Influence of mental health literacy on help-seeking behaviour for mental health problems in the Swiss young adult community: a cohort and longitudinal case–control study

In this first-time study of both cross-sectional and longitudinal predictors of help-seeking for mental problems/disorders, we examined the relationship between relevant aspects of MHL, sociodemographic predictors of help-seeking, and active help-seeking in a Swiss community sample of young adults. Our expectation that MHL, in terms of correct identification of an unlabelled vignette (schizophrenia or depression), a biogenetic causal explanation, and recommendation of seeking help from MH professionals, would be linked to subsequent active help-seeking was only partially supported for biogenetic causal explanations. In addition, endorsements of the causal explanation ‘childhood trauma’, and, in line with previous studies [25,26,27], previous help-seeking, lower psychosocial functioning, and lower health satisfaction were also associated with subsequent help-seeking. Furthermore, sensitivity analyses revealed a significant impact of sex, type of vignette, and presence of MH problems/disorders, although these variables were not associated with help-seeking in the overall prospective model.

Comparison of the cross-sectional and the prospective model

Interestingly, and in line with reports from cross-sectional studies [10, 56, 57], the expected positive association of biogenetic causal explanations with help-seeking was replicated in our prospective model but was reversed in the cross-sectional model in that the causal explanation ‘biogenetics’ was negatively associated with help-seeking. However, previous studies, including earlier analyses of this sample [12], reported an association between biogenetic causal explanations and negative stereotypes, and between negative stereotypes and a wish for social distance, which is commonly negatively associated with active help-seeking [12, 38, 58,59,60,61]. Thus, it could be assumed that the fear of stigma linked to biogenetic causal explanations because of associated negative stereotypes might have prevented active help-seeking initially. Yet, these explanations may have facilitated help-seeking in the long run when, possibly, fear of identifying with the negative stereotypes related to biogenetic causal explanations increased in terms of evolving self-stigma. Regardless, future studies will have to examine these potential and unclear relationships between biogenetic causal explanation and emerging self-stigma [62,63,64] as well as help-seeking. Another interesting difference between the cross-sectional and prospective model was the role of MH problems/disorders that were significantly associated with help-seeking only at baseline. One reason might be a change in MH state, in particular remission of symptoms, that had weakened the relationship between baseline MH problems/disorders and help-seeking at follow-up. However, at baseline, only 7.5% of persons with MH problems/disorders had sought help, while this number increased to 22.6% at follow-up. Another reason might be the new occurrence of MH problems/disorders up until follow-up. This is supported by the declining number of persons with baseline MH problems/disorders amongst help-seekers at baseline (75.5%) and follow-up (62.0%). Thus, future longitudinal studies should include MH problems/disorders at any assessment time to compare their long-term and immediate effects on help-seeking.

Contrary to previous studies [8, 9], in both models, a correct identification of the vignette was not associated with help-seeking. Since a significant association between correct labelling and help-seeking was also found in our data at follow-up (but not at baseline) when only the two variables were considered, the stronger association of causal explanations likely outperformed that of correct labelling.

A similarly unexpected finding was that both models demonstrated no associations between treatment recommendations and help-seeking. This might be due to operationalizing treatment recommendations into three categories, while the point of help-seeking was not similarly differentiated but broadly included several types of institutions, ranging from school, church and police via primary care and counselling services to MH services. Thus, likely specific associations between specific treatment recommendations and actual points of contact would not have shown up here for the single outcome ‘help-seeking’. Future studies of larger sample size or oversampled for persons with help-seeking could help to investigate these links in more detail.

Group-specific results on the role of health satisfaction and functioning

When the role of MH problems/disorders was further analysed using sensitivity analyses, clear differences emerged. While low health satisfaction was the sole predictor for help-seeking in persons without MH problems/disorders, in those with MH problems/disorders, help-seeking was predicted by lower psychosocial functioning, previous help-seeking, and the causal explanations ‘childhood trauma’ and ‘biogenetics’. Yet, for the lower number of participants with MH problems/disorders, the latter model was slightly underpowered and would need to be re-examined in larger samples of sufficient power. The differences between these two models might be explained in terms of the nature of MH problems/disorders and the point of help-seeking contact. Health satisfaction was assessed with a general question and not specifically with regard to MH. Thus, the MH problems of the group without positive screening answers to the M.I.N.I. might have been mostly emotional distress in response to intrapersonal, interpersonal, or role performance stressors or somatic health problems that would have not been considered psychopathological symptoms in the interview [65]. Therefore, emotional stress might have mostly influenced health satisfaction rather than psychosocial functioning that consequently, was significantly associated with the number of MH problems/disorders [25] and, in our sample, was more strongly correlated with MH problems/disorders (Spearman’s ρ = –0.34) compared to health satisfaction (Spearman’s ρ = –0.24).

Similar to the model on persons with MH problems/disorders, significant effects of functioning and the causal explanations ‘biogenetics’ and ‘childhood trauma’ were also found in males but not in females, in whom, similar to the model of persons without MH problems/disorders, health satisfaction and baseline help-seeking predicted subsequent help-seeking. These similarities in the two types of sensitivity models appeared to be independent of each other because baseline MH problems/disorders did not significantly differ in the follow-up sample between females (43.1%) compared to males (37.1%; χ2(1) = 1.727, p = 0.182, Cramer’s V = 0.061). The sex differences in the role of emotional (health satisfaction) and functional (psychosocial functioning) triggers for help-seeking, are in line with reports of men focusing more on problem-solving and females more on emotional distress when seeking help [66,67,68,69].

Group-specific results on the role of the previous help-seeking

The role of the previous help-seeking also differed in the sensitivity analyses, playing a significant role in females and, independent of sex, in participants with MH problems/disorders but not in males and those without MH problems/disorders. While the result in the sensitivity models according to the presence of MH problems/disorders likely reflects that a need for care had not newly occurred past baseline, the results in the sex-specific models likely reflect the fact that the MH treatment gap is larger in males [23, 24]. This had already been reported for the baseline assessment of the BEAR study, with only 34.2% of males with MH problems/disorders compared to 50.7% of females having reported help-seeking [25]. Furthermore, persons seeking help for emotional distress not captured by the M.I.N.I. screening questions, e.g. in relation to intrapersonal, interpersonal or role performance problems [65], might be more likely to seek help from their personal network rather than official institutions [70,71,72]. Thus, as our points of help-seeking contacts only included several types of institutions, they were less named by participants without MH problems/disorders compared to those with MH problems/disorders.

For the broad inclusion of institutions, however, it would be interesting to study a possible gradient from help-seeking from friends/relatives in case of emotional distress via help-seeking from primary and semi-professional care services in case of MH problems to help-seeking from professional MH services in case of MH disorders [71]. Understanding factors that influence help-seeking at different severity levels of MH problems would increase the general understanding of help-seeking and, relatedly, barriers to it. Unfortunately, for the already low number of persons with/without MH problems and, in particular, disorders, we could not study this gradient due to statistical power reasons.

Group-specific results on the role of the causal explanations ‘biogenetics’ and ‘childhood trauma’

The causal explanations ‘childhood trauma’ and ‘biogenetics’ positively influenced help-seeking only in males and in participants with MH problems/disorders. Furthermore, they were positively associated with subsequent help-seeking only in participants who had been presented with the depression vignette. In line with our overall model, an impact of sex on the relationship between causal explanations and help-seeking was not reported in previous studies when sex entered as a predictor [10, 38, 56, 57]. Yet, the results of our sensitivity analyses indicate that males are more likely to base their decision for help-seeking on their own causal explanation when these involve factors out of their current control. This would be in line with studies reporting a strong tendency for males to try to deal with their problems themselves [73]. Females, however, might be more likely seek help depending on their level of distress regardless of their own causal explanations [67, 69]. This might be another reason why females more often seek help than males [23, 24]. Furthermore, causal explanations might be more relevant to participants with MH problems/disorders compared to those suffering from emotional distress only, in relation to an already identified stressor, such as intra- or interpersonal, or role performance stressors. The exact relationship between the severity of MH problems and the importance of causal explanations in the decision to seek help needs to be explored in future studies.

The difference between the two types of vignettes might be related to the nature of MH problems/disorders for that help was sought, and their resemblance with the case vignette. Depression is the most common mental disorder [1, 74] and depressive mood is one of the main reasons for help-seeking [23, 75], and this was also found at the baseline of the BEAR study [76]. Baseline depressive problems/disorders were also frequent in help-seekers at follow-up (39.2%), whereby interviews were terminated when a diagnosis of a psychotic disorder was assured. Thus, almost every second participant with MH problems/disorder could identify with the depression but likely only few with the schizophrenia vignette and, consequently, the recommendations, beliefs and help-seeking intentions stated for the depression vignette were more likely reflecting real-life considerations underlying actual help-seeking behaviour. Therefore, the causal explanations for the depression vignette were likely more systematically related to help-seeking than the causal explanations for the schizophrenia vignette, thus resulting in significant paths and the highest explained variance of help-seeking in the subgroup with the depression vignette (R2 = 0.451) compared to all other models (R2 = 0.143–0.293).

Commonly, a schizophrenia vignette has been more strongly related to biogenetic causal explanations compared to a depression vignette, which commonly has been mostly related to psychosocial causal explanations [12, 17, 18]. Childhood trauma, however, was given as a causal explanation for several mental disorders, including alcohol abuse, where it was specifically associated with recommendation of drug treatment [77]. Interestingly, despite the relevance in our models and the growing empirical evidence [78], childhood trauma has been increasingly less regarded as a cause of mental disorders in Germany between 1990 and 2011 [17]. The difference between our findings, and the relationships between type of disorder depicted in a vignette, and main causal explanation described in the literature irrespective of their association with help-seeking [12, 17, 18] indicates that the relation between causal explanations and help-seeking may be problem-specific. Thus, general disorder- or problem-unspecific models might fail to apply to certain groups of persons or give conflicting results in different groups, such as the apparent contradictory association of the biogenetic causal explanation in the cross-sectional and prospective model. Future community-based studies on the role of causal explanations should therefore include a wider range of vignettes and consider the MH status of the participant to be able to match participants’ problems to the vignette to generate problem-specific models of help-seeking.

Strengths and limitations

This study has several clear strengths: active help-seeking behaviour as the outcome (rather than only help-seeking intentions), the prospective design, and the sufficiently large sample size that allowed consideration of complex overall path models with excellent power. Nevertheless, more than 95% of the sample consisted of Swiss people between 16 and 40 years of age at baseline, so that the results can only be generalized to young and middle-aged adults in Western cultures. The factors ‘Biogenetics,’ ‘Substance abuse,’ and ‘Self-care’ consist of only two items, which is below the recommended minimum number of four variables of a factor [79]. Furthermore, in particular due to the comparably low loading and explained variance (communality) of the causal explanation ‘Disease of the brain’, the factor ‘Biogenetics’ just reached the minimal acceptable internal consistence and eigenvalue [49, 79], while these indicated that ‘Substance abuse,’ and ‘Self-care’ were consistent and important factors despite including only two items whose variance was well explained by the factors (communalities  ≥  0.63). However, because of the construct immanence and meaningfulness of these two-item factors as well as their reported importance in MHL and help-seeking, in particular of ‘Biogenetics’ [11, 12, 17, 18, 38, 62], we decided to include these factors in our models. The very good fit of our models might be regarded as indicative of saturated models and, consequently, of over-optimistic model evaluations due to their complex nature. A saturated model would be one, in which the number of free parameters exactly equals the number of known values, i.e., a model with zero degrees of freedom [80]. Yet, in our models the number of known values has always been greater than the number of estimated parameters so that we had a positive number of degrees of freedom to conduct fit tests. In addition, two of the sensitivity analyses were slightly underpowered due to the small subsample size of males (n = 229) and participants with MH problems/disorders (n = 217). This led to empirical underidentification in these two models, with a non-reliable estimation of parameters, as indicated by negative variances [53, 80, 81]. Thus, interpretation of these two models needs to be done with some caution.

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