An examination of sociodemographic and clinical factors influencing help-seeking attitudes and behaviors among adolescents with mental health problems

Nearly half of all mental disorders begin before the age of 18, and 62% manifest before the age of 25, with a peak age of onset for all mental disorders at 14.5 years [1]. In Europe, almost one in five children and adolescents suffer from a mental disorder [2]. Developing mental health issues before 14 years of age increases the risk of adult mental disorder [3]. Mental disorders are the leading cause of Years Lived with Disability (YLDs), and self-harm is a prominent cause of Years of Life Lost (YLLs) among young people in most European countries [4], highlighting the negative long-term impact of mental disorders at a young age on both individuals and societies.

Despite the high prevalence and significant impact of mental disorders in young people, a large proportion of them do not seek help. Help-seeking is recognized as an “adaptive process that is the attempt to obtain external assistance to deal with a mental health concern” that can be professional (e.g., mental health professionals, primary health care providers, teachers) or informal (e.g., friends, parents) [5]. In a representative school-based study across 11 European countries, 61.9% of adolescents aged 13–17 years were at risk for a mental disorder or risk behavior [6], but only 10% sought professional treatment within one year. Additionally, 4.2% reported current suicidality, yet the majority did not seek professional help within a year [7]. The COVID-19 pandemic has further exacerbated the delay and reduction in help-seeking for mental health problems [8].

Recent systematic reviews of qualitative and quantitative studies exploring barriers and facilitators of help-seeking for mental health problems from the perspective of the adolescents and their parents have identified various factors influencing help-seeking behavior that lie with the adolescents/families, the society, or the healthcare system [9‐11]. These barriers include limited knowledge about mental health and available services, prior negative experiences with mental health professionals, negative attitudes towards mental health problems and help-seeking, stigmatization, preference for self-help or informal support, confidentiality concerns, service and indirect costs (e.g., travel costs, loss of wages), logistical barriers (e.g., long travel distances, limited availability of parents), and limited access to professional help (e.g., waiting times, difficulty in getting a referral, inflexible appointment systems) [10, 11]. However, the current evidence is constrained by selective samples (e.g., adolescents/families who accessed services), the lack of evaluated measures of mental health problems and of facilitators/barriers for help-seeking, the focus on help-seeking attitudes or intentions rather than actual help-seeking behavior, and the insufficient examination of the relative importance of different factors influencing help-seeking behavior.

To address these gaps, the current study had three main objectives. Firstly, to examine in a large school-based sample of adolescents the rates of professional and informal help-seeking for mental health problems. Secondly, to explore various sociodemographic and clinical factors associated with attitudes towards seeking assistance and actual help-seeking behavior and assess their relative importance. According to the theory of planned behavior, attitude is not truly a measure of help-seeking in the sense of an active coping attempt but influences observable behavior [5]. Thirdly, to investigate potential differences in sociodemographic and clinical factors influencing help-seeking attitudes and behavior between adolescents who exceeded a pre-defined threshold for relevant mental health problems (i.e., “the clinical group”) and those who did not (i.e., “the non-clinical group”).

In a large sample of German adolescents aged 12–25, 16.9% showed clinically relevant mental health symptoms according to the results of an online self-report screening. This matches the recently reported prevalence rates of mental disorders among children and adolescents in Europe [2]. Also, 17.6% reported lifetime NSSI, which is consistent with the meta-analytic finding that approximately one in five adolescents engage in deliberate self-harm over time [29]. Moreover, 34.3% of the adolescents reported suicidal ideation and 2.9% a suicide attempt in the previous 12 months. These 12-month prevalence rates are somewhat lower than the reported life-time prevalence rates for suicidal thoughts and attempts in young people [30]. Strikingly, while 55.7% of the young people with clinically relevant mental health symptoms reported having sought help (lifetime), substantially more did so from informal (51.9%) than from professional (25.6%) sources, confirming the previously reported low professional help-seeking behavior of this age group [6, 7].

A positive attitude towards professional help-seeking, reflected in higher help-seeking propensity scores, emerged as the most important factor explaining variability in professional help-seeking behavior, followed by perceived barriers to mental health help-seeking and clinical factors (i.e., increased levels of general psychopathology, NSSI, and suicidal ideations in the last 12 months). This aligns with previous findings that attitudes towards help-seeking and perceived barriers and facilitators significantly influence professional help-seeking [31, 32]. Clinical factors had, overall, a greater impact compared to sociodemographic factors on both, help-seeking attitudes, and actual help-seeking behavior, potentially indicating that the level of psychopathological distress is a key determinant of help-seeking. Therefore, initiatives aimed at increasing help-seeking behavior, especially among young people with high levels of psychopathological distress, should primarily focus on fostering positive attitudes towards professional help-seeking and reducing perceived barriers. This approach is crucial for minimizing the duration of untreated illness, which is associated with poor outcomes [33‐35]. Consistent with previous findings [11, 36‐38], higher SES, female gender, and older age were related to more positive attitudes towards professional help-seeking, and with an increased likelihood to seek professional help. The influence of SES and age may be attributed to differences in mental health literacy (which tend to increase with SES and age) [39], while the gender effect could be explained by gender-specific norms and socialization patterns [36]. Interestingly, higher levels of psychopathology (i.e., general, eating disorder, and personality pathology, NSSI, and suicidal ideation) were related to more negative attitudes (as reflected in lower levels of psychological openness, help-seeking propensity, and indifference to stigma), but increased likelihood for professional help-seeking behavior. These findings raise the question whether previous negative experiences with mental health services have contributed to the negative perception about professional help, as previously reported [40‐42]. For instance, experiencing prior treatment as stigmatizing or unhelpful may exacerbate feelings of hopelessness and distrust toward mental health professionals. Finally, the results of the moderation analyses indicate that the relevance of sociodemographic and clinical predictors for both attitudes towards help-seeking and actual help-seeking behavior were comparable for adolescents with clinically relevant mental problems (i.e., the clinical group) and those without (i.e., the non-clinical group). However, the interpretation of this finding remains complex, as the clinical group-status overlaps with clinical variables (i.e., general and eating disorder psychopathology, and alcohol problems) that were identified as important predictors of attitudes towards help-seeking and actual help-seeking behavior.

Several limitations must be considered: First, the representativeness of the sample is limited, because recruitment took place in five pre-selected regions in Germany and was dependent on the agreement of schools and students to participate. The Covid-19 pandemic as well as the low participation rate at student level made it necessary to invite more schools than originally planned (e.g., also vocational schools). A recent analysis conducted at one of the study centers identified that a primary reason for non-participation was a lack of concern about the topic of “mental health” [43]. This suggests that students who chose not to participate might have experienced fewer mental health problems compared to those who did participate in the study. Alternatively, these findings may reflect a fear of stigma related to mental health, which presents a major barrier to help-seeking. The representativeness of the sample is further constrained by including only male and female genders, which limits the generalizability of the study results to non-binary adolescents. Future research should explore gender diversity as a predictor of help-seeking attitudes and behaviors. Second, the clinical group-status of participants was based on self-report, which is not equivalent to a psychiatric diagnosis as obtained through a structured clinical interview with an adolescent and their parents. In addition, the determination of the clinical group-status in this study is somewhat arbitrary. The chosen criteria align with the allocation criteria to the first RCT of the ProHEAD consortium [26]. Notably, the initial allocation criteria were adjusted after a preliminary analysis of 10% of the sample data revealed that they were too inclusive. The adequacy of these adjusted criteria is supported by the fact that the frequencies of mental health problems in the current study correspond well with prevalence rates reported previously [2]. Third, recent social and economic changes may have affected the FAS’ ability to accurately measure adolescent SES. These changes include climate change, which may alter travel patterns (potentially influencing the car ownership item), the COVID-19 pandemic, which led to travel restrictions and a shift to online education and remote work (potentially influencing the holiday and computer items), or technological advances making personal computers more affordable and therefore less suitable as an indicator for adolescent SES [44, 45] Future research should consider multiple SES indicators when predicting help-seeking attitudes and behaviors. Fourth, the predictor variables considered in the current analyses explained less variance in help-seeking attitudes (IASMHS subscales) compared to help-seeking behavior (AHSQ subscales). This suggests that other variables not assessed in the current study, such as peer influence or exposure to mental health education, may play a significant role in shaping attitudes towards seeking professional mental health help. These factors could be important areas for future research. Finally, as the current study was cross-sectional, correlates of mental health help-seeking attitudes and behavior were examined, which does not allow for causal conclusions.

To conclude, the findings of the current study confirm attitudinal aspects, perceived barriers, as well as clinical and sociodemographic characteristics as relevant factors for the understanding of why some young people with mental health problems do seek professional help, while others do not [9‐11]. They extend previous research by demonstrating that the individual propensity and capacity to seek professional help is most relevant, followed by severity of psychopathology and perceived barriers (e.g., lack of knowledge of mental health services or lack of time resources, travel distances, and confidentiality concerns), while sociodemographic factors such as SES, age, and gender are of minor relevance. These findings overall carry noteworthy socio-political implications, as they emphasize that action is needed to enable and empower young people to seek professional help (e.g., through classroom-based interventions to increase mental health literacy), and to reduce stigma (e.g., through mental health campaigns) and structural barriers to mental health treatment [9, 26].