Databases & Search methodology
Three databases (PubMed, PsycINFO, and Cochrane) were searched in September and October 2009 using the search terms presented in additional file 1
: Search terms. These terms aimed to represent the primary concepts of 'help-seeking', 'mental health', and 'barriers' or 'facilitators'. Keywords were generated for each of these concepts by examining the terminology used in review papers in the help-seeking literature and a thesaurus to locate synonyms. In addition, the keywords were combined with standard MeSH terms from the PubMed and Cochrane databases and Subject Headings for the PsycINFO database.
Figure presents the flow chart for the selection of the included studies. The initial database search returned 3637 published English-language abstracts after removing duplicates. One of the researchers (AG) then screened the abstracts and excluded studies that did not address barriers or facilitators to help-seeking for a mental health problem. This resulted in 260 potentially relevant studies. An additional 32 studies were located through hand-searching the reference lists of reviews and key papers found through the systematic search and which were considered likely to satisfy the inclusion criteria.
The second stage of the study selection process involved examining each of the 292 articles and excluding those which met the following exclusion criteria.
1. Participants were not explicitly asked what they considered were barriers or facilitators to help-seeking for mental health problems.
2. Study participants were neither adolescents nor young adults (aged 12-25 years). This criterion was considered met if more than 25% of the participants fell outside the 12 to 25 years age range, the sample mean age was 26 years or more, the sample was specifically described as "adults" with the age of the participants no further described.
3. Study was a review.
4. Study participants were not members of the general community, or university, or school students (e.g., studies of groups with restricted access to a range of help-seeking opportunities such as prisoners and members of the military).
5. Study was focused on help-seeking on behalf of another person (e.g., carer seeking help for a consumer, or parent seeking help for a child).
6. Study contained no extractable data on barriers or facilitators.
7. Study addressed a mental health condition other than depression, or anxiety, or general "mental distress" (e.g., psychosis, obsessive compulsive disorder). Studies of pre- or post-natal depression were also excluded.
270 studies met one or more of these criteria and were excluded from further consideration. No studies were excluded on the basis of research quality. A summary of the excluded studies grouped by the primary reason for the exclusion is provided in additional file 2
: List of studies excluded from the review by exclusion category. This process resulted in a total of 22 relevant studies [20
] for inclusion into the review.
Coding of Studies
Each of the 22 included studies was coded using a pre-formulated rating sheet according to the following characteristics: Author name, year published, country (location of study), age of participants (age range or mean), population description, whether the study participants were selected regardless of mental health status or risk profile (universal) or not, sample size (for target variable), gender (male, female, both), setting (e.g., high school, community, university), research type (qualitative, quantitative), specified barriers to help-seeking (description of barrier themes or items as listed in the study), and specified facilitators of help-seeking (description of facilitator themes or items as listed by the study).
Standard methods for thematic analysis [42
] were conducted on participant reported barriers and facilitators in the qualitative studies. Barriers and facilitators reported in the quantitative studies were tabulated and top rated themes extracted.