Help-seeking behaviors among Chinese people with mental disorders: a cross-sectional study

Although mental disorders contribute significantly to global health problems and cause a severe burden on both patients and their environment, many individuals who have or experience a mental disorder do not seek treatment, especially in low- and middle-income countries, including China [1, 2]. Previous surveys in China have shown that the treatment-seeking rates of individuals with a mental disorder are low (12-month rate: 3.4%) [3] and lower than rates observed in other low and low-middle income countries [4]. It has been suggested that these comparatively low rates of mental healthcare use in China might be due to inadequate resources to meet demands, unequal distribution of mental health services across urban and rural areas, and/or inadequate training of the mental health workforce [5].

To address the problem of low mental healthcare use, Chinese healthcare policy is set to focus on increasing the availability of trained healthcare and non-healthcare workers to improve the effective delivery of mental healthcare. However, to gain better insight into the need for mental healthcare and optimal targeting of improvements, the patterns of help-seeking behaviors of mental health patients and the correlates of these patterns should be investigated more closely [6]. Surveys of help-seeking behavior in Shenzhen and in Beijing and Shanghai showed help-seeking rates of, respectively, 6.7 and 2.9% from healthcare services and of, respectively, 4.6 and 1.0% from non-healthcare services [3, 7]. Several studies have investigated correlates of help-seeking and have shown that the experience of high psychiatric stigma, low mental health knowledge, mild severity of mental disorders, being separated, divorced or widowed, having a low-income status, and living in a rural area are associated with a lower probability of seeking and receiving any help for mental disorders in China [3, 8, 9].

Although previous work has provided important insights into the general patterns and correlates of help-seeking in China, several important points are in need of closer investigation. First, little is known about the distribution of help seeking across different kinds of sources and/or providers of care. Second, the roles of lay workers or non-formal care providers have been ignored in previous Chinese studies, although it is known that these play an important role in helping people with mental health problems [5, 10, 11]. Third, previous studies on associated factors of help-seeking have mainly looked at demographic factors, whereas clinical factors, such as a patient’s diagnosis and the disorder’s severity may also be associated with help-seeking behavior [12]. Finally, the relationships between mental illness stigma and mental health knowledge (MHK), on the one hand, and help-seeking behavior, on the other hand, have so far received little attention in China, whereas the former are both considered barriers to help seeking for individuals with mental problems [5, 8, 10].

Addressing above mentioned points will contribute to gaining the specific insights that are required to guide the development of a better community-based mental healthcare system that integrates hospital and community mental services into the general healthcare system in China [6, 13]. Therefore, this study aimed to investigate: (1) the total help-seeking and first-time help-seeking rates from different types of help/healthcare providers among individuals with mental health disorders living in community, (2) the clinical (e.g., severity; diagnosis) and demographic factors related to help-seeking and different types of help/healthcare, and (3) the associations of help-seeking behavior with perceived stigma and MHK.

The results of the current survey showed that of individuals with a lifetime mental disorder, only 15.7% had ever sought any form of help, with help-seeking rates for healthcare and non-healthcare settings being 7.6 and 8.1%, respectively. This observed help-seeking rate during their entire lifetime before the interview is higher than that in previous Chinese surveys in Xi’an city (4.7%) [21] and Shenzhen City (11.3%) [7]. However, the rate is much lower than that found in Western countries (range: 31.4% in Italy to 57.9% in the Netherlands) [22] and in people of Asian ancestry in the United States (25%) [23]. The current results showed that the proportion of help seekers in healthcare settings (7.6%) was roughly similar to the 8% found in the previous four provinces study in China [8] and the 6.7% found in the Shenzhen City survey [7]. The differences in overall help-seeking rates across Chinese surveys could be explained by different factors. First, the lower rate in Xi’an may be associated with its lower economic development and fewer mental health resources compared to Tianjin and Shenzhen [21]. Second, we included psychotic disorders in our survey, which are more likely to require some form of help/treatment than many other mental disorders, whereas the Xi’an and Shenzhen surveys did not include these disorders, which could have contributed to the lower help-seeking percentages in the latter [7, 21]. Apart from socio-economic factors, the described differences between the current results (and other findings from Chinese surveys) and those from surveys in western countries could be explained by higher levels of stigma toward mental disorders and lower mental health knowledge in China [24].

Relatives and colleagues/friends/neighbors were the most commonly reported source of help and the first choice to seek help for patients with mental disorders, which is consistent with previous work [25]. It has been shown that friends or relatives play an important role in helping patients deal with illness. In addition, they can help by recommending patients with a mental disorder to eventually seek professional help [26] or traditional, complementary and/or alternative medicine approaches [11]. Folk sources such as Qigong practitioners, witchdoctors and temples have traditionally been important providers of care for people with mental disorders in China and are still consulted widely. These practices are based on folk explanatory models that ascribe mental illnesses to an imbalance in the psychosocial, physiological and/or supernatural environment [11]. A previous study among Asian Americans found that 35% of patients with a lifetime mental disorder had visited religious/spiritual advisors [27]. However, the present study showed that only 0.7% of individuals with mental disorder sought help from such sources, and that in patients who did seek any help, no more than 0.9% first went to those sources. Interestingly, these rates are much lower than the rates observed for healthcare use and in the study among Asian Americans. It may be that seeking help from traditional sources has decreased over time or is underreported because respondents are reluctant to tell this to an interviewer with a medical/healthcare-related background.

Interestingly, of the patients who sought any healthcare services, a sizable proportion only sought non-mental healthcare services and 27.5% sought their first help in non-mental healthcare. Of the non-mental healthcare services, general hospitals and TCM hospitals were found to be the most common healthcare providers. The finding that TCM plays a significant role aligns with previous work. Two studies that were conducted in Taiwan showed that 9% of patients with schizophrenia and 40% of individuals with depression had used TCM services [28, 29]. In addition, the finding that many patients visit a general hospital aligns with previous work showing that patients with a mental disorder often visit general hospitals before they go on to visit mental health professionals [26]. Only a very small percentage of patients with a mental disorder in the current survey visited a community health center, although a previous study in Chengdu showed that 71.8% individuals in an urbanized community used services from a community health center during the past year [30]. The currently observed low usage rates might be explained by low awareness [31] and/or distrust in the quality of the provided service [32], and provides an indication of where possible improvements could be made.

We found that in the individuals with mental disorders, females are more likely to seek any form of help than males, but there were no sex differences in seeking help from either healthcare or non-healthcare sources. Differences in socialization of men and women could partly explain the differences in help-seeking, because women might be more likely to seek social support in response to stressful experiences than men [33]. When comparing age-groups, the present study found that older age-groups had lower odds to seek any help, but when they did, were more likely to seek help in healthcare than in non-healthcare settings. This result aligns with a previous study that has found that older generations are less likely to seek help for their mental disorders [34]. Marital status was presently found not to be related to any help-seeking behavior, but of persons who had ever sought any help, married individuals with mental disorder were more likely to seek help in healthcare than in non-healthcare settings compared to single, divorced or widowed patients. These results are in contrast to previous studies showing separated, widowed or divorced people with mental disorders to more often seek treatment than married individuals [1, 4]. However, the current findings are in line with the results of the survey in Xi’an [21]. The observed influence of marital status could be explained by a supportive role of a spouse that motivates a patient to seek treatment. Indeed, a previous study found that medical service use was increased by about 40% in the presence of a higher than median level of spousal support [35]. Per capita family income was presently observed to be related to help-seeking behavior, with lower income being associated with higher odds of seeking any help. However, income was unrelated to seeking help in healthcare vs. non-healthcare settings. This result is not consistent with findings from previous work in China that showed individuals with a lower income to have lower odds of help-seeking [3]. One explanation for this finding could be that low-income individuals may be more impaired by mental illness in their daily functioning than individuals with a higher income. An additional explanation for this finding could be that people with low income might be more likely to report mental-illness problems and help-seeking behavior than people with a high income.

Several clinical characteristics (psychotic disorder, organic mental disorders, having more than 1 mental disorder) were related with higher odds of help-seeking. This could be explained by the fact that these characteristics are indicative of considerable severity and severity is a known determinant of help-seeking [3, 5, 8]. Indeed, a previous study found that 90% of people with dementia in rural areas and 98% in urban areas sought treatment, and that 77% of individuals with schizophrenia in urban areas and 70% in rural areas had contact with mental health providers [36].

The current study found no clear association between perceived stigma and help-seeking behavior in individuals with mental disorders. This does not align with previous findings on the role of stigma. For instance, a community-based study in the US found that 25% of people who perceived a need for help did not seek services partly because they concerned about what others might think [37] and a US-based clinical study showed that higher perceived stigma is related to lower treatment adherence and higher discontinuation [38]. However, the current results are in line with previous work that found no relation between perceived public stigma and mental health service use [39]. The lack of an association between stigma and help-seeking in the current study might be explained by the fact that only perceived public stigma (i.e. other peoples’ perceived stigmatizing ideas/thoughts/actions) and not personal stigma (e.g., respondents’ own stigmatizing ideas/thoughts/actions) was assessed, whereas previous work found only personal stigma to be associated with help-seeking for mental health [39]. The current results did show an association between help-seeking and higher MHK. Indeed, a previous study in China showed the importance of knowledge in the process of help-seeking: they found that nearly 80% of a community resident sample had the intention to seek psychological help if needed, but only 12% knew of any hospitals or clinics that provide such help [9].

Although the current study had several strengths, including the survey design, extensive diagnostics, comprehensive help-seeking measurements and the inclusion of both demographic and clinical determinants, some study limitations should be considered. First, help-seeking was self-reported and recall bias or social desirability may have affected the responses. Second, a significant group of potentially interesting service users were not captured in this study (including subthreshold/subclinical patients) because only service use of those who were screened positive for high risk and met the criteria for a DSM disorder was investigated. In addition, diagnostic assessment was limited to DSM-IV Axis I disorders. DSM-Axis II disorders were not included in the SCID, whereas such disorders would likely be associated with significant need for care and help-seeking. Third, the results of the current study apply specifically to the Tianjin region and we should be careful with generalizing the findings directly to other regions/countries. Still, the results could give an indication of the kind of help-seeking patterns and correlates that would be found in comparable regions that have undergone similar rapid socioeconomic changes. Finally, the MHKQ used in this study mainly assessed basic mental health knowledge but not mental health literacy, which refers to knowledge and beliefs about mental disorders which aid their recognition, management or prevention [40]. Mental health literacy has previously been found to be related to seeking treatment [41]. Future study should pay more attention to the relation between mental health literacy and help-seeking behaviors.

The findings of current study have significant implication for the improvement of help seeking behavior for people with mental disorders. The results showed that the initial suggestion to seek help came mostly from relatives and colleagues/friends/neighbors. This shows that the social network and support of a patient play an important role in providing help for individuals with mental disorder in the community. This indicates that the social network should be considered as an important component when building mental health system in China. In addition, for non-mental healthcare settings, more programs are needed to improve the detection of mental health problems in western and TCM hospitals and general hospitals, to make sure that patients will receive needed care or can be referred to the appropriate mental healthcare providers. Finally, the results show that men, older people, those with high family income and those with common mental disorders are less likely to seek help and could be target groups for educational programs to improve help-seeking. Such actions would align with our finding that help-seeking was associated with higher mental health knowledge.

Current findings provide important insights into the pattern and the correlates of help-seeking behavior of people with mental disorder in Tianjin which has undergone rapid economic development. This study showed that a small percentage of persons with mental disorders seek help. Of the patients who sought any healthcare services, a sizable proportion only sought non-mental healthcare services. Variations in the types of help-seeking may be partially explained by demographic and clinical characteristics. In addition, knowledge of mental health played an importance role in the process of help-seeking.