Evaluating factors and interventions that influence help-seeking and mental health service utilization among suicidal individuals: A review of the literature

Highlights

• Mental health service use among suicidal individuals is notably low.

• There are many significant barriers to help-seeking in this population.

• A number of interventions to increase service use have been developed.

• Additional research is needed to understand how to increase help-seeking.

Abstract

Connecting suicidal individuals to appropriate mental health care services is a key component of suicide prevention efforts. This review aims to critically discuss the extant literature on help-seeking and mental health service utilization among individuals at elevated risk for suicide, as well as to outline challenges and future directions for research in this area. Across studies, the rate of mental health service use for those with past-year suicide ideation, plans, and/or attempts was approximately 29.5% based on weighted averages, with a lack of perceived need for services, preference for self-management, fear of hospitalization, and structural factors (e.g., time, finances) identified as key barriers to care. Studies also revealed facilitators to care, which include mental health literacy, positive views of services, and encouragement from family or friends to seek support. To address these low rates of help-seeking and barriers to care, a number of interventions have been developed, including psychoeducation-based programs, peer and gatekeeper training, and screening-based approaches. Despite these efforts, it appears that work is still needed to gauge the impact of these interventions on behavioral outcomes and to more rigorously test their effectiveness. Additional implications for future research on help-seeking among suicidal individuals are discussed.

Introduction

Suicide continues to be a leading cause of death worldwide and in the United States (Centers for Disease Control and Prevention [CDC], 2015, World Health Organization (WHO), 2014). With over 800,000 individuals dying by suicide around the world each year, suicide prevention has been declared both a global and national imperative (Institute of Medicine (IOM), 2002, World Health Organization (WHO), 2014). One ongoing challenge has been ensuring that at-risk individuals are connected with appropriate mental health care services (U.S. Department of Health and Human Services, 2012). Although efficacious interventions exist for reducing suicidal ideation and preventing suicide attempts (for review, see Brown & Jager-Hyman, 2014), researchers continue to find that a vast number of individuals with thoughts of suicide are not engaging in treatment (Bruffaerts et al., 2011, Michelmore and Hindley, 2012, Substance Abuse and Mental Health Services Administration (SAMHSA), 2014a). This is especially concerning since studies of suicide decedents have found that the majority did not have contact with a mental health provider in the year prior to their death, with even fewer having contact in the month of death (Hamdi et al., 2008, Luoma et al., 2002).

As a result, numerous studies have been conducted to better understand help-seeking and mental health care service utilization among suicidal individuals. These studies have ranged in their scope and focus, with some aimed at identifying overall rates of help-seeking and others striving to assess specific barriers and facilitators to service use. Provided the significance of this area within suicide prevention efforts, it is helpful to understand how these studies come together to inform current practice, future research, and the development of suicide prevention programs.

In order to synthesize past work in the field, this review aims to outline and critically examine: (1) rates of help-seeking among suicidal individuals; (2) barriers and facilitators to service utilization among those at elevated risk; and (3) past interventions targeted at increasing rates of help-seeking behaviors and improving willingness to seek care. This review will also discuss current gaps in the literature and highlight directions for future research.

Relevant papers (N = 146) were identified through PubMed, PsycInfo, and Google Scholar. Search keywords included help-seeking, service use, service utilization, treatment, treatment-seeking, help-negation, facilitator, and barrier in combination with various permutations of suicide. To increase the relevance of this review to suicide prevention efforts, we chose to focus on studies of suicidal individuals, recognizing that there is a significant body of work on help-seeking for general mental health problems. For this same reason, while numerous studies located by this search included individuals with non-suicidal self-injury alongside those with suicidal ideation, the primary aim of this review is to discuss help-seeking among those with suicidal ideation or past suicidal behaviors (e.g., suicide attempts). Thus, although some studies included both groups, we will focus on findings as they relate to those with suicide ideation and/or attempts. Regarding nomenclature and definitions, although there are many forms of help-seeking (e.g., seeking friend support, online communities), this review will focus on studies of help sought from professional mental health providers since formal services are the main avenue by which individuals receive evidence-based treatment. Lastly, we recognize that the terms help-seeking and service utilization are often used interchangeably in the literature, even though those who seek help may not necessarily begin treatment. We will make every effort to offer clarifying details when these terms are used, especially when discussing the impact of interventions on help-seeking intentions, help-seeking behaviors, and long-term treatment engagement.