The perception of a personal health risk is primarily influenced by at least three factors; general health values, which include interest and concern about health, specific beliefs about vulnerability to a particular illness, and beliefs about the consequences of the illness, such as whether or not they are serious (Millstein & Halpern-Felsher, 2002). Whether an individual believes a health measure will reduce the risk breaks down into two sub-components. Whether they believe a health practice will be effective and whether the perceived cost of undertaking the measure exceeds the benefits of the measure (Outram et al., 2004). Two of the most powerful determinants of whether an individual actually practices particular health behaviours including help seeking, are the perceived barriers to the practice of the health
behaviour and the perceived risk/susceptibility of a particular illness (McNair et al., 2002).
Recognised barriers to help seeking include social, professional and personal factors as well as stigma. Additional factors such as characteristics of treatment facilities and providers including accessibility and cost have been related to delayed help seeking (Hickie et al., 2001; Jordan & Oei, 1989). The general lack of information about treatment resources amongst community gatekeepers including legal, medical, personnel and community organizations, their limited training in dealing with psychological problems, as well as mixed views about the effectiveness of treatment programmes by lay people and professionals, provide barriers to anyone seeking help for psychological problems (Jordan & Oei, 1989). Hickie (2002) argued that access to treatment does not necessarily lead to the receipt of sufficient information to make appropriate treatment or personal choices. Further, areas such as knowledge and attitudes about depression and its sufferers; an acceptance by the community, policy makers and mental health professionals of depression and sufferers of depression all act as barriers to help seeking in depression. Research such as that by Wilson and Deane (2001) argued that relationship factors such as trust were key approach factors for help seeking behaviour. They reported that in their qualitative study of 23 adolescents not feeling heard, valued, accepted and treated with dignity within a help seeking relationship were significant barriers to engaging in help seeking behaviour (Wilson & Deane, 2001).
Several factors have been found to influence the decision to consult a GP with symptoms of bad health, including knowledge, the interpretation of symptoms, as well
as fear and trust in medical treatment. Despite the GP being considered the first port of call for help, for those suffering with symptoms of depression, research has shown that individuals postpone seeing a GP for a number of reasons. Among those were a lack of knowledge about where to look for help, the stigma associated with depressive illnesses, the belief that they can somehow ‘pull themselves together’, ideas or beliefs about the treatment of illnesses, and social and emotional factors (De Noouer et al., 2001). These factors often interact to dissuade many people with depressive illnesses from directly asking the GP for help and information (Bishop, 2002). Given that knowledge is a necessary prerequisite for accurately interpreting symptoms as requiring medical attention, if individuals have insufficient or incorrect knowledge, then it becomes impossible to interpret symptoms correctly resulting in a failure to seek help (De Noouer et al., 2001). Delays were more common among people who did not believe that the GP’s action would be beneficial or if they regarded symptoms as self-treatable (De Noouer et al., 2001). When questioned, GP’s reported a lack of knowledge about symptoms and treatments by the general population, not only as a reason for delay, but also as a reason for unnecessarily seeking medical help by the worried well (De Noouer et al., 2001).
Interestingly, Jorm et al. (2002) highlighted that the community does not always see GP’s as a recognised part of the public health response to depression (Hickie, 2002). This was in part due to the persistent view that mental health is, at best, a marginal health issue, and in part, due to a lack of knowledge about available services and treatments (Highet et al., 2002). Jorm, Korten, Jacomb, Rodgers and Pollitt (1997d) observed that divergent views about treatment between the public and health professionals might lead to an unwillingness to seek or accept help from
professionals. Public attitudes to the treatment of depression were compared to the beliefs of health professionals (psychiatrists, general practitioners and psychologists) (Jorm et al., 1997b). As they predicted all health professionals gave much higher ratings than the public to the usefulness of both pharmacological and psychotherapeutic interventions. When evaluating potential differences between health professionals in attitudes to treatment modalities, Jorm et al. (1997d) confirmed that practitioners were most likely to highly rate interventions aligned with their own profession, that is, psychiatrists were less likely than general practitioners and psychologists to rate psychological and lifestyle interventions as useful and psychologists were less supportive of medical interventions.
In spite of the divergent views of professionals and the public regarding the usefulness of particular treatments, several cognitive and attitudinal barriers may by associated with primary care clinicians including GP’s competency in the recognition of psychiatric illness and depression in particular. These barriers include clinician’s discomfort with confronting issues about depression, their perceived lack of time, their beliefs about the medical professional’s role in treating psychological conditions, and the influence of the biomedical model (Main et al., 1993). Personal barriers to help seeking for mental health problems from professionals were reported by Outram, and colleagues (2004) and included a desire for privacy (16%), confidentiality (5%), fear of being judged by professionals (7%), believing no one can help (9%), pride, (3%) and a desire to cope alone (13%).
As well as the factors described by Outram and colleagues (2004) negative myths / expectancies and the impact of the knowledge gap create additional barriers for
women seeking help for mental illness generally, and depression more specifically (Jordan & Oei, 1989; Rylands & Rickwood, 2001). The gap created when those who need help do not receive it has been conceptualised as a service gap (Raviv et al., 2000). The emergence of a service gap is commonly explained to be the result of a threat to the self, which is believed to incur psychological costs that hinder help seeking behaviour. There are several variables that affect help seeking behaviour by imposing a threat to their self, such as egocentricity of the problem, self-esteem and feelings of inferiority and dependence (Raviv et al., 2000). Research has noted that seeking help is often tantamount to an open admission of failure and inadequacy, that is self-threatening for the individual in need of help (Jordon & Oei, 1989). Due to the self-threatening nature of help seeking many choose not to seek help even if this decision means continued difficulties (Nadler, 1987). This threat to self often incurs psychological costs that exceed the perceived benefits of seeking help (Raviv et al., 2000). Not perceiving a problem or symptom as serious enough, learned helplessness, a lack of social support, a lack of knowledge of how and where to seek help, and an unwillingness to disclose personal information related to psychological problems were additional barriers to help seeking identified by Lyu (1999) and Rickwood and Braithwaite (1994).
Empirical evidence has suggested that the stigma of depression is a major factor hindering the effective treatment of depression (Haslam, 2005; Hunt et al., 2003; Sims, 1993). The ongoing stigma associated with depression within the community has major negative effects on sufferers of depression, resulting in overt and covert barriers to social participation that continues even when these people have recovered (AIHW, 1998). Despite significant progress in recent years, mental health diagnoses
still carry powerful stigma and are likely to arouse strong self-presentation concerns and socially desirable responding (Haslam, 2005). Haslam (2005) argued that folk psychiatry clarifies the psychological basis of stigma, in particular the moralizing dimension, which has established correlations between controllability attributions and stigma. Finding a way to reduce stigma and help distressed individuals acknowledge their symptoms should lead to better diagnosis and treatment outcomes overall (Haslam, 2005; Hunt et al., 2003). The problems associated with stigma can act as important barriers to treatment entry, particularly for women suffering from depression.
Preboth (2000) asserted that at times, overcoming real and perceived barriers to help seeking and convincing patients to seek, start and adhere to treatment is difficult. Some patients may refuse to accept a diagnosis of psychiatric illness; therefore, they will not accept treatment for the disorder. Others may be hesitant to begin specific treatments. Parker and colleagues (2001) reported that while medical professionals viewed antidepressants as helpful for depression, the public viewed them as harmful. Correspondingly Preboth (2000) suggested that some patients are reluctant to take antidepressant medications because they fear "becoming addicted," "needing a crutch," taking "mind-control drugs" or for other reasons (Preboth, 2000). When people do begin treatment, some may be dissuaded by unexpected or unpleasant side effects of medications, delay in sufficient improvement or difficulty in forming an alliance with a psychotherapist. In addition, people often perceived medical treatments for depression as harmful or leading to adverse outcomes. Patients who initially agree to treatment report a feeling that they must follow the treatment plan closely to ensure improvement of the illness and feel under pressure to succeed in
overcoming their symptoms. Findings such as these demonstrate that facilitating sufferers to seek treatment is one piece of a complex puzzle with important implications for prevention, management and treatment outcomes.