Help-seeking behaviour of depressed students

Sot. Sci. Med. Vol. 18. No. 6. pp. 511-514, Printed in Great Britain. 411 rights reserved

HELP-SEEKING

1984 Copyright

BEHAVIOUR

OF DEPRESSED

0277-9536/84 $3.00 + 0.00 ci; 1984 Perg+mon Press Ltd

STUDENTS

MARY KAY O’NEIL’, WILLIAMJ. LANCEE* and STANLEYJ. J. FREEMAN’ ‘University of Toronto, University Health Service (Psychiatric Division), Toronto, Ontario M5S IAl,

*Clarke Institute of Psychiatry, Toronto and ‘Institute of Medical Science, University of Toronto, Toronto, Ontario M5S lAl, Canada Abstract-Depression, the most common form of psychological distress among university students, is often serious enough to warrant professional help but only a minority of depressed students seek formal help. This paper reports on the characteristics which differentiate two groups of depressed students--the help-seekers from the non-help-seekers. A university psychiatric clinic population (N = 183) was compared with a non-clinic sample (N = 55). Data about depressive symptoms, social supports, the use of medical, psychiatric and other helping services, sources of referral and the usual demographic and sociocultural information were obtained. The Beck Depression Inventory was used as the measure of depression. Severity of depression was the single most important predictor of use of the psychiatric service. In addition, being female was also an important predictor. After controlling for severity and sex, the demographic factors which distinguished help-seekers from non-help-seekers were as follows: The help-seekers were more likely to be graduate students, older, living away from family and/or to use a non-psychiatric physician. Contrary to expectation, having a confidant was not related to help-seeking, suggesting that the presence of a confidant may be preventive but does not necessarily decrease the need for professional help once a student has become depressed. A depressed student’s decision to seek help may be influenced by four factors: the severity of the problem; the individual’s propensity to seek help; the availability of alternate resources; and the accessibility of psychiatric services. The findings are discussed in the light of these factors.

INTRODUCTION Depression is known to be the most common form of psychological distress among university students [l-3]. Prevalence rates of significant emotional problems in students have been reported consistently in the l&20% range [2,4-61. The predominant manifestation of these problems is depression [3,7]. Although the depression experienced by students is often serious enough to warrant professional intervention, only a minority seek formal help [6,8,9]. This is of major concern, since students are at a critical developmental phase, and treatment of their depression may be crucial in facilitating a successful transition from adolescence to adulthood [lo]. Both psychiatric disturbance and help-seeking in students have received some research attention 18, 11, 121. However, to date, there are no reported studies comparing depressed students receiving psychiatric treatment with those not receiving psychiatric help. It was possible to extract data bearing on this question from the data pool of a study designed to elucidate psychosocial factors related to depression in university students which will be reported at a later date. This paper reports on the characteristics which differentiated two groups of depressed students-a university psychiatric clinic population (the help-seekers) and a non-clinic sample (the non-help-seekers). METHOD

Sample A group of depressed students attending

a univer-

This research was funded by the Physician’s Services Incorporated Foundation (Grant No. 821-76). 511

sity psychiatric clinic was contrasted with a group of depressed students not attending the psychiatric clinic. The clinic users were selected from consecutive new admissions to the clinic. Seventy-six percent of clinic students who were asked, agreed to participate. The presence of depressive symptoms was defined as a score of 9 or more on the Beck Depression Inventory. If a depressed clinic student had a clinical diagnosis other than depression, that student was excluded. The size of the depressed clinic group is 183 subjects. Students were randomly selected from the general student population for the non-clinic contrast sample. Seventy-five percent of those approached agreed to participate in the study. These 229 students were assessed using the Beck Depression Inventory. Fifty-five students had a Beck score of 9 or more. This research project was not designed originally for testing hypotheses about helpseeking but rather for testing hypotheses about psychosocial risk factors for depressive symptoms in university students [13]. Therefore the design called for stratification of the depressed group. The effect of this sampling technique is to yield a disproportionate number of females and graduate students in the non-clinic depressed group. When percentages are reported in this paper, adjustments have been made to correct for this stratification, where necessary. Usually BDI scores of 10-63 are considered indicative of depression; subjects with scores of 9 were included here to increase the total number of subjects. This seemed justified since there were a number of clinic subjects with scores of 9 who had been diagnosed by clinicians as being depressed [ 141. The final contrast groups consisted of 183 clinic subjects and 55 non-clinic subjects.

512

MARY KAY O’NEIL el al.

Research instruments

Data were obtained by asking subjects to complete an author designed questionnaire in the presence of a research assistant. The following measures were employed for this investigation of help-seeking. The Beck Depression Inventory (BDI) [14, 151 was used with both clinic and non-clinic groups to measure the level of depression in terms of the number and intensity of depressive symptoms. This standardized 21 item, self-report scale, widely used in clinical research [14] has been shown to be reliable and valid in a university student population [16] and has been used frequently in other studies with comparable populations 117-191. The presence of a ‘conjdant’ as described by Brown and Harris [20] was used as one indicator of social support. This indicator was based on positive answers to questions which defined a confidant as possessing all three of the following attributes: someone easily available; someone with whom the most personal difficuities were often or always discussed; and with whom the confiding relationship was reciprocal. A number of questionnaire items provided data on the use of medical and other professional helping services, hospitalization for emotional problems, use of a distress centre, and sources of referral. The usual demographic and sociocultural information was elicited, as well. RESULTS

Help-seeking at the University Psychiatric Service

Rimmer et al. [2] estimated the annual incidence of depression among college students to be 8.5%. Assuming this incidence to hold true for the University of Toronto, only 8% of depressed students found their way to the psychiatric service. Even allowing for considerable inaccuracy in the foregoing estimate, it is evident that only a small percentage of those who need formal psychiatric help receive it. Predictors and correlates of seeking psychiatric help

Contingency analyses (cross-tabulations of the users and non-users of the University Psychiatric Service with the outcome variables as well as sociocultural, biographical and demographic variables) revealed that the groups were comparable with respect to the following background characteristics: marital status; religion; ethnicity; parents’ socioeconomic status (Hollingshead), parents’ marital status (deceased or living separately); family history of psychiatric illness; previous psychiatric hospitalization. Severity of depression turned out to be the single most important predictor of use of the psychiatric service. Students who found their way to the psychiatric service were more likely to be moderately or severely depressed than those who did not (Table 1). Two further facts support this statement. A higher frequency of suicidal thought (x’ = 6.04, P < 0.05) and previous psychotherapy (x2 = 10.35, P < 0.001) were found in the clinic as opposed to the non-clinical subjects. The influence of other demographic variables on help-seeking was investigated after controlling for

severity. The clinic subjects were compared with non-clinic subjects separately for the mildly depressed students (BDI scores 9-15) and for the moderate to severeIy depressed students (BDI scores 16+ ). In addition to severity, sex was identified as an important predictor of clinic use. Even though the ratio of depressed women to depressed men in the University population is 1: I, female students were twice as likely to seek help from the clinic (x? = 5.58. P < 0.05). This was true for both the mild and the more severely depressed groups. In order to avoid the confounding effects of severity and sex, further comparisons of clinicnon-clinic subjects were made for three subgroups: mildly depressed clinic/non-clinic males; mildly depressed clinic/non-clinic females; moderately and severely depressed clinic/non-clinic females. There were not enough moderately and severely depressed males in the non-clinic for a fourth subgroup. Table 2 gives the demographic profile of the three subgroups. The demographic factors which distinguished the help-seekers were as follows: The help-seekers were more likely to be graduate students, older and/or living away from family, than the nonhelp seekers. These clinic students were also more likely to use non-psychiatric physicians. An important finding was that the clinic group were not more or less likely to have a confidant. The findings in both the mildly depressed males and females were similar in pattern but they lacked significance in the mildly depressed male students, possibly because of small numbers. In the more severe female subgroup none of these factors were related to clinic use. Apparently, severity is the overriding factor for these students. In order to shed some light on the degree to which various characteristics contribute to seeking help from the clinic, a two group discriminant analysis was performed. Again, the clinic depressed were compared with the non-clinic depressed. Five factors were found to account for a total of 34”; of the variance (Table 3). The BDI score (severity) alone accounted for 22% of the variance in being in the clinic group. The addition of being female accounted for an additional 1%; being a graduate student, 696; living away from family, 2% and visits to a non-psychiatric physician another 37;.

DISCUSSION

A depressed student’s decision to seek psychiatric help may be influenced by four factors: the severity of depression; the individual’s propensity to seek help; the availability of alternate resources: and the accessibility of psychiatric services.

Table

I

Disrriburmn in chc

BDI Mild (9-I 5) Moderare (1623) Severe (24 + ) z2= 31.69

of Beck Depressron hventory and non-clime groups

scores

Clinic (IV = 183) S’J

Non-chc (N = 55) (“,,I

36 38 26 d.f. = 2

80 19 I P < 0.001

Help-seeking Table 2. The demographic

profile

behaviour

of depressed

of depressed

students

grouped

Mildly

depressed Males (N = 32)

Characterisw Graduate Older Living away from family* Seeing physician Have a confidant

Nonclinic (N = IO) (“0)

Clinic (N = 22) (“0)

IO 30

27 55

40 40 30

72 45 18

*When mild males and females were combined. tP (0.01.

according

to severity

x2

Nonclinic (N = 33) (xl

Clinic (N = 45) (%)

I .20 I .67

IO 39

38 73

3.14 0.08 0.56

58 30 36

76 64 47

The severity of depression, as measured by the Beck Depression inventory. and confirmed by the presence of suicidal thoughts was found to be the single most important factor differentiating the depressed clinic users from the non-users. This is in accordance with Mechanic and Greenley [I I] and others [8, 121 who have also shown that the severity of psychiatric disturbance is the single best predictor of use of a university psychiatric service. Propensit_y to seek help A number of personal, social and cultural factors are likely contributors to an individual’s propensity to seek help. In this study, three such factors (being female, being a graduate student and being older) were found to be significantly correlated to helpseeking. Other authors [9, 11,21,22] have reported that women (including female students) are more likely to seek help than men for emotional problems. Similarly in this study, mildly depressed female students are overrepresented at the psychiatric service in a ratio of 2 : 1. Of considerable interest are the reasons why depressed female students are likely to seek help. The question of sex differences in depressed university students has been explored by the authors in a separate investigation and will be reported at a later data. Graduate students (who are, of course older) were differentiated from undergraduates in that a greater proportion of graduates were depressed and a greater proportion used the clinic. Perhaps two factors provide some explanation for this finding. Since older, more adult graduate students are more emancipated from family, the idea of outside professional help is more acceptable than a return to family. Also, for graduate students, psychotherapy is often considered Table 3. Items and standardized

Beck Sex (female) Graduate Living away from family Seeing a physician

of depression

and sex

Severely depressed Females (N = 87) Nonclinic (N = IO) (3:)

Clinic (N = 77) (‘:6)

X?

8.22t 9.06t

IO 70

33 60

2.13 0.39

2.83 8.88t 0.83

70 40 30

74 70 27

0.03 3.62 0.03

X2

at P co.05

‘Living I awaY, from family’ was significant

Items mcluded

513

Mildly depressed Females (N = 78)

Severity of depression

level (X’ = 5.24, d.f. = I).

to be a sophisticated rather than a shameful method of help. Ethnic background and lack of religious affiliation have been found, in other studies to influence helpseeking behaviour [ 111. Neither of these findings were confirmed in the present study. However it is not surprising that depressed students who have a propensity to seek medical help are more likely to be referred for psychiatric assessment. In this study, the use of non-psychiatric physicians, especially those at the University Health Service (Medical Division) was predictive of psychiatric service use. Availability of alternate resources Not unexpectedly, depressed students are more likely to turn to a psychiatric service when they lack alternate resources to help them cope with their problems. It is generally held that the first level of help is family and friends. If they are inadequate or are unavailable, the individual turns to the next level which comprises personal caregivers-family physicians, ministers, student advisors, etc. If these resources are unavailable or unable to help, the person seeks or is sent to the third level-specialist helpers e.g. private psychiatrist or psychiatric clinics. Students more likely to use a university clinic are those living away from home who lack the usual supportive benefits of family, friends and community resources, as well as older students who are expected to be financially independent and cannot afford the private practitioner’s fee. It is worth noting that when the severity of depression was controlled for, the availability of a confidant did not reduce help seeking behaviour. Other studies f13,20,23] have demonstrated that the absence of a confidant is associated with an increased incidence of depression. It would seem reasonable then to suppose

discriminant

Standardized coefficients

function

coefficients

0.735 0.162 0.391 0.272 0.367 F rario is a slepwise at P < 0.001.

for the deuressed

Additional proportion of variance explained 0, (io) 22

1 6 2 -3 Total

*The partial multivariate AI1 items are significant

students

clinic

F* 76.49 2.95 17.44 7.68 16.36

347:

test of the discriminarory

power of items.

514

MARY KAY O’NEIL et al.

that the presence of a confidant would also decrease the need for professional help. However, this was not borne out in the present study. Where the need for help was great; i.e. when the depression was severe enough, students turned to the psychiatric service whether or not they had a confidant. In this population then, it seems that the presence of a confidant may be preventive but does not necessarily decrease the need for professional help once a student has become depressed. Accessibility

of a psychiatric

service

All students at the University of Toronto have equal opportunity to learn of the existence of the University Health Service (Psychiatric Division). The University Health Services are advertised in the student handbook, the campus newspapers and literature pertaining to student services. Deans, dons, professors and other university personnel who come into contact with the troubled student know that medical and psychiatric help exists on campus. Treatment is free as the cost is covered by student fees and Provincial Health Insurance. Appointments are booked within a day or so of initial contact. Therefore, psychiatric help is readily and equally accessible once a depressed student has decided to seek assistance. CONCLUSIONS

The finding that severity of depression is by far the major factor in seeking professional help is not very surprising. However, at a given level of depressive symptoms, help-seeking is influenced by being female, being a graduate student, living away from home and seeking help from a non psychiatric physician. These factors alone or in combination provide the path to professional help. What happens to those depressed students who are less likely to obtain professional help because they do not have these help-seeking characteristics? Are they at greater risk for suicide? Do they have a greater tendency to drop out of University or to fail their courses? Are they unsuccessful in their attempts to deal with crucial developmental issues and consequently develop unsatisfying social and sexual relationships? Or are their depressive episodes self-limited with no important negative consequences? At present, definitive answers to these questions are not available, although the existing evidence [24] would point to the less favourable outcomes. Certainly, the results of this study indicate that more vigorous case finding strategies are warranted especially for those students who tend not to seek heID. These strategies would include education of stuhents, universit;personnel and physicians regarding early indicators and risk factors for depression [13] as well as the availability of helping resources.

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