, 1975). Support derived from the subject’s marital relationship was assessed with a 5-item scale (1 = poor, 5 = excellent relationship, Cronbach’s alpha = 0.75; adapted from Spanier, 1976 and Pearlin and Schooler, 1978). Finally, subjects’ pre-existing coping style was determined with the 7-item Mastery scale (Pearlin and Schooler, 1978) which assesses the degree to which subjects feel they have control over their problems (1 = little control, 5 = great deal of control, alpha = 0.75).

Interviewers Subjects were initially randomly assigned to interviewers with an average of eight years of clinical experience (range: 4-12 years) and with at least a master’s degree in a mental health discipline. To reduce subject attrition, interviewers administered instruments to the same subjects at both interviews whenever possible. Comprehensive training programs were conducted before both interviews to standardize instrument administration (Bromet et al., 1986). Anai)ses The major analyses examine differences between individuals who (a) did and did not seek help during depression, and (b) engaged in varying help-seeking activity (i.e., consulted a mental health professional vs. consulted a nonpsychiatric physician vs. did not seek help). For each class of these analyses, univariate tests were initially performed to evaluate group differences on each psychiatric and psychosocial variable. Direct discriminant function analyses were then performed to determine whether the entire set of psychiatric characteristics could reliably discriminate between groups. and, similarly, whether the set of psychosocial characteristics could discriminate between groups. (Although it would have been informative to include both psychiatric and psychosocial characteristics in a single discriminant analysis in order to examine their relative effects, the sample size was too small to permit such an analysis.) Within the context of the discriminant analyses, cross-validation procedures were utilized to determine the generalizability of statistically significant results to a second community sample (to be described below). Finally, a ‘dose-response’ analysis was conducted to explore whether the probability of seeking help from specific sources increased as a function of the total number of predisposing psychiatric and psychosocial characteristics that subjects possessed. Prior to discriminant analyses, variables were examined and found adequately to meet analytic assumptions (Tabachnick and Fidel], 1983). One subject without data on family psychiatric history was excluded from multivariate analyses of the psychiatric variables. Four divorced subjects with no data on social support from the spouse (but

221

who otherwise were similar to remaining subjects on psychosocial characteristics) were excluded from multivariate analyses of psychosocial variables. Results Among the 96 diagnosed subjects, 39 (40.6%) sought professional help while experiencing their index depressive episode. Of these, 16 consulted a mental health professional, 17 went to a nonpsychiatric physician, and 6 exclusively consulted other human service professionals. Differences between subjects who did and did not seek help The first columns of Tables 1 and 2 display psychiatric and psychosocial characteristics of these two groups. As shown in the sixth column of each Table, univariate analyses indicate that helpseekers were more likely to have sought help for emotional problems previously, had a longer index episode, and had more severe somatic complaints of sleep disorder and energy loss (symptom factor C). Only one psychosocial characteristic, i.e., recommendations by others to seek professional help, distinguished those who sought help from those who did not. Not surprisingly, given the few significant univariate findings, discriminant function analyses could not reliably distinguish help-seekers from the no-help group on the basis of either the entire set of psychiatric (x2 (8, n = 95) = 14.75, P > 0.07) or psychosocial characteristics (x2 (8, N = 92) = 14.43, P > 0.07). Differences between subjects according to specific help-seeking activity Tables 1 and 2 also present descriptive data on subjects by their choice of caregiver. Analyses in this section examined whether individuals seeking specific types of help could be distinguished from each other, and from those who did not consult a helping professional. Due to the very small number of individuals in the ‘Other Professional’ category, we necessarily focus on the remaining three groups. It is noteworthy, however, that the characteristics of subjects in the Other Professional group tended to resemble those of subjects in the Mental Health Professional group.

Univariate results show that the three groups differ in several respects (see seventh column of Tables 1 and 2). The descriptive data indicate that with regard to psychiatric characteristics, subjects consulting mental health professionals were more likely than other subjects to have sought prior professional help and had longer index episodes. They also expressed more severe feelings of guilt/worthlessness and suicidal ideation. As would be expected (e.g., Wilson et al., 1983), subjects visiting nonpsychiatric physicians had the most severe somatic complaints of sleep difficulties and energy loss. With respect to psychosocial characteristics, subjects in the Mental Health Professional group had lower levels of pre-existing marital support, and were also more likely to have been told by friends and relatives during the episode that they needed professional help. The univariate tests reveal group differences, but do not directly evaluate whether subjects consulting mental health professionals can be reliably distinguished from remaining subjects. The two discriminant function analyses described below indicate that subjects consulting mental health professionals are truly unique from other groups on both psychiatric and psychosocial dimensions. Psychiatric characteristics. A single discriminant function accounted for the bulk of the discriminating power of the eight psychiatric variables (64% of the between-group variability in help-seeking). After removal of this function, insignificant discriminating power remained (prior to removal: x2 (16, n = 89) = 30.43, P < 0.02; after removal: x2 (7, n = 89) = 11.31, P < 0.12). The function maximally discriminated those who consulted a mental health professional (group centroid of 1.00) from those who went to a nonpsychiatric physician or did not seek help (centroids of -0.60 and -0.11, respectively). Indeed, additional results indicated that the Mental Health Professional group differed significantly from the two other groups (F (8, 79) = 2.48, P < 0.02; F (8, 79) = 2.22, P < 0.03 for comparison to the Nonpsychiatric Physician and No Help groups, respectively), while the latter two groups did not reliably differ from each other (F (8, 79) = 1.60, P > 0.14). The psychiatric characteristics’ loadings on the discriminant function are shown in the last col-

1

characteristic

OF PREDISPOSING

correlation

coefficient

I (94) for continuous variables, x2 (1, n = 96) for Comparing No Help, Mental Health Professional, Test statistic calculated omitting one case without Transformed prior to analysis to reduce skewness untransformed units. * P < 0.05. **p < 0.001.

a ’ ’ d

Canonical

2.2 3.1 4.0 3.5

2.0 3.1 3.5 3.3

2.7 3.4 3.7 3.7

12.2

62.5 87.5 81.3

1.7 2.9 4.2 3.4

9.4

35.3 64.7 52.9

2.4 3.3 3.6 3.2

12.3

66.7 83.3 83.3

Other Professional (n=6)

1.14 0.04 2.51* 0.69

2.38 *

0.02 5.08 * 2.15 ’

a

6.33 * * 0.79 3.83 * 0.49

3.36 *

2.58 5.88 * 3.46 ’

0.45

0.72 0.24 -0.11 0.14

0.50

0.27 0.42 0.37

Discriminant b function loading

DEPRESSION

Three-group comparison

DURING

Help vs. No Help comvarison

Analysis

TO HELP-SEEKING

discrete variables. and Nonpsychiatric Physician groups, F (2, 86) for continuous variables, x2 (2, n = 90) for discrete variables. data from the Mental Health Professional group. (0 = 1 week (n = 31), 1 = 2-8 weeks (n = 42) 2 = 9 or more weeks (n = 23)). Group means are presented in original,

change

11.0

51.3 76.9 71.1

6.0

52.6 54.4 56.1

Nonpsychiatric Physician (n =17)

Mental Health Professional (n =16)

Yes (n = 39)

No (n = 57)

CHARACTERISTICS

Type of help sought

PSYCHIATRIC

Help sought

AND EPISODE-RELATED

Index episode Length (weeks) d Mean symptom severity (l-6 points) Factor A: guilt, suicidal ideation Factor B: interest, concentration, psychomotor Factor C: sleep, energy Factor D: appetite, weight change

Predispmng Prior depressive episodes (W yes) Prior professional help (W yes) Family history of disorder (S yes)

Psychiatric

RELATIONSHIP

TABLE

2

characteristic

OF PREDISPOSING

a b ’ d *

correlation

coefficient

(% yes)

2.9

2.8

23.1 35.9 17.9

2.0 3.8

2.0 3.9

42.1 15.8 26.3

3.4 4.4

3.4 4.9

18.8 56.3 18.8

2.7

1.7 3.5

3.1 4.3

23.5 17.6 23.5

3.0

2.1 4.1

3.8 4.7

Nonpsychiatric Physician (n =17)

Mental Health Professional (n =16)

Yes (n = 39)

Type of help sought

CHARACTERISTICS

Help sought

PSYCHOSOCIAL

No (n = 57)

AND EPISODE-RELATED

33.3 33.3 0.0

2.9

2.3 3.5

2.8 3.3

Other Professional (n=6)

3.72 5.15 * 0.10

0.88

0.07 0.62 d

0.92 1.22

Help vs. No Help comparison

Analysis

TO HELP-SEEKING

a

4.12 11.81 0.40

2.72

l

*

1.53 3.02 *d

1.89 0.60

b

variables.

0.44

-0.28 0.73 -0.11

-0.29

- 0.35 -0.50

- 0.26 -0.17

Discriminant function loading

DEPRESSION

Three-group comparison

DURING

f (94) for continuous variables, x2 (1, n = 96) for discrete variables. Comparing No Help, Mental Health Professional and Nonpsychiatric Physician groups; F (2, 86) for continuous variables, x2 (2, n = 90) for discrete See text for exact scoring of these variables. Test statistic calculated omitting one and three cases without data from the Mental Health Professional and No Help groups, respectively. P < 0.05, * * P -c 0.001.

Canonical

Index episode Sought support from others (% yes) Others recommended help (W yes) External life event precipitating depression

Predisposing Demographic Education (1 = less, 7 = more) ’ Income (1 = less, 8 = more) ’ Social support From friends (0 = less, 3 = more) From spouse (1 = less, 5 = more) Coping style Sense of mastery (1 = less, 5 = more)

Psychosocial

RELATIONSHIP

TABLE

230

umn of Table 1. These are interpretable in the same manner as factor loadings in factor analysis, and indicate that the best predictors (with loadings of at least 0.30; Tabachnick and Fide& 1983) of help-seeking from mental health professionals as opposed to nonpsychiatric physician consultation or no help - were prior professional helpseeking, a family history of psychiatric disorder, a longer index episode, and relatively more severe guilt/worthlessness and suicidal ideation symptomatology (symptom factor A). The psychiatric variables classified 54% of the subjects correctly. Classification accuracy was similar for all three groups (50%, 59%, and 54% for the Mental Health Professional, Nonpsychiatric Physician, and No Help groups, respectively). Although these results indicate that the discriminant function does not fully explain the nature of group differences, the canonical correlation of 0.45 indicates that these particular psychiatric variables, as a set, are important correlates of help-seeking behavior. This classification is based on parameters derived from the sample itself. Since they only approximate population parameters, it is critical to explore how well the classification model generalizes to other samples. Such cross-validation was performed with data collected from 468 randomly selected male nonmanagerial employees of power plants located in the communities where our female sample resided. These subjects were interviewed at the same time points with the same instruments, and they demographically resembled the female sample on the variables assessed in this study (see Bromet et al., in press, for a detailed description of the male sample). Twenty-four of the 468 men (5%) met criteria for either definite (n = 15) or probable major depression (n = 9) during the 12month study period. While the small male sample size precluded its use in developing the classification scheme, it sufficed to cross-validate findings from the larger female sample (Tabachnick and Fidell, 1983). The 24 men resembled the women in the percentage who sought professional help (41.7%, n = 10). However, more men consulted nonpsychiatric physicians (n = 6) than mental health (n = 2) or other professionals (n = 2). Cross-validation of the female sample classification model to the male

sample was achieved by calculating group membership (in the Mental Health Professional, Nonpsychiatric Physician, and No Help groups) based on the classification function derived from the larger female sample. Sixty-one percent of the male workers were correctly classified, a degree of accuracy comparable to the 54% of the female sample correctly classified. This indicates a high degree of consistency, and hence generalizability. for the psychiatric variable classification model. Psychosocial characteristics. The second discriminant function analysis for the sample of women focused on the eight psychosocial variables in Table 2. One discriminant function accounted for 63% of the between-group variability; insignificant discriminating power remained after removal of this function (prior to removal: x2 (16, n = 86) = 28.39, P < 0.03; after removal: x2 (7, n = 86) = 10.87, P > 0.14). As with the psychiatric variables, the psychosocial discriminant function maximally separated those who consulted a mental health professional (group centroid of 1.06) from those who did not (centroids of -0.31 and -0.20 for the Nonpsychiatric Physician and No Help groups, respectively), Additional analyses indicated that the Mental Health Professional group differed significantly from the remaining groups (F (8, 76) = 2.08, P < 0.05 and F (8, 76) = 2.24, P -C 0.04 for comparison to the Nonpsychiatric Physician and No Help groups, respectively). These latter two groups were more similar to each other (F (8, 76) = 1.40, P > 0.20). The loadings of the characteristics on the discriminant function, shown in the last column of Table 2, indicate that subjects in the Mental Health Professional group were likely to have had less pre-existing support from friends and spouse. They were substantially more likely to have been told during the index episode that they needed professional help. They were also somewhat more likely to feel that they had little control over things that happened to them and to have sought less support from others during their episode. Classification on the basis of the eight psychosocial predictors was 57%. It was best for the Mental Health Professional group (80%) and more modest for the Nonpsychiatric Physician and No Help groups (65% and 48%, respectively). The canonical correlation of 0.44 indicates a mod-

231

erately strong association between discriminant function scores on the predictors and group membership. Stability of the classification for the psychosocial variables was also checked by cross-validation with the male sample. Sixty-one percent were correctly classified, again indicating a high degree of generalizability for the classification model.

4

sz

1.00 -

! p ;a 2' a fi iG s $

Dose-response analysis To assess whether the likelihood of mental health help-seeking during the index depressive episode increases with the total number of predisposing psychiatric and psychosocial characteristics possessed by subjects, a logistic regression model was fit by maximum likelihood. In keeping with findings of the discriminant function analyses, this final analysis compared subjects in the Mental Health Professional group to subjects who either sought help from a nonpsychiatric physician or did not seek help. A ‘dose’ variable was created by determining how many of seven contributory factors a subject possessed, and these factors were those found to be most strongly related to mental health help-seeking in the preceding discriminant function analyses (i.e., those with discriminant function loadings >, 0.30). These included prior professional help-seeking, a family history of disorder, a relatively long index episode (more than 8 weeks), guilt/worthlessness and suicidal ideation symptomatology (symptom factor A) in the moderate to severe range (scores of at least 4, the ‘moderate’ point, on the 6-point scale), relatively little pre-existing support from friends (scores above the median of 2 on the 4-point scale), relatively little pre-existing spouse support (scores above the median of 2.1 on the 5-point scale), and being told by friends to seek help. (Cutoffs for dichotomizing these factors for the logistic regression analysis were determined a priori.) The relationship between probability of mental health help-seeking and number of contributory factors is depicted in Fig. 1. The logistic model indicates a strong dose effect (B = 1.07, SE = 0.29; improvement over the null hypothesis of no effect: x2 (1, n = 85) = 21.26, P < 0.001). The data in the Figure suggest that the likelihood of seeking mental health treatment only begins to increase if two or more contributory factors are present. When

.90 .a0 70 .60.50.40 30.20 10 -

NUMBER~FCONTRIBUTORY (n,$)a

(O/6)

(0118)

(l/12)

FACTORS (3117)

(2110)

(8/7)

(l/O)

Fig. 1. Effect of number of contributory factors on help-seeking from mental health professionals. a n, = number consulting a mental health professional; n2 = number consulting a nonpsychiatric physician or seeking no help.

five or more factors are present, the likelihood of such help-seeking is substantially increased over the likelihood for individuals possessing fewer factors. Discussion The present data are unique in focusing on a full range of help-seeking behaviors during a specific depressive episode. Less than half of our sample of women (40.6%) sought professional help during their index episode. In keeping with previously reported patterns (e.g., Regier et al., 1978; Schurman et al., 1985) they were less likely to consult a mental health specialist (16.7%) than other helping professionals (23.9%). These findings were corroborated in our smaller sample of men, and underscore the importance of improving helping professionals’ skills at recognizing depression and utilizing appropriate treatment and referral strategies (Schurman et al., 1985; Schulberg and McClelland, 1987). Although we examined numerous clinical and psychosocial variables related to the episode, as well as those characterizing subjects prior to their episode, we identified strikingly few that could distinguish individuals who did and did not seek help. Instead, the additional analyses provided convincing evidence that the critical distinctions in help-seeking pertain to which individuals seek help from whom. Subjects consulting mental health

232

professionals differed not only from subjects who did not seek help, but also from those who consulted nonpsychiatric physicians. In contrast, subjects consulting nonpsychiatric physicians were indistinguishable on the assessed variables from persons seeking no professional help. The Mental Health Professional group’s distinctiveness from these other two groups emerged on baseline characteristics assessed prior to the episode, as well as on clinical and psychosocial features associated with the episode. It is possible that our results apply only to help-seeking behavior among women, but cross-validation of our model with a smaller sample of men argues against this gender-related interpretation. * Our data suggest that the profile of the depressed individual who specifically consults a mental health professional includes both clinical and psychosocial impairment. Compared to depressives who consulted nonpsychiatric physicians or who sought no help, the former individuals had a longer index episode, and their guilt/worthlessness and suicidal ideation symptoms during the episode were more pronounced. They not only possessed fewer psychosocial assets in the form of social support from spouse and friends prior to the episode, but appeared less likely to use existing resources when depressed. * * Instead, consistent with other evidence regarding the central role that individuals’ social networks play in referral to professional services (e.g., Liberman,

It is also possible that our findings would have differed if we had employed DSM-III criteria (American Psychiatric Association, 1980) instead of the RDC to identify subjects. Although the RDC and DSM-III criteria for major depression are very similar, DSM-III does not require evidence of treatment, referral for treatment or impairment in functioning, but does require an episode duration of 2 or more weeks. To our knowledge, there has been no evaluation of the effect such differences in criteria might have on the relationship of help-seeking to other clinical and psychosocial variables. Their underutilization of supports during the episode is not likely due to the fact that these subjects in the Mental Health Professional group had less pre-existing support available, because pre-existing support variables were only weakly correlated with whether individuals subsequently sought social support (r = 0.06 and r = 0.08 for the relationships of support sought during the episode to pre-existing marital support and to pre-existing friend support).

1965; Booth and Babchuk, 1972; Leutz, 1976) their lay support network appeared to act primarily to urge subjects in the Mental Health Professional group to seek professional help during their episode. Given the nature and average duration of these subjects’ symptoms, friends and relatives may have felt that they could not themselves provide adequate assistance. Taken together, our findings indicate that even though only a relatively small proportion of our sample sought specialized mental health care when depressed, this subcohort included relatively impaired individuals. It is unlikely that this pattern is an artifact of professional referral practices since only two of the 17 individuals consulting mental health professionals had been referred (both by clergy). Historically, people have turned to specialized mental health services only after exhausting other avenues of lay support and professional health services (Gourash, 1978). Attitudes toward seeking care for mental health problems have become much more positive, however, during the past 20 years (Leaf and Bruce, 1987). Although we did not directly assess subjects’ attitudes in this area (cf. Leaf and Bruce, 1987) our findings regarding help-seeking specifically from mental health professionals may reflect community residents’ growing awareness of the availability of specialized mental health care in the U.S.A. and of the legitimacy of seeking it, at least for the most severe psychiatric distress. Our data on help-seeking prior to the depressive episode suggest that such earlier experiences may also facilitate help-seeking from mental health professionals during distress. While subjects consulting mental health professionals were only somewhat more likely than other subjects to have a history of depression, their greater previous contact with helping professionals for emotional problems increased their readiness to seek specialized professional help during their index episode. The fact that mental health utilizers were also more likely to have a family history of psychiatric disorder may also reflect a greater previous exposure to the specialist system, further contributing to a willingness to use such services for their personal distress. The results of the dose-response analyses, on the other hand, emphasize that no single variable alone can adequately predict the likelihood of

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seeking specialized professional help. Instead, in keeping with other mental health care utilization studies in the U.S.A. (e.g., Shapiro et al., 1985) we found that the likelihood of seeking specialized help only accelerates when multiple contributory factors are present. In conclusion, the present study represents an initial effort to identify factors that influence whether and from whom professional help is sought during episodes of depression. Despite differences in accessing specialty mental health care in the U.S.A. and the U.K., our results confirm those of British investigators who have consistently noted greater levels of impairment among diagnosable cases of mental disorder seen by psychiatrists as compared to primary care physicians. On the other hand, with the exception of somatic complaints, our general inability to distinguish individuals who consulted nonpsychiatric physicians from those who sought no help suggests the need for more detailed examination of variables potentially influencing help-seeking decisions among individuals not seen in the specialty mental health sector. Acknowledgements This research was supported in part by National Institute of Mental Health Grant MH-35425 and Training Grant MH-15169. We wish to thank David K. Parkinson, M.D., for his help in implementing the study and the Psychiatric Epidemiology Program Data Analysis Seminar for suggestions regarding the analyses. References American Psychiatric Association Committee on Nomenclature and Statistics (1980) Diagnostic and Statistical Manual of Mental Disorders, 3rd edn., American Psychiatric Association, Washington, DC. Andersen, R. and Newman, J.F. (1973) Societal and individual determinants of medical care utilization in the United States. Milbank Mem. Fund. Q. 51, 95-124. Booth, A. and Babchuk, N. (1972) Seeking health care from new resources. J. Health Sot. Behav. 13, 90-99. Bromet, E.J., Parkinson, D.K., Schulberg, H.C., Dunn, L.O. and Gondek, P.C. (1982) Mental health of residents near the Three Mile Island reactor: a comparative study of selected groups. J. Prev. Psychiatry 1, 225-276. Bromet, E.J., DUM, L.O., Connell, M.M., Dew, M.A. and Schulberg, H.C. (1986) Long-term reliability of lifetime

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