Help-seeking intentions for early signs of mental illness and their associated factors: comparison across four kinds of health problems

The Global Burden of Disease Study 2013 [1] revealed that mental and substance abuse disorders accounted for 21.2 % of years lived with disability (YLDs). Major depressive disorder was a crucial contributor in both developed and developing countries: it is the leading cause of YLDs in 56 countries, the second leading cause in 56 countries, and the third leading cause in 34 countries. There is now a variety of effective treatments available for mental disorders. To prevent negative sequelae of mental disorders, prompt initial contact with healthcare providers is needed after first onset of symptoms. However, many affected individuals in both developed and developing countries delay in seeking professional help and fail to receive effective treatment [2, 3].

Jorm et al. have coined the term “mental health literacy” with the definition “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” [4]. According to the concept of mental health literacy, recognition of symptoms is crucial to making decisions to seek or not seek professional help [5]. Signs and symptoms of mental illness include a variety of psychological as well as somatic symptoms. As for patients with depression in primary care, approximately two thirds of the patients present with somatic symptoms [6]. People who begin to exhibit a symptom of mental illness should recognize the early signs and take prompt action to recover their own health. Unfortunately, a number of population surveys have revealed that many people cannot correctly recognize symptoms depicted in a vignette as a mental disorder [5]. If people do not recognize the signs and symptoms of mental illness, they will not seek help, and thus healthcare services will be ineffective regardless of their availability.

People who should receive professional help are not limited to those who meet the diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM). In order to encourage early help-seeking for mental illness, policymakers need to understand what kinds of early signs of mental illness are less likely to induce help-seeking behavior. Previous studies have revealed that the majority of patients who were diagnosed with major depressive disorder had reported only somatic symptoms as the reason for visiting the physician [6]. This indicates that patients with depression in primary care tend to report somatic symptoms more readily than they report psychological symptoms. Unfortunately, most of the previous studies have been conducted among clinical populations, i.e. patients who visited their physicians to seek help. It has been reported that the likelihood of seeking help varied depending on the type of disorder [7, 8]. However, to our knowledge, there have been no attempts to identify differences in seeking help for different kinds of symptoms of mental illness. It remains unknown how much more likely people are to seek help for somatic symptoms as compare to psychological symptoms. Such symptom-based approaches may provide useful information for dealing with the problem of failure and delay in initial treatment contact after first onset of symptoms.

Japan has achieved universal health coverage, which provides relative equality of access to healthcare services [9]. Despite having the universal healthcare system, failure and delay in initial treatment contact for mental disorders has been recognized as an important public health problem in Japan [2, 3]. A comparative survey between Japan and the United States [10] indicated that Japanese people exhibited greater reluctance to seek professional help. A comparative survey between Japan and Australia [11] indicated that Japanese people were more reluctant to use psychiatric labels, more reluctant to discuss mental illness with others outside the family, and less positive about the benefits of seeking professional help. An international study as well as other cross-cultural comparative studies suggested that the experience of symptoms varies little across countries and cultures, whereas the reporting of symptoms can be influenced by sociocultural factors, particularly stigma surrounding mental illness [12‐14] These findings suggest that the public beliefs about mental illness and its treatment may contribute to failure and delay in initial treatment contact. Unfortunately, only a few studies have addressed help-seeking behavior of Japanese people, [15‐17] and very little is known about the barriers and facilitators of seeking professional help in Japan. Previous studies in different countries have proposed a variety of factors that may influence help-seeking behavior for mental illness, including physical dysfunction, [18] psychological distress, [18] exposure to mental illness, [19‐21] knowledge about mental illness, [22] stigmatizing attitudes to mental illness, [20, 21] perceived effectiveness of professional help, [23] social network, [24] and neighborhood context [25] In order to develop public health strategies for encouraging help-seeking for mental illness, policymakers need to have a clear understanding of help-seeking behavior of their target population groups and to identify the factors that will have a significant impact on their help-seeking behavior.

The aims of this study were to investigate the types of health problems for which Japanese adults intend to seek help, their preferred sources of help, and the factors associated with help-seeking intentions. The study participants were asked their intentions to seek help in four health conditions indicated by irritability, dizziness, insomnia, and depressive mood, respectively. A variety of factors mentioned above were examined for their associations with help-seeking intentions. In contrast to previous studies that examined help-seeking intentions for specific mental disorders, [7, 8] this study focused on early signs that could appear before it is officially diagnosed as major depressive disorder [6, 26]. Depressed mood and insomnia are included in the DSM-5 diagnostic criteria for major depressive disorder [26]. Dizziness and irritability are not part of the diagnostic criteria but are most commonly reported symptoms in patients with depression in primary care [6]. A follow-up study of Japanese workers suggested that dizziness, as well as loss of interest, may be a significant predictor of depression [27]. Recent studies on the significance of irritability in major depressive disorder in adults suggested that irritability may serve as a severity marker, [28, 29] or a subtyping distinction [29, 30]. We believe the findings of this study will provide a new direction for public health strategies for encouraging help-seeking for mental illness as well as contribute to a better understanding of help-seeking behavior of Japanese people.

Table 3 shows the percentages of participants reporting a positive help-seeking intention for the four health problems. In the case of dizziness, 85.9 % of the participants were recognized as having a positive help-seeking intention; 67.8 % reported that they would seek help from formal sources at any time; and 42.7 % gave first priority to seeking help from formal sources. These percentages were smaller in the cases of irritability, insomnia, and depressed mood, and the smallest values were found in the case of irritability. McNemar test was performed to compare the percentages of participants reporting a positive help-seeking intention for each pair of health problems. Significant differences were found between all pairs of the health problems except the comparison between insomnia and depressed mood (p = 0.405).

Table 4 shows the comparisons of percentages of participants reporting a positive help-seeking intention. Most of the variables of interest showed significant associations with the help-seeking intention for all the health problems in univariate analyses.

Table 5 shows the results of multiple logistic regression analysis for the overall help-seeking intention. Perception of family and friends regarding help-seeking (their family and friends would think that they should receive help from others for the problem) showed the strongest association with the help-seeking intention for all the health problems. Besides this, the following factors were significantly associated with the help-seeking intention for all the health problems: female gender, unmarried status, psychiatric history, contact with people with mental illness, higher HLS-14 scores, higher LSNS-6 scores, and one of the neighborhood contexts (communicative).

Table 6 shows the results of multiple logistic regression analysis for help-seeking intention from formal sources. Although the perception of family and friends was significantly associated with help-seeking intention from formal sources, the effect-sizes were lower than its association with overall help-seeking intention. Besides this, the following factors were significantly associated with the help-seeking intention for all the health problems: presence of any disease, psychiatric history, contact with people with mental illness, higher HLS-14 scores, one of the stigmatizing attitudes to mental illness (blameworthy), positive perception of the effectiveness of professional help, and one of the neighborhood contexts (communicative).

Table 7 shows the major reason for no help-seeking intention for the four health problems. Of the participants reporting no help-seeking intention, those who had hoped to receive help accounted for 35.7 % (321/898) for irritability, 23.9 % (111/465) for dizziness, 29.6 % (241/813) for insomnia, and 41.2 % (342/831) for depressed mood. The most frequently cited reason for no help-seeking intention for irritability was lack of awareness of potential sources of help. That for dizziness was willingness to handle the problem by oneself. For insomnia and depressed mood, negative perception of the effectiveness of help, lack of awareness of potential sources of help, and willingness to handle the problem by oneself were the three most frequent reasons for no help-seeking intention. On the other hand, when the reasons why they would avoid seeking help from formal sources were asked, the most frequently cited one was lack of awareness of potential sources of help for all of the problems of dizziness, insomnia, and depressed mood.

This study examined the help-seeking intentions for four kinds of health problems and their associated factors at the individual and neighborhood levels among Japanese adults. In contrast to previous studies that examined help-seeking intentions for specific mental disorders, [7, 8] this study focused on early signs that could appear before it is officially diagnosed as major depressive disorder. The four health problems presented in the questionnaire were designed so as to represent common signs and symptoms of depression. Our symptom-based approach may provide useful information for dealing with the problem of failure and delay in initial treatment contact after first onset of symptoms.

When the four health conditions indicated by irritability, dizziness, insomnia, and depressed mood were presented, the majority of participants recognized that help-seeking would be useful for solving the health problems and thus indicated their intentions to seek help. The greatest percentage of participants reporting a positive help-seeking intention was found for dizziness (physical problem), followed by insomnia (psychological problem), depressed mood (psychological problem), and irritability (non-medical problem). A similar result was obtained from the analysis for help-seeking intention from formal sources. These results indicated that psychological problems were less likely to induce help-seeking than a physical problem. Surprisingly, the likelihood of help-seeking for psychological problems was not greater than that for a non-medical problem. Cross-cultural comparative studies suggested that sociocultural factors influence symptom reporting in patients with depression; in particular, stigma surrounding mental illness increases the tendency to emphasize somatic symptoms [14, 52]. We infer from these findings that the difference in help-seeking intentions we observed in this study may be attributed to stigma surrounding mental illness. Many people probably considered dizziness as a symptom arising from physical causes, so that they may not have hesitated to seek help for this health problem.

Depressed mood and insomnia are included in the DSM-5 diagnostic criteria for major depressive disorder [26]. As a general rule in Japan, people who report these symptoms for over 2 weeks often screen positive for suspected depression. The depressed mood and insomnia problems of this study were intended to present health conditions that require prompt initial contact with healthcare providers. However, more than half of the participants did not choose medical professionals as a potential source of help for these health problems. This result supports the notion that many people with mental disorders tend not to receive professional help or use mental health services [53‐56]. A negative perception of the effectiveness of help, a lack of awareness of potential sources of help, and willingness to handle the problem by oneself were the three most frequent reasons for no help-seeking intention. A lack of awareness of potential sources of help was also cited as the most common reason not to seek help from formal sources. In order to increase intentions to seek help from formal sources, policymakers should consider implementing universal interventions such as an education program [16] and an awareness campaign [57] which give all people a better understanding of potential benefits of professional help along with providing information on professional help available to the general public.

As for the depressed mood and insomnia problems, approximately half of the participants gave first priority to seeking help from informal sources, which were two to three times more than those who chose the options of seeking help from formal sources. Moreover, multiple logistic regression analysis revealed that perception of family and friends regarding help-seeking was significantly associated with the help-seeking intention from formal sources. As suggested in previous studies, [58, 59] family and friends may be regarded more favorably as helpful advisers, so that many people tend to first seek help from them. There is no doubt about the importance of having support from family and friends. However, family and friends may be both a positive and negative influence [24, 58, 59]. If the family and friends have inadequate knowledge about mental illness, their support could be unhelpful or even harmful. In order to increase prompt initial contact with healthcare providers, policymakers should consider improving support from family and friends. Public education campaigns to improve knowledge about mental illness may be adequate to this purpose [60]. Such universal interventions have the advantage of simultaneously targeting both affected individuals and their family and friends.

Multiple logistic regression analysis revealed that the factors significantly associated with help-seeking intentions were almost identical across the four health problems. This result can hardly explain the difference across types of health problems in the likelihood of help-seeking, but it supports the presence of factors associated with help-seeking intentions common to all problem types. In particular, perception of family and friends regarding help-seeking, psychiatric history, contact with people with mental illness, higher HLS-14 scores, and neighborhood communicativeness were significantly associated with the overall help-seeking intention and also the help-seeking intention from formal sources for all the problems of dizziness, insomnia, and depressed mood. Those who have had some exposure to mental illness are less likely to feel reluctant to seek help for mental illness [19‐21]. Those who have better health literacy are more likely to acquire exact knowledge of mental illness and apply their knowledge to solving their health problems [44]. Those living in a neighborhood where neighbors say hello whenever they pass each other are more likely to receive the benefit of daily interactions with weak ties (i.e. peripheral members of social networks such as acquaintances) [61, 62]. People who often interact with weak ties, as well as strong ties (i.e. core members of social networks such as family and friends), are more likely to have a sense of belonging and thus less likely to hesitate to seek help from people around them. Besides developing health literacy skills, community-based interventions for creating a friendly approachable atmosphere and facilitating daily interactions with family, friends, and acquaintances may be worth considering as a possible public health strategy for encouraging help-seeking whether for psychological or physical problems. To date, several interventions that focus on facilitating social contact have been reported. For example, NOCOMIT-J is a community-based multimodal intervention program for suicide prevention in Japan, which set up regional social gatherings to reinforce human relationships in the community [57]. Further studies are needed to determine whether this kind of interventions can be recommended.

This study provides the first step toward understanding the types of health problems for which people intend to seek help. On the contrary, it has a number of potential limitations. First, the study participants were recruited from a nationwide panel of an online research company. As described in the methods section, the study participants included highly educated people twice as many as in the Japanese population. Although we confirmed that the distribution of HLS-14 scores in the study participants was quite similar to that obtained from our previous paper-based survey in Japanese healthcare facilities, [44] the selection bias may have influenced the results to some extent. Second, the web-based survey was self-administered, so that the accuracy of responses must depend on their understanding of questions and their motivation to answer questions accurately. Although the understandability of wording were checked prior to the web-based survey, it is almost impossible to eliminate the information bias completely. Third, the method of measuring help-seeking intentions was based on the most commonly used methodologies, [35‐38] but its validity has not been fully confirmed. Respondents were asked to imagine themselves in specified hypothetical health conditions and then report their help-seeking intentions. If some people underestimated the severity of the health problem, the percentage of participants reporting a positive help-seeking intention in this study may have been somewhat different from the actual value. Fourth, the procedure of giving all four health problems to each participant may have affected participants’ responses. We cannot deny such influence, but the results of McNemar test indicated that those who thoughtlessly repeated the same responses across four health problems were few, if any. Fifth, because of the cross-sectional design, this study cannot provide definitive evidence of causality. There was no knowing whether the self-reported help-seeking intentions accurately reflect the actual help-seeking behaviors if they become mentally ill. Intention is recognized as a key predictor of behavior, but the strength of the intention-behavior relationship can vary depending on the type of behavior [63]. The findings of this study should be considered preliminary and need to be confirmed in other populations. In future studies, we intend to examine the relationship between intention to seek professional help and subsequent healthcare service use and elucidate in more detail the difference across types of health problems in the likelihood of help-seeking.

The majority of participants indicated their intentions to seek help, but psychological problems (insomnia and depressed mood) were less likely to induce help-seeking than a physical problem (dizziness). A number of individual and neighborhood factors were significantly associated with help-seeking intentions across different problem types. In particular, perception of family and friends regarding help-seeking, psychiatric history, contact with people with mental illness, better health literacy, and neighborhood communicativeness were identified as the factors associated with help-seeking intentions common to all problem types. Besides developing health literacy skills, community-based interventions for creating a friendly approachable atmosphere and facilitating daily interactions with family, friends, and neighbors may be worth considering as a possible public health strategy for encouraging help-seeking whether for psychological or physical problems.