The present review identified six randomised controlled trials of help-seeking interventions for depression, anxiety, and general psychological distress. Overall the results indicated that improvement in some aspects of help-seeking was achievable, with all of the studies finding a positive effect relative to control for at least one intervention on at least one aspect of help-seeking attitudes, intentions or behaviour. However, median effect sizes were small.
It is difficult to locate reliable trends in the data for intervention content with so few studies. However, almost all of the interventions that delivered information targeting mental health literacy were associated with improved attitudes, although none of them were able to influence help-seeking behaviour out of the three studies measuring this aspect. Results were mixed for the interventions delivering destigmatisation information, with two out of the three finding significantly improved attitudes at post-test [43
]. Providing information about help-seeking sources was common to three interventions [40
], and all three successfully improved attitudes. Finally, there were no discernable effects for contact with mental health consumers [44
], or contact with the research team via telephone [37
]. The only study to produce reported behaviour change was that involving CBT and personalised feedback about symptoms.
Importantly, in almost all studies the interventions incorporated more than one type of content. This made assessing the individual contributions of content components problematic [48
]. However, one study did attempt to dismantle the effects of the content of messages on help-seeking willingness for depression [42
]. They compared the effect of providing information about the physiological aspects of depression including genes, neurotransmitters, and endocrine systems (biological attribution condition) with providing information aimed at reducing psychological blameworthy attitudes towards depression. They concluded that only the biological attribution intervention increased willingness to seek help. This is an important result, as it is possible that less content may be needed to facilitate help-seeking than is currently being trialled. Further research in this area is required to assess the efficacy of individual content components with a view to ensuring future interventions are comprised of brief but highly effective components [48
It is encouraging that all studies found a positive outcome on at least one measure of help-seeking. It appears that attitudes, including the measures of ‘beliefs’ and ‘willingness’, may be the most malleable of the three help-seeking facets, as all of the trials measuring this outcome found a significant improvement at post-test for at least one of their comparison conditions [40
]. Help-seeking intentions
may be more difficult to change, with the only study of help-seeking intentions
] and two of the three studies measuring help-seeking behaviour
failing to find a positive effect compared to the control [37
]. Theories of help-seeking predict that attitudes and beliefs influence behaviour [22
]. However, currently there is little empirical evidence to support this hypothesis with respect to mental illness. In fact, it is known that attitudes do not necessarily translate into behaviour [42
]. In the case of help-seeking for mental illness, behaviour may be more difficult to change than beliefs as it is external and thus potentially more vulnerable to the stigmatising of others, which in turn has been linked to help-seeking avoidance [49
]. Further work is needed to develop interventions that are effective agents for help-seeking behaviour change.
Three of the studies provided follow-up data at 2
weeks and 6
months respectively. Both studies that measured the shorter follow-up time period [43
] measured attitudes and reported a significant positive effect of the intervention at both post-test and follow-up but the study with the longest follow-up time measuring behaviour found an effect at immediate post-test only [37
]. This raises questions about the sustainability of the effects of the interventions in general as well as on the different aspects of help-seeking. Thus, further studies investigating the longer term effects of help-seeking interventions are required.
Study quality was moderate, with all of the studies successfully satisfying at least five of the nine quality criteria. However, there was poor adherence to four of the criteria. In particular, a number of studies failed to describe or adequately generate the allocation sequence for randomisation, conceal the unit of allocation, provide the baseline characteristics of providers, or address incomplete outcome data. It is important for future trial research to appropriately address and report on these potential areas of bias.
Almost all of the studies used an attention placebo rather than a less conservative control such as a Wait List or no intervention Control. Thus, it is unlikely that the positive effects that were observed on help-seeking attitudes and behaviour were the consequence of non-specific factors such as social support or attention [48
]. Future help-seeking intervention research should continue to utilise attention placebos, particularly those in which the content is unlikely to affect the primary outcomes.
The results of the present review demonstrate that the majority of randomised controlled trials investigating help-seeking for common mental health problems and general psychological distress target young people. A focus on this age group is appropriate given that the prevalence of mental disorders is highest in adolescents and young adults [11
]. However, there is also a need for further research involving other age groups.
Additionally, almost all of the present study trials were conducted with universal samples reflecting that the current focus in the literature is on promoting positive help-seeking attitudes and intentions prior to the development of symptoms. Detecting help-seeking change in universal populations employing short-term follow-up periods may be difficult given that only a minority of the target group will have a mental disorder that requires help. It would be expected that help-seeking behaviour would be more likely if the individual is symptomatic and therefore had a perceived need to seek help [26
]. Consistent with this, the single trial [37
] that did investigate the effects of the intervention on a symptomatic population found positive results for behaviour. Given the importance of help-seeking behaviour for those experiencing current symptoms [21
], this is an essential area for future research.
The majority of trials were conducted in person. However, two of the more recent trials involved content delivered via the internet [37
] and both successfully increased professional help-seeking behaviour or intentions. There is an increasing focus on delivering mental health prevention and treatment services over the internet, with research indicating that online services are highly acceptable to young people [50
]. Additionally, a survey of over 50,000 young people in Australia [51
] indicated that after parents, relatives and friends, the next most common source of advice and support for personal problems is the internet. It has been reported that the online delivery of interventions targeting health-related behavioural change are as effective as face-to-face forms of delivery [52
]. In addition, online delivery may be a relatively inexpensive means of delivering treatments to a wide range of people [53
], particularly for rural residents [54
] whose access to in-person interventions may be limited. Given the reported positive effects of the internet interventions in the present study on formal help-seeking, there may be value in using online help-seeking applications to promote the use of online evidence-based treatment services. Further research is required to explore this possibility and the cost-effectiveness of such models.
With respect to length, the duration of the interventions varied from 5–10 minutes to 6
weeks. The longest, and possibly the most intensive intervention utilising CBT and brief feedback for depression [37
], was the only one that successfully increased professional help-seeking behaviour, out of three studies measuring behaviour [37
]. However, this study was also the only trial to specifically select participants with psychological symptoms, and thus a greater proportion of this than the other trial groups had a need for professional help [55
All of the measures of help-seeking involved self-report, although they varied in type and in what they measured. The studies in the present review rarely measured attitudes, intentions, and behaviour in the one study. Given that these three may be impacted on differently by different interventions, and indeed different components of the interventions, it may be important to measure all of these outcomes in the same trial. However, this might require long-term follow-up to detect effects on behaviour if the studies involve universal populations unselected for symptom levels. In addition, there is a need for consensus on the most appropriate measures of help-seeking to facilitate comparison between studies. Further, it may be useful to assess knowledge about and stigma towards help-seeking for mental disorders in order to understand more about the help-seeking process. Providing destigmatising material as well as measuring its effect is particularly important, as subjective norms or beliefs about what others think about help-seeking, are thought to influence intentions [22
]. Research to refine and test models of help-seeking for mental disorders is warranted. In addition, only one study [40
] in the present research designed an intervention based on a help-seeking model. It may be of benefit to the help-seeking field if future researchers were to use a model or theory of help-seeking as a basis for their intervention design. As Costin et al. [40
] noted with respect to the Rickwood et al. model [31
], this may allow the targeting of model-specific factors that could inhibit the progression through the help-seeking process, such as how to contact a mental health professional, and what to expect in a consultation.
There are some limitations to the present review that require consideration. Firstly, the measures of help-seeking found varied and this lack of standardisation makes comparison between studies difficult. Secondly, only one study investigated actual help-seeking behaviour; it is possible that positive help-seeking attitudes and intentions do not translate into action.
The present review searched three databases and it is possible that some relevant journals are not indexed by these databases. However, an attempt was made to address this by hand-searching the reference lists of papers that were captured [57
]. In addition, the restriction of the inclusion criteria to English-language journal papers may have introduced a level of bias into the present review, as may the incorporation of published papers only given that publication may be biased towards papers with positive outcomes [58
A final limitation is the subjective nature of the coding. To address this, two coders extracted data from each paper and discrepancies were discussed and resolved.