Depression is treatable and manageable, through several available evidenced-based pharmaceutical and psychological treatments. The most well-known treatments are anti-depressants and psychotherapies (including cognitive behavioural therapy). Stepped- care approaches are used to guide delivery of the most effective interventions in line with the individual’s severity and presentation of depression (NICE, 2009), with the least intensive treatment provided first. Likewise, access to relevant healthcare professionals is directed through the same stepped approach. Several self-help interventions have been identified as helpful for depression, and their use does not necessarily require any professional contact. A systematic review of 38 self-help treatments for depressive disorders and symptoms in adult populations found support for ten
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interventions, including St John’s Wort, bibliotherapy, computerised interventions and exercise (Morgan & Jorm, 2008).
Self-management is also important to consider, as depression is often long-lasting and is susceptible to relapse and recurrent episodes (van Grieken, Kirkenier, Koeter, Nabitz, & Schene, 2013). Self-management places empowerment and responsibility upon the individual in the independent daily care required to manage their chronic condition (Houle, Gascon-Depatie, Bélanger-Dumontier, & Cardinal, 2013). Applied to depression, this refers to the daily behaviours and actions which moderate and alleviate depressive symptoms (Pinto, Hickman Jr, Clochesy, & Buchner, 2013). Depression self-management involves symptom recognition and awareness of triggers; use of personal goals and action planning in managing potential relapses; knowledge of help sources available; personal ability to access help and communicate with healthcare professionals; and use of positive lifestyle changes to ameliorate symptoms (Houle, et al., 2013). Self-management may help individuals both in recovering from a depressive episode and in long-term coping with depression (van Grieken, et al., 2013). Self- management appears to refer to how individuals combine treatment and self-help interventions, and is used by individuals who meet diagnostic depression criteria to prevent relapse (Houle, et al., 2013). Self-help treatments have been adapted into self- management approaches (e.g. CBT-based bibliotherapy and online programs) (van Grieken, et al., 2013). As self-management also
19 includes symptom recognition and seeking out appropriate help, it appears self-help and appropriate help-seeking are aspects of self- management. Importantly, self-management may also be used by individuals who are experiencing distressing emotions or symptoms prior to diagnosis, or have sub-threshold or non-diagnostic depression (van Grieken, et al., 2013). This suggests the potential to use self-management as preventive health promotion to individuals who have not experienced a depressive episode, in order to help them recognise depression and improve their mental well- being through lifestyle management. The very nature of depression affects treatment and self-management, as it causes apathy and indifference towards seeking help, which may further impair motivation and decision making (Wilson & Deane, 2012). The negative thinking and cognitive distortions common in depression may further hinder help-seeking decisions, which can result in delaying or non-receiving of treatment (Sawyer et al., 2012; Wilson & Deane, 2010).
1.3 Help-seeking for mental health problems in young people
Definitions of help-seeking revolve around behaviour and actions reflecting adaptive coping to resolve a problem which challenges the individual’s capabilities (Cornally & McCarthy, 2011). Help-seeking concepts arose from illness behaviour theory and how individuals
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appraise their health and identification of, and response to, symptoms (Rickwood, Thomas, & Bradford, 2012). Help-seeking is a multi-factorial process which focuses on how cognition (e.g. beliefs, attitudes) influences intentions and subsequent behaviour, and involves communication and action to gain advice, treatment and support for a health problem (Rickwood, et al., 2012). Mental health help-seeking is “an adaptive coping process that is the attempt to obtain external assistance to deal with a mental health concern” (Rickwood, et al., 2012). Help-seeking consists of five aspects. Firstly, it is a process on a spectrum of activity, involving cognitions, intentions and actual behaviour. Secondly, sources of help are categorised into informal help originating from social relationships (e.g. family, friends), formal help from professionals/services with expertise (e.g. healthcare professionals), and self-help interventions delivered independently without requiring help/assistance from others. Thirdly, the type of health problem requiring help is considered; symptoms of mental disorders vary in their severity, longevity, and diagnostic criteria, which may affect help-seeking actions. Fourthly, the type of assistance sought includes providing information, understanding the problem, emotional or social support, and treatment. Finally, the timeframe: help-seeking occurs over a period of time and involves a range of actions, including seeking out information about available help, and seeking out face-to-face help (Rickwood, Deane, Wilson, & Ciarrochi, 2005; Rickwood, et al., 2012).
21 The nature of the mental health problem can affect young people’s help-seeking. Those experiencing severe mental distress (e.g. severe depression, suicidal ideation) have the greatest need for urgent treatment, but are often less likely to seek help than those experiencing milder symptoms (Ryan, Shochet, & Stallman, 2010). ‘Help negation’ refers to avoidance or refusal of help in spite of significant suicidal ideation, but is also used for other severe mental symptomology (Wilson & Deane, 2010). ’Appropriate help-seeking’ refers to “a match between problem type, severity [of problem] and help source” (Wilson & Deane, 2010: p292). For mental health problems, an individual should ideally seek out help before the problem becomes more severe and detrimental. Seeking appropriate help is important because early intervention is associated with better long-term mental health outcomes (Farrer, Leach, Griffiths, Christensen, & Jorm, 2008; Wilson & Deane, 2010).
The type of help sought depends on the severity and type of presenting issue (Wilson & Deane, 2010). For example, a new student experiencing transition-related anxiety may seek out informal support (e.g. friends) to help alleviate their worries. However a student experiencing severe depression will probably require professional help and treatment. Young people may perceive teachers/academic staff as being for academic problems only (Rickwood, et al., 2005) and it is possible that students may not perceive their tutors as potential help sources for their health issues.
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The mental health problem and its treatment both impact upon an individual’s self-image (Pestello & Davis-Berman, 2008), and stigmatising attitudes relating to mental illness and help-seeking are a major barrier to mental health help-seeking in young people (Gulliver, Griffiths, & Christensen, 2010). Stigma presents in several forms: personal stigma refers to an individual’s own negative perceptions (e.g. stereotypes, prejudices) about mental health and help-seeking; public stigma is defined as negative perceptions held by a collective (e.g. local community, society); perceived public
stigma is an individual’s own perception of public stigma; and self- stigma occurs wherein the individual identifies with the stigmatised
group and applies this stigma to themselves (Eisenberg, Downs, Golberstein, & Zivin, 2009). Young people may see themselves as “weak” due to having depression, perceive treatment as validating their “weakness”, and so not disclose their illness or their treatment to others (Kranke, Floersch, Kranke, & Munson, 2011).
Rickwood et al. (2005) note a lack of universal theory in predicting mental health help-seeking, but the literature focuses on three aspects: attitudes towards help-seeking, intentions to seek help, and actual behaviour (Gulliver, Griffiths, Christensen, & Brewer, 2012). Insufficient theories can hinder the development of interventions to promote help-seeking (Griffiths, 2013). Models of mental health-related help-seeking usually theorise it as a multi- stage process involving several interconnected cognitions and behaviours (Downs & Eisenberg, 2012).
23 1.3.1 The Process Framework Model
Rickwood et al. (2005) conceptualised help-seeking in young people as a four-step framework process model incorporating psychological and individual factors (Figure 1). Help-seeking is seen as social negotiation between the individual’s intra-personal ‘world’, consisting of internal thoughts and feelings, and the interpersonal external ‘world’ of social relationships. Help-seeking is the ‘link’ between these intra-personal and interpersonal worlds, wherein the intra-personal domain becomes more interpersonal as the individual seeks help from others. Help-seeking begins with self-recognition of symptoms and appraisal of need for help. The individual must then be able to communicate this need in an understandable manner to others, and need to be willing to communicate their ‘internal’ world to somebody trustworthy. The model also incorporates an individual’s knowledge and perceptions about available help sources, as well as attitudes and beliefs towards seeking help and treatment effectiveness.
Figure 1. Rickwood et al.’s (2005) process framework model of help-seeking.
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This model was developed to guide the authors’ own research, and so it is uncertain whether it can be applied to intervention development (Griffiths, 2013). Gulliver et al. (2012) developed and trialled three online interventions, each of which were developed and focused on different stages of the model. Participants who received the intervention which covered the model’s initial three stages reported the greatest improvements in depression and anxiety literacy, and decreases in stigma. At three-month follow-up there was no effect in any condition upon help-seeking attitudes, intentions or behaviour. This may have been too short to analyse behaviour, but it is surprising that no intervention-induced changes in attitudes and intentions were reported. It is possible the number of trial arms coupled with the sample size (n=59) meant the study lacked power to detect significant differences.