Mental health help-seeking barriers, facilitators and interventions. A systematic review


 Background: Increasing rates of mental health problems among adolescents are alarming. Teens who are most in need of mental health attention are reluctant to seek help. A better understanding of the help-seeking in this population is crucial to overcome this gap. Methods: Five databases were searched to identify the principal barriers, facilitators and interventions targeting help-seeking for common mental health problems in adolescents aged 10-19 years. The search was performed in June 2018 and updated in March 2019. Two independent screening processes were made using the eligibility criteria. Quality assessment of each study was performed and findings summarised using a narrative synthesis. Results: 90 studies meet the inclusion criteria for this review for barrier and facilitators (n=54) and interventions (n=36). Stigma and negative beliefs towards mental health services and professionals were the most cited barriers. Facilitators included previous positive experience with health services and mental health literacy. Most interventions were based on psychoeducation, which focused on general mental health knowledge, suicide and self-harm, stigma and depression. Other types of interventions included the use of multimedia and online tools, peer training and outreach initiatives. Overall, the quality of studies was low to medium and there was no general agreement regarding help-seeking definition and measurements. Conclusion: Most of interventions took place in an educational setting however, it is important to consider adolescents outside the educational system. Encouraging help-seeking should come with the increased availability of mental health support for all adolescents in need, but this is still a major challenge for Child and Adolescent Mental Health Services. There is also a need to develop shared definitions, theoretical frameworks and higher methodological standards in research regarding help-seeking behaviours in adolescents. This will allow more consistency and generalisability of findings, improving the development of help-seeking interventions and ensuring timely access to mental health treatments.


Introduction
Young people present with the highest prevalence of mental health disorders compared to individuals at any other stage of the lifecycle [1], with up to 20% of adolescents likely to experience mental health disorders [2]. Around 50% of mental health conditions start before the age of 14 [3] and the onset of 75% of cases is before the age of 18 [4]. The most common diagnoses are depression and anxiety [4][5] and around 25% of young people experience psychological distress [6]. Depression is one of the principal causes of illness and disability in teenagers, and suicide is the third most common cause of death among older adolescents [3]. Mental health problems can significantly affect the 6 For the purpose of this review, help-seeking was defined as the action of actively searching for help for mental health problems, including informal (family, friends) or formal (GP, mental health professionals, etc.) sources, based on interpersonal and social abilities [11]. "Adolescents" were people aged 10 to 19 years, as defined by the World Health Organisation [3]. This review was prospectively registered on PROSPERO (CRD42018096917) and reported in accordance with the PRISMA guidelines [17]. The search terms were developed using the PICO structure, then expanded using MeSH terms and combined using Boolean operators. Four databases were selected including MEDLINE®, Embase, PsycINFO, and Web of Science, as well as the search engine Google scholar. Grey literature from the mentioned databases was also included and a search was carried in Open Grey. An initial version of the proposal for this study was reviewed by the McPin Foundation. The feedback was considered in the developmental stage, in order to evaluate the relevance and reception of the protocol by Patient and Public Involvement (PPI) organisations.
We included studies published in English, Spanish and French and focused on identifying barriers, facilitators and interventions targeting help-seeking behaviours for mental health problems in adolescents, specifically depression, anxiety, suicidal ideation, emotional distress and general symptoms of mental illness. Other mental health problems such as psychosis, anorexia, among others were excluded, because we decided to focus on most prevalent mental health problems which share a more similar help-seeking process. All study designs were considered, including feasibility studies and study protocols. We excluded studies that referred to young people over the age of 19 or children under 10 years old. When study populations included adolescents outside of the established age range, the paper was included if over 50% of the individuals in the sample were within the 10-19 years category or if separate outcome data was provided for the participants in this age range. Studies meeting the inclusion criteria and including parents in their sample were also considered. Finally, other exclusion criteria were articles written in other languages, or if the intervention did not explicitly target help-seeking behaviours or was not related to mental health conditions (Appendix S1)..
Once the search was performed, the results were exported to EndNote X8 and duplicates were removed. Titles and abstracts were screened by one author (AA) at the first stage. At a second stage, two authors (AA and IS) checked the full articles using the pre-determined inclusion and exclusion criteria. A third member of the research team (MJ) was available to solve discrepancies. Authors were when relevant information was missing or when we could not find the articles retrieved by the databases. Reference list of all included studies were screened in case we found other studies relevant to our review. Data were extracted using a predefined form, which allowed the research team to identify the main characteristics of each study. This process was executed by one author (AA) after a complete review of the included papers, and an independent data extraction process was performed for each of the two questions. For the first question, data extraction focused on identifying barriers and facilitators and for the second question, intervention and effect size when reported. We created an additional form to extract data regarding the secondary outcome (age and sex). For the quality assessment, we used the Joanna Briggs Institute Critical Appraisal Checklist [18] and the Mixed Methods Appraisal Tool (MMAT) [19], which were appropriate due to the variety of study designs included in this review; both have been previously validated [20][21]. The Joanna Brigss tool has a number of checklists to evaluate the main features of each study design. We used the checklist for cross-sectional studies, RCT, quasi-experimental studies and qualitative studies. Each checklist had a number of item to evaluate the most relevant aspect of the specific design (e.g: for RCT was allocation to treatment groups concealed? Were treatment groups similar at the baseline?). After completing the checklist an overall quality appraisal score was calculated to provide a measure (low, medium and high) of the quality of each study.
The MMAT included a similar checklist but is specific to mixed method design. Overall study quality was not used as an exclusion criteria because we opted to be overly inclusive and provide a thorough overview of help-seeking in adolescents. Results have been summarised using a narrative synthesis. We identified the most relevant features regarding help-seeking barriers, facilitators and interventions. These features were grouped into themes that capture the essential aspects regarding the main outcome of this review. Due to the heterogeneous nature of the studies included, a meta-analysis was not conducted.

Results
Two independent searches were carried out during June 2018 and then updated in March 2019. A total of 90 studies were included in this review, combining both barriers and facilitators (n = 54) and the intervention (n = 36) questions. PRISMA diagrams displaying the number of papers retrieved and the process of selection of the included studies is available in Figures 1 and 2. Regarding the inter-rater reliability for this review, the agreement between the researchers screening the papers was high, with a 85% accuracy and 95% precision (Kappa = 0.954). Disagreement on twelve studies was attributed mainly to differences concerning the definition and measurement of help-seeking, and was resolved in a discussion with a third author (MJ) not involved in the process of screening.
Three articles included adolescents and their parents, while one article included just adolescents' mothers. Three studies focused on the rural population, and six studies on minority ethnic groups, refugees and immigrants.
The majority of studies were conducted in educational settings, such as schools (n = 24) and tertiary education (n = 11) focusing in non-clinical samples. Sixteen studies included participants from other community settings and two studies were conducted in mental health care facilities. Among the studies that include actual help-seekers (n = 7), the most common reason for seeking help was suicidal ideation, self-harm, depressive symptoms, and general mental health concerns (e.g., anxiety/nervousness/fear). Therefore, the conclusion drawn by the majority of the articles were based on help-seeking intentions rather than actual behaviours, since the participants were not experiencing mental health problems and focused on hypothetical scenarios.
More than half of the included studies (n = 30) made reference to stigma and other negative attitudes towards mental health problems as the main obstacle to help-seeking behaviours in adolescents. Of these, twenty-five studies referred to stigma as the primary obstacle, describing it through different concepts such as, "stigma", "fear of stigmatisation", "community stigma", "perceived stigma" and "self-stigma. Other negative attitudes towards mental health problems included shame, fear, and embarrassment.
Moreover, fears of adverse reactions from others may also act as a prominent barrier. For instance, Ijadi-Maghsoodi and colleagues (2018), found that the fear of being judge as not being able of "handling your own problems" and being judge of being wimp and weak, prevented adolescents of seeking help for mental health problems [69].
The second most mentioned barrier was associated to adolescents' family beliefs toward mental health services and treatment (n = 15). Barriers related to problem with communication and distrust towards health professionals, negative past experiences with mental health services, and believing that the treatment is not going to be helpful. This was especially true for studies including immigrant and refugee populations, which referred to cultural barriers including mistrust of mental health diagnosis and practitioners, and lack of cultural sensitivity in services as a significant barrier.
Almost one-third of the articles (n = 14) referred to problems related to mental health literacy as a significant barrier, including poor recognition of mental health conditions (self and others) and lack of awareness of available sources of help. Adolescents' attitudes towards help-seeking revealed a perceived need of self-sufficiency and autonomy were recognised as a relevant barrier in twelve studies, as well as fears of confidentiality breaches. Six studies focused on the relationship between symptomatology and help-seeking. These found that higher levels of psychological distress, suicidal ideation and depressive symptoms were linked to lower help-seeking behaviours.
To a lesser extent, problems regarding service and personnel availability and other structural factors (such as cost, transportation and waiting times) were mentioned as obstacles to help-seeking (n = 8). Most of the studies did not identify these structural elements. However, it was a significant barrier for studies including rural and immigrant populations, and in studies that included parents in their sample.
Of the 56 included studies, 19 also referred to facilitators of help-seeking behaviours.
Mental health literacy and prior mental health care were the most cited facilitators for help-seeking for mental health problems (n = 10). Specifically, timely access to mental health was facilitated by having a previous positive experience with mental health services or help-seeking, being familiar with the sources of help, and good symptom and problem recognition. Higher engagement with the community and having a trusting and committed relationship with relevant adults such as parents, school teachers and counsellors also facilitated seeking help among adolescents. Further details of the included articles are available in Table 1.

Secondary outcome
Few studies identified a significant difference when comparing younger and older adolescents in relation to barriers and facilitators to help-seeking, with no conclusive findings being reached. Some findings suggested that older adolescents tended to establish to feel more comfortable with people with mental health issues [77], and had less help-seeking fears [36]. In contrast, younger adolescents had greater knowledge about professional sources of help [30]. Only one study found a significant difference between ages regarding help-seeking, with younger adolescents reporting higher [ Table 1] Question 2: Help-seeking interventions Thirty-six studies on interventions targeting help-seeking behaviour were included in the review ( Table 2). All studies were conducted in educational setting including high school (n = 35) and college (n = 1). The majority of studies developed interventions for nonclinical samples, and their focus was the prevention of mental health problems and the promotion of healthy coping strategies via help-seeking behaviours. Outcomes varied between help-seeking intentions, attitudes and behaviours. Almost half of the studies focused on the effectiveness of the interventions, while sixteen were feasibility or pilot trials and study protocols. Most of the studies used a quasi-experimental design (n = 21) followed by randomised controlled trials (n = 15). The age of participants ranged from 11 to 19 years old, although one study that included participants under 29 years old was incorporated as more than half of the sample were adolescents. The sample size ranged from 14 to 6551 participants. Most studies had a comparison group (no intervention, waiting list and other interventions) and eight had no control group. Interventions were delivered using four main methods: psychoeducation, outreach interventions, multimedia tools and peer leader training. Four interventions targeting help-seeking for suicide were identified within five studies.

Types of intervention
One was a suicide awareness programme [83], prompting adolescents to seek help from adults by focusing on psychoeducation. Three suicide prevention programmes focused on increasing mental health literacy and providing guidance about formal sources of help [84-85-86-87].
Five interventions explicitly targeted help-seeking for depression in school-based settings their focus being to educate the school population about adolescent depression and thereby encourage help-seeking [88-89-90-91-92].
Two studies evaluated the effectiveness of an intervention combining depression awareness and a suicide prevention programme focused on providing general information about teen depression, including recognising early signs of suicide risk, help-seeking strategies for self and others, promoting early identification and self-referral [93][94].
Six classroom-based interventions addressing stigma were identified, two of which used psychoeducation to overcome myths regarding mental illness [95][96] and four focused on providing interpersonal contact with people with mental health conditions in order to improve acceptance and increase help-seeking intentions [97-98-99-100]. One intervention [99] had a particular focus on the male population within the school setting, working with male role modelling and normalisation of mental health problems.

Outreach interventions
Three studies used outreach interventions to target mental health help-seeking [101- [102][103]. These aim to establish contact with adolescents who may be experiencing psychological and emotional distress in order to help them get the attention they need and increase their access to health services. They were based on the Building the Bridges to General Practice (BBGP) programme, developed by Wilson et al. (2005), a programme that aims to target help-seeking obstacles for physical and psychological problems by promoting contact between high school students and general practitioners [104].

Multimedia interventions
Six types of multimedia interventions have been developed to address some of the difficulties of reaching an adolescent population, such as fear of confidentiality breaches, stigma and self-reliance [77-105-106-107-108-109].
The interventions included interactive films to engage students with mental health related topic and online platforms providing personalised information regarding the decision-aids process.

Peer training interventions
Peer training interventions focused on the training of peers who act as active agents of change and social interactions incorporated into the daily activities within the school environment [110]. These interventions are based on the notion that most adolescents are more likely to seek emotional support from friends; therefore, targeting specific individuals within the school context could be crucial in terms of enhancing mental health literacy, social connectedness and appropriate help-seeking behaviours. All three programmes followed similar principles concerning improving the climate around mental health problems, promoting social connectedness, and challenging norms and behaviours associated with help-seeking [111-114-115-116]. "Peer leaders" acted as a link between the student population and mental health literacy, promoting the acceptability of seeking for help for mental health problems. Further details of the included articles are available in Table 2.

Secondary outcome
No studies referred to significant differences concerning the effectiveness of help-seeking interventions when comparing ages. No significant gender differences were identified regarding the effectiveness of the help-seeking interventions [83-95-97-105]. However, before the intervention females tended to have higher mental health literacy and more adaptive attitudes regarding mental health problems , including greater helpseeking knowledge and intentions [101-106-107].

Effectiveness
The main goal of this review was to describe the interventions targeting help-seeking in adolescents and therefore did not include an analysis of their effectiveness. Almost half of the included studies were study protocols and feasibility studies, so effect sizes were not reported. However, some findings are worth mentioning.
Four studies which looked at effectiveness of the interventions focused on psychoeducation about depression found a significant effect in increasing help-seeking.
The three studies that looked at the effectiveness of stigma reduction identified positive effects of the intervention on help-seeking. Two studies [95-98] found a significant reduction in self-stigma surrounding seeking help after the intervention (p0.05) and one study [97] found a significant effect of the intervention in help-seeking intentions (Wilks' =.942, F (4,417) = 6.428, p0.001).
Finally, all the studies that focused on outreach found a significant effect of the intervention in help-seeking intentions. One detected an increase in intentions at three months follow-up (F(2,217) = 3.04/ p0.05) [102], Rughani [101] found short terms improvements in help-seeking intentions (F (14,225) = 1.87 p <.03)and Wilson [103] found a significant effect in the intention of seeking help for psychological problems after the intervention (F(2,598) = 4.31 p0.01).

Quality assessment
The majority of the studies were low to medium quality with moderate to high risk of bias. Overall there was inconsistency regarding the measurements of help-seeking, with most of the studies focusing on help-seeking intentions, which is not necessarily related to future behaviours. Moreover, many studies did not use valid and reliable instruments for measuring help-seeking. This is especially true for the experimental studies since most of them developed tools focused on their intervention rather than standardised help-seeking measures. Finally, most of the studies only used self-report measures, increasing the risk of bias of the findings. We did not assess the quality of study protocol, feasibility studies and pilot studies.

Question 1: Barriers and facilitators
This review focused on identifying barriers, facilitators and interventions targeting helpseeking behaviours in adolescents. Consistent with previous findings [1], the most prominent barrier identified was stigma. Negative attitudes and beliefs about mental health services and professionals was the second most prominent barrier. Trusted and strong relationships with possible gatekeepers (teachers, parents, GPs, health professionals, etc.) and prior positive help-seeking experience were the most cited facilitators.
Few studies related symptom severity with help-seeking. Of those that did, higher symptomatology was associated with lower help-seeking intentions and behaviours. This is in line with previous studies suggesting that teens who are most in need are less likely to seek help [1-10-12]. It is possible that the nature of mental health symptoms such as selfblame, emotional distress, difficulty in speaking to others and diminished cognitive ability contribute to lower help-seeking behaviours. Adolescents with higher symptom severity may be even more vulnerable experiencing difficulties with the help-seeking process in areas such as identifying the need for professional assistance or fear of stigmatisation. This could be due to higher rates of isolation and exclusion from their peers. Increasing mental health literacy among this population may provide a way of improving social support between peers [115].
There are structural barriers affecting the help-seeking process that go beyond attitudes, for example, costs, waiting times and transportation. These barriers were not among the most prominent reasons cited in the research review; however, this may be related to the limited amount of studies that included parents' perceptions. A previous review, which focused on the parents of children and adolescents, concluded that structural barriers were the most relevant [116]. This suggests that adolescents are less worried about the practical implications of accessing help for mental health problems and are more affected by being attitudinal barriers, but that structural barriers may be more relevant to parents.
Key facilitators to help-seeking should be considered when creating new interventions such as trusted relationships with gatekeepers, and familiarisation with the help-seeking process. However, the lack of studies focusing on facilitators precludes many conclusion being drawn. The majority of studies used sub-clinical samples an/or hypothetical helpseeking scenarios rather than asking genuine help-seeker with mental health problems who could refer to the real circumstances leading them to ask for help. More research including young people who have sought help from services would be useful in understanding the idiosyncrasies of this process.
These findings provide a useful overall picture of the relevant factors influencing the helpseeking process in adolescents. However, the included studies did not share a clear definition and framework regarding help-seeking. A wide range of tools were used to measure help-seeking, varying in their validity and reliability, and also in the constructs they measured. This limits the generalisability of the findings and the our understanding of the help-seeking process. Rickwood & Thomas (2012) have proposed a framework regarding help-seeking, identifying the different parts of the process, sources of help, types of help and main concerns [11]. In the future, sharing such a framework could be a useful means to reach a general agreement regarding the definition of help-seeking and its components. Most of interventions studies included on this review did not investigate mechanisms of change with regards to help-seeking behaviour. The relevance of studying underlying mechanisms and practical requirements related to the functionality of interventions has been previously discussed [117], and most of the interventions included in this review did not refer to these processes. Identifying such mechanisms could help understand how interventions work, enlightening and optimising the process of decision-making and design [87]. Adolescence is a period essentially characterised by emotional, behavioural, hormonal, and neuronal changes [118][119]. Interventions congruent with the developmental stages may be useful to target age-appropriate factors.
All interventions were conducted within an educational setting. Special attention should also be paid to young people outside of the educational system, who are particularly vulnerable in terms of economic and social deprivation [103]. Around one in five children and adolescents are out of school according to the UNESCO [121], with psychosocial factors appearing to obstruct traditional educational trajectories [122]. Health and mental health conditions have a relevant role in terms of absenteeism and truancy [123].
Adolescents experiencing symptoms of depression and anxiety or in charge of a chronically sick relative can be more prone to avoid school and stay at home. These children can be even more vulnerable and harder to reach, and there is a lack of collaborative effort attempting to overcome this situation. Encouraging partnerships between the health and educational systems, community settings, youth detention centres, among other institutions providing social care, should be promoted with the purpose of supporting mental healthcare and provision for young people [124].
Encouraging adolescents to seek help for mental health problems is a key priority however, this does not resolve the discrepancy between needs and resources worldwide [124][125]. "Mental health services for children and adolescents have internationally been poorly understood, underfunded and even neglected by governments" [126, p.92]. This may be associated with the lack of a general understanding of this population's needs (including developmental issues), and the "implementation gap", referring to the challenges of translating evidence to health service development and practice [126].

Limitations
This review has a number of limitations. First, we included 5 databases and one search engine, so it is possible that some relevant articles were not captured by our search strategy. We addressed this by hand searching the reference lists of all included studies and developed an over-inclusive search strategy. Second, only one author performed the data extraction and critical appraisal of papers therefore the data analysis is at risk of some subjectivity. Third, there is an increasing debate regarding the age that adolescence comprises, with some suggesting the age should be extended to 10 to 24 years old [129].
However, we decided to follow the definition of adolescent stablish by international organisation including the OMS and UNICEF. A significant number of papers were excluded considering our age range (n = 104). Defining adolescence as a period between 10 to 19 years old could be a limitation to our study. Fourth, this review focused on common mental health problems such as depression, anxiety and emotional distress and excluded psychiatric conditions such as anorexia, schizophrenia and substance misuse, mainly due to the particular nature of the help-seeking processes. However, the exclusion of substance misuse problems could be seen as a limitation of this study due to its high prevalence in adolescence, making it a particularly sensitive issue during this period of life [130]. Finally, this review prioritised the overinclusion of studies to have an overall picture of the existing evidence regarding help-seeking for mental health problems in adolescents. As a result, low quality studies were included in the analysis and may affect the interpretation of the findings.

Conclusion
In conclusion, stigma and negative beliefs about mental health services appear as the most significant barriers to help-seeking, whereas previous positive experiences with services and good mental health literacy are the most relevant facilitators. There are a number of interventions being developed to promote help-seeking for mental health problems in adolescents, and most of them take place in high education settings. They include a range of delivery methods including psychoeducation, stigma and depression awareness campaigns, online tools and peer training. Since such initiatives are relatively new, there is a need for more trials, with longer follow-up periods and the use of reliable and validated tools focused in future help-seeking behaviour. Despite school seeming to be the ideal setting for deploying these interventions, it is important to consider adolescents outside the school system who may be in more need of attention for psychosocial and mental health problems.  "EspaiJove.net"-a school-based intervention programme to promote mental health and eradicate stigma in the adolescent population: study protocol for a cluster