Introduction:
A high prevalence of common mental disorders has been found among young adults in the community.(1) The National Mental Health Survey of India 2015-16 (NMHS) revealed a treatment gap of 85% for common mental health disorders indicating an increased disease burden and disability.(2) Young adults forming the largest part of the productive segment of Indian society bear the maximum burden of mental disorders.(3) Despite the availability of evidence-based interventions, they are highly unlikely to seek professional help.(4,5)
Several studies have been conducted on pathways to care, attitudes and barriers to help-seeking.(6) However, most of them have been carried out in clinical and community samples. Although a sub-sample of distressed individuals not seeking help has been identified in community-based studies, there is a severe dearth of research singularly focused on distressed individuals not seeking professional help.(7)
Low rates of help-seeking among young adults have been extensively researched across the globe(8); however, most Indian studies have not focused on young adults.(9) Moreover, they adopted quantitative methodologies indicating a need to supplement their findings with an in-depth exploration.(10) While there are ample studies on barriers, exploring the facilitators could aid in development of help-seeking interventions to reduce the treatment gap. Against the above backdrop, the present study aimed to explore barriers and enablers of professional help-seeking for common mental health concerns among distressed non-treatment seeking young adults (D-NTS) in the urban Indian context.
Methods
This study employed an explanatory sequential mixed methods design including two phases. The first phase involved a survey with a sample of D-NTS young adults (quantitative phase), followed by second phase of semi-structured interviews with a sub-sample of survey participants (qualitative phase). This approach was utilized to gain a deeper understanding of participants’ viewpoints than elicited by solely quantitative or qualitative method.(11) Approval was sought from the Institute Ethics Committee before initiating the study.
Survey with distressed non-treatment seeking young adults
Quantitative data were collected in first phase with D-NTS young adults. Sample inclusion criteria are described in Box 1.
| Box 1. Sample inclusion criteria |
a) young adults aged 20 to 35 years with at least 12 years of formal education
b) working knowledge of the English language
c) self-reported depressive/anxiety symptoms for minimum two weeks and not seeking professional help for their current distress
d) a score of 20 or above on Kessler psychological distress scale (K10).(12)
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Purposive and snowball sampling methods were used for recruitment. Announcement flyer was circulated on social media and was put up at a health service centre and one college campus alongside word-of-mouth publicity. Interested participants were encouraged to share the flyer on their social media platforms and with individuals they thought to be in distress. Those interested to participate were sent a hyperlink containing the informed consent form and the survey.
The online survey assessed socio-demographic details and their current distress level was ascertained through K10. Inclination to seek help was examined using General Help-Seeking Questionnaire(GHSQ),(13) rated on a 7-point Likert scale. Barriers to professional help-seeking were assessed using a checklist developed with the help of literature review and authors’ clinical experience. Information was gathered on duration of current distress, perceived distress severity, its effect on functioning and past treatment history.
Once the responses were received, individualized feedback was sent to all participants, including recommendations to seek help as appropriate and referral-related guidance was provided, as requested.
Semi-structured interview phase
Second phase consisted of collecting qualitative data using a semi-structured interview schedule with a sub-sample of first ten participants who had completed the survey and consented to the same. It was built on survey results, relevant literature and authors’ clinical experience to explore the barriers and enablers of professional help-seeking (table 1). The interview probes were preceded by a brief introduction to young adults’ low rates of professional help-seeking for mental health. They were explained that the purpose was to gain a deeper understanding of their barriers and enablers and their general perspective for young adults towards professional help-seeking.
| Table 1: Semi-structured interview schedule |
I. Barriers |
1. You have realized that you are experiencing distress but are not seeking professional help. What factors are making it difficult for you to come to that decision to seek professional help? |
2. What factors are making it difficult for you to actually seek professional help? |
2a. (If only structural barriers were reported) In addition, are there hesitations/factors within you that may be delaying professional help-seeking? |
3. Now, focusing on young people in general, why do you think young people in distress may delay help-seeking or not seek help? |
II. Potential Enablers |
1. What do you think are the factors that can help you arrive at the decision to seek professional help? |
2. What do you think are the factors that can help you actually seek professional help? |
3. What factors can help young people in distress to overcome their barriers, reach out and seek professional help early? |
Interviews were transcribed orthographically, cross-checked against the recordings and subjected to thematic analysis.(14) Explicit methods used to enhance rigor included data triangulation and peer debriefing.(11) After the initial codes were developed, they were collated and grouped into clusters to form focused codes and subsequently into potential themes. This process was supplemented by memoing and constant comparison back-and-forth with the coded data and the transcripts to enhance the rigor. The final themes and sub-themes were determined only after rigorous brainstorming among the researchers until a consensus was reached.
Results
Survey outcomes
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Fig. 1 Recruitment of non-treatment seeking distressed young adults (N=37) |
Out of the 53 potential participants that showed interest, 16 were excluded. Total 37 D-NTS young adults completed the survey (figure 1). Out of the 37 completers, 75.7% (N=28) scored above the cut-off on K10, indicating the presence of psychological distress. Out of these, 75% were females (N=21), and 25% were males (N=7). Further analyses were conducted with these 28 participants. The average age of the sample was 25.6 years (±3.9). A majority had completed post-graduation (60.7%), were unmarried (75%), belonged to the Hindu religion (71.5%) and lived with their families (51.7%). Most were salaried employees (57.1%) earning an individual annual income of INR 1 lakh and above (50%). Figures 2 and 3 represent the participants' psychological distress reported on K10 and their self-reported distress severity.
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Fig. 2 Distress severity on K10 (N=28) |
Fig. 3 Perceived distress severity (N=28) |
Majority of the sample reported both depressive and anxiety symptoms (42.9%), followed by only depressive symptoms (28.6%), only anxiety symptoms (25%) and no perceived self-reported symptoms (3.6%). Most reported the duration of current distress to be more than six months (28.6%). Functioning difficulty was reported at a moderate-severe level by 35.7%. Out of the 28 participants, 32.4% (N=12) had sought professional help in the past. Half of them reported discontinuing treatment as it did not make a difference (50%). Figure 4 represents participants’ inclination to seek professional help for their current distress. Those who did not report any perceived distress selected ‘not applicable’ option.
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Fig. 4 Inclination to seek professional help (N=28) |
Table 2 shows participants’ average help-seeking inclination from various sources assessed using GHSQ.
| Table 2. Average help-seeking inclination from various sources on GHSQ (N=28). |
Sources |
Mean (SD) |
Partner/Friend |
4.7 (1.7) |
Mental Health Professional |
3.8 (2.1) |
Social media/online forum/informational websites/self-help books |
3.3 (1.8) |
Parent/relative |
2.7 (1.5) |
General physician/helpline |
2.4 (1.6) |
Teacher/Religious/spiritual leader |
2.4 (1.7) |
Help Negation |
3.1 (2.1) |
Figure 5 describes barriers reported by participants to seek professional help.
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Fig. 5 Barriers to seek professional help (N=28)
Note: The percentage does not add up to 100 since multiple options were provided. |
Interview findings
Themes derived from the thematic analysis included personal and general barriers and enablers of professional help-seeking. Sub-themes under these are elaborated below.
Theme: Personal barriers
Distress Perception
Participants normalized the distress and considered it a part of their daily lives. They did not perceive their distress severity to be significant enough to consult as it was not experienced continuously and without any difficulty in the daily routine.
“I am pretty sure that the distress that I am going through, a professional would be very helpful for me. But, it hasn’t gone to a level where I can’t handle it, or it’s hampering my day-to-day activities.” (D-NTS-4)
Preference for self-reliance and self-stigma
Participants reported wanting to manage their distress without any external help or resources. Some mentioned perceiving themselves as weak and not fit to live in society if they had to seek professional help.
“I don’t want my brain to depend on medicines. I don’t want to alter my brain's activities through external agents. Also, even after so much education, telling (someone) that I’m going to a psychologist causes discomfort to me.” (D-NTS 2).
Poor knowledge and awareness of mental health
Poor knowledge of mental health concerns, treatment options and mental health professionals was noted, along with misconceptions regarding psychotropic medications. Several participants considered their mental health a low priority to be taken care of.
Perceived sufficiency of informal support and social stigma
Several participants believed that seeking help from significant others was enough to deal with their distress.
“Most of the time, I’m comfortable sharing with my friends. Sometimes, venting makes me feel better, so I don’t access professional help. I talk to my friends because of trust, they have known me for a long time. I don’t have to explain everything from scratch. They have been through this journey with me, so they would know what I have been through.” (D-NTS 2)
In contrast, participants also reported difficulty in having open discussions about mental health with people around them.
Family’s awareness of mental health, attitude and support for professional help-seeking
Distress was reported to be normalized or trivialized by family members. This stemmed from misconceptions about the treatment options rooted in lack of knowledge. Some participants were discouraged by their family members from seeking professional help fearing social stigma.
“I try talking to my parents. They’re very empathetic, but initially, they couldn’t accept it. They told me, ‘It’s okay, this is just part of life. You need to go ahead, you’re just being lazy.” (D-NTS-1)
Past negative experiences of self/others, and apprehensions about consultation process and outcome
Perceived ineffectiveness of treatment in known others had a negative impact on participants’ help-seeking. Past treatment-seekers reported confidentiality being broken by the professionals and felt judged. Apprehensions among those who had not consulted before included fear of being misdiagnosed, being judged, or misunderstood by the professional. Concerns about confidentiality and the professional not being a good fit were reported. Fear of being overwhelmed by discussing the past and difficulty in opening up to a stranger were described as other reasons under this sub-theme. Participants reported not being clear about process to seek help, treatment duration, effectiveness and utility as some other reasons.
“My friends told me that when they spoke to the counsellor in their college regarding private issues, it’s deemed as stupid, and told publicly, and they’ve been shamed even more.”
(D-NTS 1)
Instrumental barriers
Time required to seek help, cost of treatment, distance and unavailability of services nearby were some logistic barriers.
“You don’t know how much it’ll cost you, especially time and distance. A friend of mine who has referred a few locations are very far. Single consultation can be around fifteen hundred rupees. I don’t mind going for one consultation, but it’s also the duration you have to go for.” (D-NTS 4)
Theme: General Barriers
In addition to the personal barriers, responses to participants’ perspectives on general barriers to help-seeking among young adults were also elicited. The sub-themes were similar to personal barriers, including distress perception, preference for self-reliance, self-stigma, poor awareness, past negative experience, apprehensions about the consultation process and outcome and instrumental barriers. However, social stigma also included factors like poor social support and mental health being stigmatized by the popular media. Family perception included poor support and prioritizing physical health over mental health.
While eliciting the general barriers, perceived sufficiency of coping methods emerged as a sub-theme. Participants reported that young adults often rely upon self-help methods and the internet for self-diagnosis and relief from distress. Cultural barriers pointed towards the upbringing, including beliefs inculcated to always being strong, staying ahead of others and restricting the expression of negative emotions.
“In Indian families, you don’t openly talk about such things unless the problem is physical. If you have stomach pain, you tell your parents… but when you have mental health issues, especially male members… Men are told not to show emotions, they just hold it back… they don’t feel good enough…to seek professional help.” (D-NTS 1).
Theme: Personal enablers
Distress perception and increased awareness
Participants reported that increased distress intensity, continuous course, and functioning difficulty would act as enablers of help-seeking. Gaining awareness of one’s mental health condition, types of mental illnesses, treatment options and benefits acted as other potential enablers.
“If I ever feel helpless with my mental health, if I am not able to help myself, my friends are not able to help me, if I don’t have any sense of direction, then I would definitely be more ready to seek help.” (D-NTS 4)
Normalizing professional help-seeking and independence
Participants understood that normalizing help-seeking and having open discussions about mental health played crucial role in consulting a professional. Independence was considered valuable in terms of making one’s own decisions, having financial stability and living away from the family and acted as facilitators.
Enablers related to the organization of mental health services and access to information on the same and instrumental enablers
Assurance of confidentiality, access to information on availability and quality of services in the form of reviews, ratings or a trusted source and clarity on help-seeking process were cited as enablers of help-seeking. Service provided in settings other than a hospital setup, offering first consult free-of-cost, affordability and availability of continued service nearby were reported as additional facilitators.
“A trusted counsellor who is good enough, like I don’t have to take a leap of faith. Also, if the place is close to me. Third, if it’s not too expensive because I know, many counsellors are good but I have to break the bank to pay them which I don’t want to. This is external. Internally, I have many questions like how this works, how does counselling help, and what can I expect going into it. If I have a one-to-one for 15 minutes with counsellor and all these questions are answered…” (D-NTS 4)
Theme: General enablers
When asked about participants’ views on what could help young adults to overcome their barriers and seek help early, sub-themes were similar to personal enablers including distress perception, support and encouragement from significant others and independence. The sub-theme of increased awareness also included the need for mandatory mental health education in academic settings and enhancing family’s knowledge about the same. Normalizing professional help-seeking included sensitive portrayal of mental illness in media. Enablers related to the organization of mental health services and access to information on the same also included assurance of non-judgmental attitude by the professional and provision for anonymous online consult. Sub-themes found only under this category included perceived insufficiency of coping methods and informal sources, and positive past experience of self/others.
“They need moral support and acceptance from family. Second is self-acceptance and awareness that there are mental health conditions like physical conditions. Third is supportive social circle. Instead of commenting on their condition, they should be encouraging the person to initiate and continue treatment till needed.” (D-NTS 3)
Discussion
The present study employed an explanatory sequential mixed methods design to explore the barriers and potential enablers of professional help-seeking among the distressed non-treatment seeking young adults in the urban Indian context. Distress severity on K10 for majority of participants was high showing the success of recruitment method. Creswell and Plano Clark(15) recommend using a collaborative approach for sampling strategies that improve inclusion to increase probability of adequate sample representation. Since this is a hard-to-access sample, only purposive sampling proved insufficient. Thus, snowball sampling was beneficial for the recruitment.
Discrepancy was observed between the K10 scores and perceived distress severity that could have resulted in reporting low inclination to seek professional help while preferring to manage the distress on one’s own. Denial and normalization of distress have been known to delay the awareness and recognition of a mental health problem.(16) There is higher likelihood of endorsing self-stigmatizing beliefs and self-reliance for one’s mental health problems when individuals perceive others as viewing them negatively for seeking professional help.(17) Thus, strength-based approaches targeting self-stigma and self-reliance can facilitate help-seeking process.
Majority of the participants reported experiencing distress for more than six months. This hesitation to seek professional help could be due to multiple barriers as reported in qualitative findings ranging from distress perception to instrumental barriers.(7) The role of educating and increasing awareness regarding mental health conditions and treatment options at an individual, community and systemic level cannot be underplayed. This can help to break the myths by normalizing conversations around mental health and help-seeking.
Most participants preferred seeking help from either a friend or partner, whereas the mean inclination to seek help from parents or other family members was low. The decision to disclose one’s health condition to family depends on their thoughts of how it would affect the family members. In the independent cultures of the West, a person has a greater autonomy, and individual needs are prioritized over the group, whereas, in the interdependent cultures of the East, values of co-operation, collectivism and upholding of group harmony have a greater emphasis.(18) This interplay could lead to hesitation as well as a desire to solicit support from the family members to seek help. Young individuals who believe that professional help needs to be reserved for ‘serious’ conditions prefer seeking help from significant others.(19) Thus, support provided by the peers can play crucial role in encouraging young individuals to consult a mental health professional.(20) Empowering informal support providers by involving them in help-seeking process can prove immensely beneficial considering the impact of significant others on decision-making process for help-seeking in a collectivistic culture.
Confidentiality concerns, fear of being misdiagnosed or judged, professional expertise and service quality have been consistently reported in the past.(9) Majority of the participants reported practical constraints to seek help. The NMHS 2015-16(2) attributed the widespread treatment gap not only to demand-side but also supply-side barriers that could explain the practical constraints in this group. Thus, the help-seeking interventions need to target internal as well as external barriers to seek professional help keeping this population’s preferences in mind.
Higher number of females participated than males in the present study. Internalized masculine norms negatively affect men’s help-seeking behavior,(21) primarily shaped by socio-cultural factors.(22) Considering low help-seeking rates for men, there is an urgent need to develop interventions to address internalized masculine norms to inculcate positive attitude and inclination towards help-seeking.
Several limitations of the study could have impacted the findings. Due to small sample size of the survey participants, the results have limited generalizability. Barriers and enablers across genders may not have been comprehensively captured owing to under-representation of men. Qualitative findings are intended to offer direction for additional research and not for generalizability. Additional themes could have been identified with a larger sample. The sample was restricted to urban context, making it difficult to compare the perceptions in rural context.
Conclusion
This is the first study to highlight a complex interplay of the barriers and enablers of professional help-seeking among young adults in the urban Indian context. It points towards a need for multi-component help-seeking interventions developed explicitly for distressed non-treatment seeking young adults. Present study focuses solely on the distressed non-treatment seeking individuals, a relatively neglected sample in the research community. Qualitative findings provide rich narrative of the sample hesitant to consult a mental health professional and reveal a path towards overcoming these obstacles. Results highlight the opportunities and challenges of nudging these young adults towards appropriate help-seeking to reduce the treatment gap.
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
Acknowledgement: The first author gratefully acknowledges support from the Indian Council of Medical Research, New Delhi, India, for fellowship support for her ongoing doctoral work on help-seeking in young adults.
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