Help Seeking and Mental Health Service Utilization Among College Students With a History of Suicide Ideation Amelia M. Arria, Ph.D. Emily R. Winick, B.A. Laura M. Garnier-Dykstra, M.A. Kathryn B. Vincent, M.A. Kimberly M. Caldeira, M.S. Holly C. Wilcox, Ph.D. Kevin E. O’Grady, Ph.D.
Objective: This study examined help seeking among 158 college students with a lifetime history of suicide ideation. Methods: Students were interviewed about episodes of psychological distress, formal treatment, and informal help seeking during adolescence and college. Results: Of the 151 students reporting any lifetime episodes of distress, 62% experienced the first episode in adolescence, and 54% had episodes in both adolescence and young adulthood. Overall, 87% received informal help, 73% received formal treatment, and 61% received both. Among the 149 who ever sought help or treatment, the most commonly reported sources of help were family (65%), friends (54%), psychiatrists (38%), and psychologists (33%). Of the 94 in-
Dr. Arria, Ms. Winick, Ms. Garnier-Dykstra, Ms. Vincent, and Ms. Caldeira are affiliated with the Center on Young Adult Health and Development, Department of Family Science, University of Maryland School of Public Health, 1142 School of Public Health Building, College Park, MD 20742 (e-mail:
[email protected]). Dr. Wilcox is with the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University, Baltimore, and Dr. O’Grady is with the Department of Psychology University of Maryland, College Park. 1510
dividuals who experienced suicide ideation in college, 44% did not seek treatment during young adulthood. Treatment barriers reflected ambivalence about treatment need or effectiveness, stigma, and financial concerns. Conclusions: Most students had some contact with treatment, but family and friends might be important gatekeepers for facilitating treatment access. (Psychiatric Services 62:1510–1513, 2011)
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uicide remains a leading cause of death among young adults in the United States (1), particularly among college students. One in ten college students contemplated suicide during the previous year, and between 1% and 2% made an attempt (2,3). Suicide ideation is sometimes regarded as a transitory phenomenon in youths (4), yet epidemiologic evidence indicates that adolescent suicide ideation often recurs in adulthood (5). Directors of campus counseling centers have observed recent increases in the number of college students exhibiting severe mental health problems (6), including suicidality (7). Unfortunately, only 28% of U.S. adolescents who reported suicide ideation received counseling in the past year (8). Help-seeking rates are similarly low among college students with suicide ideation (3,9), who typically cite a preference to manage the PSYCHIATRIC SERVICES
problem on one’s own, fears about what others might think (10), negative attitudes and beliefs about mental health services, and stigma (11) as barriers to treatment. Help seeking can include both formal professional treatment and informal help, such as help from friends, parents, and informational resources. Few studies have explored informal help seeking by young adults. Australian researchers asked youths about recent problems that caused them “considerable distress” and found that students sought help more readily from informal sources than from professionals (12). This study used a novel life history interview method to examine a broad range of help-seeking behaviors among college students with a lifetime history of suicide ideation. We also explored the degree of continuity between precollege and college experiences of psychological distress and help seeking, examined the sociodemographic correlates of service utilization, and described barriers to treatment among students with an unmet need for help.
Methods This study was a supplement to the College Life Study (CLS), a longitudinal study of health risk behaviors by 1,253 students assessed annually beginning in their first year in college (13). CLS participants (N=182) who
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reported suicide ideation at least once on the Beck Depression Inventory (BDI) in years 1 through 4, lifetime suicide ideation in year 4, or both were invited to participate in a 30minute interview sometime during 2009. The University of Maryland Institutional Review Board granted approval for the study, and written informed consent was obtained. The interview consisted of questions developed and piloted for this study to assess lifetime episodes of psychological distress and help-seeking behavior. Participants were asked about times in their lives when they felt in need of any type of help or treatment for problems with their emotions, nerves, or mental health, broadly defined as episodes of psychological distress. [A chart outlining the format of the interview and a description of the interview procedure are included in an online appendix to this report at ps.psychiatryonline.org.] Summary variables were computed for total number of episodes of psychological distress, age at first episode, and the presence or absence of an episode before the start of college and after the start of college. Analyses were conducted in Stata 10. Lifetime help-seeking data were consolidated into two binary variables representing any use of informal help or formal treatment, respectively. Formal treatment included services provided by health professionals, counselors, campus- or communitybased health or counseling centers, hospitals or other facilities, law enforcement officials, support groups, rehabilitation clinics, or hotlines. Informal help was defined as talking to friends, family members, significant others, or other trusted adults or clergy; conducting Internet research; reading self-help books; or engaging in prayer. The average BDI score from the four annual CLS assessments was used as an indicator of depression severity. Possible scores range from 0 to 63, with higher scores indicating more depressive symptoms. The BDI has good psychometric properties when used with young adults (14). Data about demographic characteristics collected in the parent study included gender and self-reported PSYCHIATRIC SERVICES
race. Socioeconomic status was approximated by the mean adjusted gross income for the zip code of the participant’s permanent residence (publicly available data).
Results A total of 158 of the 182 (87%) eligible students, ranging in age from 21 to 24, completed the 30-minute interview assessment; 102 were female, 97 were white, and ten were Hispanic. According to their BDI responses from the CLS, 94 individuals had had suicide ideation since starting college; the remaining 64 had ideation sometime in their lives, but of indeterminate timing. Of the 94 with ideation in young adulthood, 25 (27%) sought treatment in both adolescence and young adulthood, and another 28 (30%) sought treatment for the first time in young adulthood. The remaining 41 (44%) did not seek treatment during young adulthood. Of those, 31 (76%) had never sought treatment in their lifetimes, and ten had sought treatment in adolescence. Most participants (N=151, 96%) reported at least one lifetime episode of psychological distress. Almost twothirds (N=94, 62%) had their first episode in adolescence. A majority (N=138, 91%) experienced an episode after starting college, and more than half (N=81, 54%) experienced an episode in both college and adolescence. Thus of the 138 students who reported an episode of psychological distress in college, 81 (59%) also experienced at least one earlier episode in adolescence. Of the 151 individuals who ever experienced an episode, 110 (73%) received formal treatment, 131 (87%) received informal help, 92 (61%) received both types of help, 39 (26%) received only informal help, 18 (12%) received only formal help, and two (1%) neither sought nor received any type of help. The likelihood of seeking treatment was similar regardless of whether the distress occurred in adolescence or young adulthood (66% versus 65% of individuals, respectively). Of the 81 individuals who reported episodes in both adolescence and young adulthood, those who received formal treatment in adolescence were signif-
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icantly more likely to receive treatment for a later episode compared with those whose adolescent episode was untreated. Of the 51 who received formal treatment for the earlier episode, 42 (82%) received formal treatment in young adulthood, compared with 14 of the 30 (47%) individuals who did not receive formal treatment as an adolescent (p=.001). Correlates of obtaining treatment were examined by comparing characteristics of the 39 individuals who sought only informal help with those of the 110 individuals who obtained treatment (Table 1). Obtaining treatment was associated with more lifetime episodes of psychological distress (3.1 versus 2.5, p=.05) and younger age at first episode (15 versus 18, p
