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Asnakew S, Haile K, Kassa BG, Ayehu GW, Beyene GM, Feleke DG, Endalew DG, Legas G, Munie BM, Tedila A, Shiferaw K, Belete A, Chanie ES, Aytenew TM. Patterns of help-seeking behavior among people with mental illness in Ethiopia: a systematic review and meta-analysis. Front Psychiatry 2024; 15:1361092. [PMID: 38563032 PMCID: PMC10982478 DOI: 10.3389/fpsyt.2024.1361092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 02/21/2024] [Indexed: 04/04/2024] Open
Abstract
Background Despite the availability of evidence-based and effective treatments, significant numbers of people living with mental illness do not receive treatment or do not seek help from providers of formal modern treatment. Although numerous primary studies have been conducted on patterns of help-seeking behavior among individuals with mental illness with respect to modern therapy, the evidence has not been aggregated nationwide. Therefore, the aim of this review was to investigate pooled data on patterns of help-seeking behavior among individuals with mental illness in Ethiopia. Methods All available primary studies were searched via the Google Scholar, HINARI, and PubMed databases from June 22 to December 20, 2023; 912 articles were identified. Sixteen articles were included in the final review; data from them were extracted to an Excel spreadsheet and exported to Stata version 17 for analysis. The search terms used were: "Pattern of help-seeking behavior'' OR "Pattern of treatment-seeking behavior" OR "Health care-seeking behavior" OR "Help-seeking intention" OR "Help-seeking preferences" OR "Perceived need" OR "Pathways to psychiatric care", AND "Common mental disorders" OR "Mental illness" OR "Mental health problems" OR "Depression", AND "Predictors" OR "Determinate factors" OR "Associated factors", AND "Ethiopia". The quality of the studies included was critically appraised using the modified The Joanna Briggs Institute (JBI) Joanna Briggs Institute quality assessment tool, adapted for observational studies. During critical appraisal, disagreements between the two authors conducting the assessment were resolved by the involvement of a third author. Effect sizes were pooled using the random effects model, and the presence of publication bias was detected based on asymmetry of the funnel plot and a statistically significant result of Egger's test (p<0.05). Results The pooled rate of positive help-seeking behavior with respect to modern treatment among people living with mental illness was 42.21% (95% CI: 29.29, 55.12; I2 = 99.37%, P=0.00). Factors significantly associated with a positive pattern of help-seeking behavior were: having a secondary education or above (AOR=5.47, 95% CI: 2.33, 12.86); believing that mental illness requires treatment (AOR=2.76, 95% CI: 2.02, 3.78); having strong social support (AOR=2.00, 95% CI: 1.64, 2.44); having a family history of mental illness (AOR=2.68, 95% CI: 1.38, 3.97); having awareness of the availability of treatment (AOR=2.92, 95% CI: 1.56, 5.46); having previously engaged in positive help-seeking behavior (AOR=3.28, 95% CI: 1.63, 6.60); having comorbid disorders (AOR=4.25, 95% CI: 1.69, 10.66); not using alcohol (AOR=3.29, 95% CI: 1.73, 6.27); and the perceived severity of mental illness (AOR=2.54, 95% CI: 1.490, 4.33). Conclusions The majority of people with mental illness in Ethiopia exhibited a poor pattern of help-seeking behavior with respect to modern treatment. Therefore, mobilization of the community should be encouraged via regular public awareness campaigns regarding mental illness and the availability of evidence-based and effective modern treatment in Ethiopia. Moreover, the design of effective community-based mental health interventions is recommended in order to improve public attitudes and rates of help-seeking behavior in relation to mental health problems.
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Affiliation(s)
- Sintayehu Asnakew
- Department of Psychiatry, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Kalkidan Haile
- Department of Psychiatry, Amhara Public Health Institute, Bahirdar, Ethiopia
| | - Bekalu Getnet Kassa
- Department of Midwifery, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Gashaw Wale Ayehu
- Department of Anatomy, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Getnet Mihretie Beyene
- Department of Psychiatry, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Dejen Getaneh Feleke
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | | | - Getasew Legas
- Department of Psychiatry, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Birhanu Mengist Munie
- Department of Psychiatry, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Assasahegn Tedila
- Department of Psychiatry, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Kirubel Shiferaw
- Department of Psychiatry, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Amsalu Belete
- Department of Psychiatry, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Ermias Sisay Chanie
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Tigabu Munye Aytenew
- Department of Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
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Pizzicato LN, Xie RZ, Yang Y, Grabner M, Chapman RH. Real-world treatment modalities, health care resource utilization, and costs among commercially insured patients with newly diagnosed major depressive disorder in the United States. J Manag Care Spec Pharm 2023; 29:614-625. [PMID: 37276037 PMCID: PMC10387971 DOI: 10.18553/jmcp.2023.29.6.614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND: In the United States, major depressive disorder (MDD) is one of the most prevalent mental health disorders. Treatment guidelines for MDD recommend pharmacologic and nonpharmacologic therapies tailored to the patient's disease severity, level of function, and comorbid health conditions. While previous studies examined real-world pharmacologic treatment patterns and costs among patients with MDD, few have examined the use of nonpharmacologic treatments and their association with health care resource utilization (HCRU) and cost. OBJECTIVE: To describe prevalence and associations between patient/provider characteristics and treatment modality and characterize HCRU and cost by treatment modality for patients with newly diagnosed MDD. METHODS: Commercially insured US patients, aged 18-62 years with newly diagnosed MDD between January 1, 2017, and September 30, 2019, were retrospectively identified from the Healthcare Integrated Research Database. Eligible patients were continuously enrolled in the health plan for 1 year before and 2 years after the first MDD diagnosis (index date). Those with co-occurring schizophrenia, bipolar disorder, postpartum depression, substance use disorder, and any prior MDD treatments were excluded. Treatment modalities assessed in the 2-year post-index period included antidepressant only (Rx-only), nonpharmacologic only (non-Rx-only), both antidepressant and nonpharmacologic (combination), and no treatment. HCRU and costs were assessed in the 2-year post-index period by treatment modality. Regression models identified associations between patient/provider characteristics and treatment modality, and the relationship between treatment modality and MDD severity changes. RESULTS: In total, 12,657 patients were included (mean age: 36 years; 60% female). During follow-up, 34% of patients received Rx-only, 25% received non-Rx-only, 28% received combination, and 13% received no treatment. MDD severity at diagnosis (26% mild, 54% moderate, 20% severe) was available for 51% of patients. Post-index inpatient hospitalizations were 11% for those with Rx-only, 10% for non-Rx-only, 16% for combination, and 29% for no treatment, whereas all-cause mean monthly total costs were $792, $633, $786, and $1,292, respectively. In multinomial logistic regression, age, sex, geographic region and urbanicity of patient residence, socioeconomic status, diagnosing provider specialty, and initial diagnosis location were significantly associated (P < 0.05) with treatment modality. In multivariable logistic regression, recipients of Rx-only (odds ratio = 2.03, P < 0.01) or combination (odds ratio = 3.26, P < 0.01) had higher odds of improving MDD severity than patients who received no treatment. CONCLUSIONS: In this real-world sample of commercially insured patients, we observed variations in outcomes by treatment modality and an association between treatment modality and disease severity. Further research is needed to explore the underlying causal relationships between treatment modality and patient outcomes. Study Registration: https://doi.org/10.17605/OSF.IO/YQ6B3 DISCLOSURES: Dr Grabner is an employee of Carelon Research, which received funding from the Innovation and Value Initiative for the conduct of the study on which this manuscript is based. Ms Pizzicato and Mr Yang were employees of Carelon Research at the time the study was conducted. Dr Grabner is a shareholder of Elevance Health. Drs Xie and Chapman are employees of the Innovation and Value Initiative.
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Xie Z, Tanner R, Striley CL, Marlow NM. Association of functional disability with mental health services use and perceived unmet needs for mental health care among adults with serious mental illness. J Affect Disord 2022; 299:449-455. [PMID: 34942217 DOI: 10.1016/j.jad.2021.12.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/29/2021] [Accepted: 12/18/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Approximately 13.1 million U.S. adults experienced serious mental illness (SMI) in 2019. Persons with disability (PWD) have higher risks of SMI. Ensuring adequate access to mental health (MH) services for PWD is imperative to ameliorate this burden. METHODS Using the 2015-2019 National Survey on Drug Use and Health, we obtained study variables for U.S. adults with SMI in the past year and used multivariable logistic regression models to examine the association of disability with MH services and perceived unmet needs. RESULTS The sample comprised 12,532 respondents, representing 11,143,650 U.S. adults with SMI. Overall, PWD had higher proportions of using prescription medications (64.7% vs. 46.2%), outpatient treatment (48.4% vs. 36.5%) and inpatient treatment (8.6% vs. 4.7%) compared to persons without disability; however, the prevalence of perceived unmet MH service needs was also higher (46.3% vs. 39.4%) among PWD. Multivariable logistic regression models showed presence of any disability, cognitive and ≥2 limitations were significantly associated with MH services use (all p<0.01). However, PWD were significantly more likely to report perceived unmet MH service needs (p<0.01 for any disability as well as cognitive, complex activity, and ≥2 limitations). LIMITATIONS Due to data limitations, disability status and SMI may be misclassified for some respondents, and the results may not be generalized to all individuals with SMI. CONCLUSION While PWD were more likely to use MH services, they also had higher odds of unmet MH needs. These results call for more effective and tailored mental health services for PWD.
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Affiliation(s)
- Zhigang Xie
- Department of Health Services Research, Management and Policy, University of Florida, PO Box 100195, Gainesville, FL 32610-0195, United States
| | - Rebecca Tanner
- Department of Health Services Research, Management and Policy, University of Florida, PO Box 100195, Gainesville, FL 32610-0195, United States
| | - Catherine L Striley
- Department of Epidemiology, University of Florida, Gainesville, FL, United States
| | - Nicole M Marlow
- Department of Health Services Research, Management and Policy, University of Florida, PO Box 100195, Gainesville, FL 32610-0195, United States.
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Reinhold AK, Magaard JL, Brütt AL. Influence of established and subjectively perceived as well as evaluated individual characteristics on the utilization of mental health services among individuals with depressive disorders: protocol of a longitudinal study examining how to supplement the "behavioral model of health services use" and on need-congruent use of mental health services. BMC Psychiatry 2021; 21:68. [PMID: 33530953 PMCID: PMC7851814 DOI: 10.1186/s12888-021-03065-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/21/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Approximately one out of every three people in Germany who meets the diagnostic criteria for major depression has contact with mental health services. Therefore, according to treatment guidelines, two thirds of all individuals with depression are insufficiently treated. In the past, the subjective perspective of people who (do not) make use of mental health services has been neglected. Factors related to the use of health services are described in Andersen's Behavioral Model of Health Services Use (ABM). The aim of this study is to supplement operationalizations of subjectively perceived and evaluated individual characteristics in the ABM and to evaluate whether the supplemented model can better explain mental health services use in individuals with depression than established operationalizations. METHODS A representative telephone study with two measurement points will be conducted. In an explanatory mixed-methods design, qualitative interviews will be added to further interpret the quantitative data. A nationwide sample scoring 5 or more on the Patient Health Questionnaire (PHQ-9) will be recruited and interviewed via telephone at T0 and 12 months later (T1). Data on established and subjective characteristics as well as mental health service use will be collected. At T1, conducting a diagnostic interview (Composite International Diagnostic Interview, DIA-X-12/M-CIDI) enables the recording of 12-month diagnoses according to DSM-IV-TR criteria. Ideally, n = 768 datasets will be available and analyzed descriptively by means of regression analysis. Up to n = 32 persons who use or do not use depression-specific health services incongruent with their objective or subjective needs will be interviewed (face-to-face) to better explain their behavior. In addition, theories of non-need-based mental health service use are developed within the framework of the grounded theory-based analysis of the qualitative interviews. DISCUSSION The study intends to contribute to the theoretical foundation of health services research and to specify the characteristics described in the ABM. Thus, after completion of the study, a further sophisticated and empirically tested model will be available to explain mental health services. The identified modifiable influencing factors are relevant for the development of strategies to increase mental health service use in line with the objective and subjective needs of individuals with depression.
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Affiliation(s)
- Anna Katharina Reinhold
- Department of Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.
| | - Julia Louise Magaard
- grid.13648.380000 0001 2180 3484Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Levke Brütt
- grid.5560.60000 0001 1009 3608Department of Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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Schriver E, Lieblich S, AlRabiah R, Mowery DL, Brown LA. Identifying risk factors for suicidal ideation across a large community healthcare system. J Affect Disord 2020; 276:1038-1045. [PMID: 32763588 DOI: 10.1016/j.jad.2020.07.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 05/14/2020] [Accepted: 07/05/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Suicide is the tenth leading cause of death in the United States. Several studies have leveraged electronic health record (EHR) data to predict suicide risk in veteran and military samples; however, few studies have investigated suicide risk factors in a large-scale community health population. METHODS Clinical data was queried for 9,811 patients from the Penn Medicine Health System who had completed a Patient Health Questionnaire-9 (PHQ-9) documented in the EHR between January 2017 and June 2019. Patient demographics, PHQ-9 scores, and psychiatric comorbidities were extracted from the EHR. Univariate and multivariable logistic regressions were applied to determine significant risk factors associated with suicide ideation responses from the PHQ-9. RESULTS One-quarter (25.8%% of patients endorsed suicide ideation. Univariate analysis found 22 risk factors of suicide ideation. Multivariable logistic regression found significant positive associations (Odds Ratio, (95% Confidence Interval)) with the following: younger ages less than 18 years: 2.1, (1.69, 2.60) and 19-24 years: 1.55, (1.29, 1.87)), single marital status (1.22, (1.08, 1.38)), African American (1.22, (1.08, 1.38)), non-commercial insurance (1.16, (1.03, 1.31)), multiple comorbidities (1 comorbidity (1.65, (1.32, 2.07); 2 comorbidities (2.07, (1.61, 2.64)), 3+ comorbidities (2.49, (1.87, 3.33))), bipolar disorders (Type I: 1.38, (1.14, 1.67) and Type II: 1.94, (1.52, 2.49)), depressive disorders (1.70, (1.49, 1.94)), obsessive compulsive disorder (OCD) (1.43, (1.08, 1.90)), and stress disorders (1.53, (1.33, 1.76)). CONCLUSION Community EHR information can be used to predict suicidal ideation. This information can be used to design tools for identifying patients at risk for suicide in real-time.
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Affiliation(s)
- Emily Schriver
- Data Analytics Center, Penn Medicine; Institute for Biomedical Informatics, University of Pennsylvania
| | | | - Reem AlRabiah
- Department of Psychiatry, University of Pennsylvania
| | - Danielle L Mowery
- Institute for Biomedical Informatics, University of Pennsylvania; Department of Biostatistics, Epidemiology, & Informatics, University of Pennsylvania
| | - Lily A Brown
- Department of Psychiatry, University of Pennsylvania.
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Guzmán EM, Cha CB, Ribeiro JD, Franklin JC. Suicide risk around the world: a meta-analysis of longitudinal studies. Soc Psychiatry Psychiatr Epidemiol 2019; 54:1459-1470. [PMID: 31485691 DOI: 10.1007/s00127-019-01759-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/20/2019] [Indexed: 01/20/2023]
Abstract
PURPOSE Suicidal thoughts and behaviors (STBs) have been a persistent problem worldwide. Identifying risk factors for STBs across distinct areas of the world may help predict who or where requires the greatest attention. However, risk factors for STBs are infrequently explored cross-nationally. The present study examined whether psychopathology prospectively predicts STBs across different areas of the world, and whether certain country-level factors moderate the degree of risk conferred. METHODS We conducted a meta-analysis of 71 longitudinal studies from 30 different countries that featured psychopathology-related variables predicting STB outcomes. Meta-regression was used to evaluate whether the following country-level factors modified risk: geographic region, income level, and degree of mental health structural stigma. RESULTS Over 90% of studies had been conducted in North America and Europe. When assessed by country income level, it was found that only one longitudinal study on psychopathology and STB was conducted outside of a high-income country. Moreover, less than 10% of studies were conducted in high structural stigma contexts. Meta-regression findings revealed that the variation in risk effect sizes across studies was not explained by models including country-level factors. CONCLUSIONS Our findings show critical underrepresentation of low- and middle-income countries, which account for a large proportion of global suicide deaths. This reveals a need to broaden the scope of longitudinal research on STB risk, such that countries across more regions, income levels, and degrees of structural stigma are fully accounted for. Such lines of research will improve generalizability of findings, and more precisely inform prevention efforts worldwide.
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Affiliation(s)
- E M Guzmán
- Department of Counseling and Clinical Psychology, Teachers College, Columbia University, 525 West 120th Street, Box 102, New York, NY, 10027, USA
| | - C B Cha
- Department of Counseling and Clinical Psychology, Teachers College, Columbia University, 525 West 120th Street, Box 102, New York, NY, 10027, USA.
| | - J D Ribeiro
- Department of Psychology, Florida State University, 1107 West Call Street, Tallahasee, FL, 32306, USA
| | - J C Franklin
- Department of Psychology, Florida State University, 1107 West Call Street, Tallahasee, FL, 32306, USA
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Fang S, Wang XQ, Yang BX, Liu XJ, Morris DL, Yu SH. Survey of Chinese persons managing depressive symptoms: Help-seeking behaviours and their influencing factors. Compr Psychiatry 2019; 95:152127. [PMID: 31669791 DOI: 10.1016/j.comppsych.2019.152127] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 07/24/2019] [Accepted: 09/09/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To explore help-seeking behaviours of Chinese persons managing depressive symptoms and factors that influence these behaviours. METHODS A survey of residents living in communities in Wuhan, China was conducted using stratified random sampling. The Patient Health Questionnaire (PHQ-2), the Actual Help-Seeking Questionnaire (AHSQ) and a socio-demographic questionnaire were completed by participants. Descriptive statistics were analyzed. A multiple linear regression model was used to explore factors associated with help-seeking behaviours. RESULTS Of the 1785 respondents, 672 (37.6%) reported that they experienced depressive symptoms during the past year, and of these respondents, 517 (76.9%) indicated that they sought assistance. Among help-seeking sources utilized by participants, informal help was sought most frequently (72.9%), followed by hotline/Internet assistance (14.3%), mental health professionals (MHPs) (7.9%) and general physicians (GPs) (3.7%). The results of multilinear regression analysis showed that participants who were adults (aged 25-64 years), attended junior and high school (7-12 years education), and lived in urban areas were more likely to seek additional assistance for their depressive symptoms. CONCLUSION Mental health promotion and education efforts are needed to improve the public's mental health literacy and to promote appropriate utilization of informal sources of assistance in managing depressive symptoms such as a hotline or the Internet. Further interventions need to be considered to reinforce use of social supports and mental health professionals, especially in rural areas.
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Affiliation(s)
- Shu Fang
- School of Health Sciences, Wuhan University, China
| | | | | | - Xiu Jun Liu
- Affiliated Mental Health Center, Tongji Medical College of Huazhong, University of Science & Technology, China
| | - Diana L Morris
- Florence Cellar Associate Professor of Gerontological Nursing, Frances Payne Bolton School of Nursing, University Center on Aging & Health, Case Western Reserve University, USA
| | - Si Hong Yu
- School of Health Sciences, Wuhan University, China
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Ko J. Help-seeking Pathway among Working-Age Adults with Suicidal Ideation: Testing the Integrated Model of Suicide Help-seeking. SOCIAL WORK IN PUBLIC HEALTH 2018; 33:467-482. [PMID: 30451101 DOI: 10.1080/19371918.2018.1546251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Despite a high suicide rate among working-age adults, there is a significant lack of empirical evidence on their help-seeking behavior. This study tested the integrated model of suicide help-seeking to examine help-seeking behavior as a continuous decision-making process. Data were drawn from the 2011 and 2012 National Survey on Drug Use and Health (N = 1,414). Results from structural equational modeling analyses demonstrated that the integrated model fit reasonably well among the sample. Suicide help-seeking behavior is characterized by an inequitable access, where enabling factors affect throughout the help-seeking pathway. The results provide a foundation for future help-seeking interventions.
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Affiliation(s)
- Jungyai Ko
- a School of Social Welfare , Hallym University , Chuncheon , Gangwon-do , Korea
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Roberts T, Miguel Esponda G, Krupchanka D, Shidhaye R, Patel V, Rathod S. Factors associated with health service utilisation for common mental disorders: a systematic review. BMC Psychiatry 2018; 18:262. [PMID: 30134869 PMCID: PMC6104009 DOI: 10.1186/s12888-018-1837-1] [Citation(s) in RCA: 166] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/07/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is a large treatment gap for common mental disorders (CMD), with wide variation by world region. This review identifies factors associated with formal health service utilisation for CMD in the general adult population, and compares evidence from high-income countries (HIC) with that from low-and-middle-income countries (LMIC). METHODS We searched MEDLINE, PsycINFO, EMBASE and Scopus in May 2016. Eligibility criteria were: published in English, in peer-reviewed journals; using population-based samples; employing standardised CMD measures; measuring use of formal health services for mental health reasons by people with CMD; testing the association between this outcome and any other factor(s). Risk of bias was assessed using the adapted Mixed Methods Appraisal Tool. We synthesised the results using "best fit framework synthesis", with reference to the Andersen socio-behavioural model. RESULTS Fifty two studies met inclusion criteria. 46 (88%) were from HIC. Predisposing factors: There was evidence linking increased likelihood of service use with female gender; Caucasian ethnicity; higher education levels; and being unmarried; although this was not consistent across all studies. Need factors: There was consistent evidence of an association between service utilisation and self-evaluated health status; duration of symptoms; disability; comorbidity; and panic symptoms. Associations with symptom severity were frequently but less consistently reported. Enabling factors: The evidence did not support an association with income or rural residence. Inconsistent evidence was found for associations between unemployment or having health insurance and use of services. There was a lack of research from LMIC and on contextual level factors. CONCLUSION In HIC, failure to seek treatment for CMD is associated with less disabling symptoms and lack of perceived need for healthcare, consistent with suggestions that "treatment gap" statistics over-estimate unmet need for care as perceived by the target population. Economic factors and urban/rural residence appear to have little effect on treatment-seeking rates. Strategies to address potential healthcare inequities for men, ethnic minorities, the young and the elderly in HIC require further evaluation. The generalisability of these findings beyond HIC is limited. Future research should examine factors associated with health service utilisation for CMD in LMIC, and the effect of health systems and neighbourhood factors. TRIAL REGISTRATION PROSPERO registration number: 42016046551 .
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Affiliation(s)
- Tessa Roberts
- Centre for Global Mental Health, Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. .,Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Georgina Miguel Esponda
- 0000 0004 0425 469Xgrid.8991.9Centre for Global Mental Health, Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Dzmitry Krupchanka
- grid.447902.cDepartment of Social Psychiatry, National Institute of Mental Health, Prague, Czech Republic ,0000 0001 2322 4988grid.8591.5Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Rahul Shidhaye
- 0000 0004 1761 0198grid.415361.4Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, India ,0000 0001 0481 6099grid.5012.6Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - Vikram Patel
- 000000041936754Xgrid.38142.3cDepartment of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Sujit Rathod
- 0000 0004 0425 469Xgrid.8991.9Centre for Global Mental Health, Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
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Teo AR, Liebow SB, Chan B, Dobscha SK, Graham AL. Reaching Those At Risk for Psychiatric Disorders and Suicidal Ideation: Facebook Advertisements to Recruit Military Veterans. JMIR Ment Health 2018; 5:e10078. [PMID: 29980498 PMCID: PMC6053612 DOI: 10.2196/10078] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/25/2018] [Accepted: 05/13/2018] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Younger military veterans are at high risk for psychiatric disorders and suicide. Reaching and engaging veterans in mental health care and research is challenging. Social media platforms may be an effective channel to connect with veterans. OBJECTIVE This study tested the effectiveness of Facebook advertisements in reaching and recruiting Iraq and Afghanistan-era military veterans in a research study focused on mental health. METHODS Facebook ads requesting participation in an online health survey ran for six weeks in 2017. Ads varied imagery and headlines. Validated instruments were used to screen for psychiatric disorders and suicidality. Outcomes included impressions, click-through rate, survey completion, and cost per survey completed. RESULTS Advertisements produced 827,918 impressions, 9,527 clicks, and 587 survey completions. Lack of enrollment in Veterans Affairs health care (193/587, 33%) and positive screens for current mental health problems were common, including posttraumatic stress disorder (266/585, 45%), problematic drinking (243/584, 42%), major depression (164/586, 28%), and suicidality (132/585, 23%). Approximately half of the survey participants (285/587, 49%) were recruited with just 2 of the 15 ads, which showed soldiers marching tied to an "incentive" or "sharing" headline. These 2 ads were also the most cost-effective, at US $4.88 and US $5.90 per participant, respectively. Among veterans with current suicidal ideation, the survey-taking image resulted in higher survey completion than the soldiers marching image (P=.007). CONCLUSIONS Facebook advertisements are effective in rapidly and inexpensively reaching military veterans, including those at risk for mental health problems and suicidality, and those not receiving Veterans Affairs health care. Advertisement image and headlines may help optimize the effectiveness of advertisements for specific subgroups.
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Affiliation(s)
- Alan R Teo
- HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States.,Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States.,School of Public Health, Oregon Health & Science University and Portland State University, Portland, OR, United States
| | - Samuel Bl Liebow
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States
| | - Benjamin Chan
- School of Public Health, Oregon Health & Science University and Portland State University, Portland, OR, United States
| | - Steven K Dobscha
- HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, United States.,Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States
| | - Amanda L Graham
- Schroeder Institute for Tobacco Research & Policy Studies, Truth Initiative, Washington, DC, United States.,Department of Oncology, Georgetown University Medical Center, Washington, DC, United States
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11
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Wolford-Clevenger C, Frantell K, Smith PN, Flores LY, Stuart GL. Correlates of suicide ideation and behaviors among transgender people: A systematic review guided by ideation-to-action theory. Clin Psychol Rev 2018; 63:93-105. [PMID: 29960203 DOI: 10.1016/j.cpr.2018.06.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/19/2018] [Accepted: 06/20/2018] [Indexed: 11/18/2022]
Abstract
Transgender people are at high risk for suicide ideation, attempts, and deaths compared to the general population. Several correlates of suicide ideation and attempts have been identified empirically to understand this increased risk. However, few attempts have been made to systematically review this literature. Further, a theory to understand and identify targetable factors for intervention has rarely been applied to this population. In the first systematic review guided by ideation-to-action frameworks of suicide, we systematically reviewed the literature from January 1991 to July 2017 regarding correlates of suicide ideation, attempts, and deaths among transgender people. To be included in the review, articles must have been reported in English, reported on empirical data, included a sample or subsample of transgender people, and reported separately on correlates of suicide ideation, attempts, or deaths. Two independent reviewers searched three major databases, references of included articles, and unpublished literature, which produced 45 articles for review. The review suggested that ideation-to-action frameworks would be worth investigating within this population, with attention to sources of psychological pain, social connectedness, and capacity/capability for suicide unique to this population. Additionally, other aspects of cultural identity were often studied (e.g., race, religion), suggesting the need to understand intersectionality of identities among transgender people and their effects on suicide risk. Finally, the review highlighted important limitations of the literature, namely measurement of suicide ideation and attempts and sampling method, which future work should seek to improve.
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12
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House J, Marasli P, Lister M, Brown JSL. Male views on help-seeking for depression: A Q methodology study. Psychol Psychother 2018; 91:117-140. [PMID: 29087607 DOI: 10.1111/papt.12144] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 07/18/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify viewpoints among men with depression about depression and its treatment, consider how these might influence help-seeking behaviour, and generate ideas for interventions and future research. DESIGN Q methodology. METHODS Twenty-nine men with depression completed a Q sort by ranking a set of statements about depression and help-seeking according to their relative agreement with each statement. Factor analysis was used to identify viewpoints relating to male understandings of depression and help-seeking, which were interpreted in the context of participant characteristics and additional information from post-sorting interviews. RESULTS A two-factor solution accounting for 45% of the total variance was considered the best fit for the data. The 2 factors were: (1) Help is available if you can get to the point of asking for it (34% of the variance) and (2) depression should be dealt with in private; help-seeking makes you vulnerable (11% of the variance). Participants who were significantly associated with both factors described a sense of shame, relating to their own or others' views that being depressed and help-seeking are in conflict with socially constructed 'masculine' values, such as strength and self-sufficiency. In the viewpoint represented by Factor 1, however, the benefits of help-seeking outweigh the negatives. In contrast, the viewpoint represented in Factor 2 holds that depression should remain a private struggle and that help-seeking is too risky a move to make. CONCLUSIONS In order to access treatment, men must first recognize depression, then overcome considerable perceived and internalized stigma to ask for help. Improving public knowledge about the nature of depression; positive messages about the act of help-seeking, types of treatment available, and effectiveness of treatments; and work to overcome the challenges posed by long waiting times and other service constraints may increase rates of help-seeking, and represent areas for future research. PRACTITIONER POINTS Interventions to improve recognition of depression symptoms, particularly in the absence of recent negative life events or suicidal ideation, might help to improve help-seeking rates among men. Media campaigns should consider focusing on the positive elements of help-seeking and potential for recovery, and the impact of such campaigns should be evaluated. Improving public knowledge of the types of non-medical intervention that are available for depression may help to increase help-seeking rates. Clinical services and commissioners should be aware of the impact of long waiting times and strict discharge policies on service users, especially those who have difficulty asking for help.
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Affiliation(s)
- Jennifer House
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | | | | | - June S L Brown
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
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13
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Ghorbani F, Khosravani V, Sharifi Bastan F, Jamaati Ardakani R. The alexithymia, emotion regulation, emotion regulation difficulties, positive and negative affects, and suicidal risk in alcohol-dependent outpatients. Psychiatry Res 2017; 252:223-230. [PMID: 28285249 DOI: 10.1016/j.psychres.2017.03.005] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 01/22/2017] [Accepted: 03/03/2017] [Indexed: 01/21/2023]
Abstract
The aim of this study was to evaluate the potential contributing factors such as alexithymia, emotion regulation and difficulties in emotion regulation, positive/negative affects and clinical factors including severity of alcohol dependence and depression connected to high suicidality in alcohol-dependent outpatients. 205 alcohol-dependent outpatients and 100 normal controls completed the demographic questionnaire, the Persian version of the Toronto Alexithymia Scale (FTAS-20), the Difficulties in Emotion Regulation Scale (DERS), the Emotion Regulation Questionnaire (ERQ), the Positive/Negative Affect Scales, the Alcohol Use Disorders Identification Test (AUDIT), and the Beck Depression Inventory-II (BDI-II). The suicidal risk was assessed using the Scale for Suicide Ideation (SSI) and history taking. Alcohol-dependent outpatients showed higher means in alexithymia, difficulties in emotion regulation, suppression subscale, negative affect, and suicide ideation than normal controls. Logistic regression analysis revealed that negative affect, duration of alcohol use, externally-oriented thinking, and severity of alcohol dependence explained lifetime suicide attempts. Depression, impulsivity, severity of alcohol dependence, reappraisal (reversely), externally-oriented thinking, difficulties engaging in goal-directed behaviors, and negative affect significantly predicted the suicidal risk. The findings may constitute useful evidence of the relevancies of alexithymia, emotion regulation, emotion regulation difficulties, and affects to suicidality in alcoholic patients.
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Affiliation(s)
- Fatemeh Ghorbani
- Toxicological Research Center, Department of Clinical Toxicology, Loghman-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Vahid Khosravani
- Psychosocial Injuries Research Centre, Ilam University of Medical Sciences, Ilam, Iran.
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14
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Magaard JL, Seeralan T, Schulz H, Brütt AL. Factors associated with help-seeking behaviour among individuals with major depression: A systematic review. PLoS One 2017; 12:e0176730. [PMID: 28493904 PMCID: PMC5426609 DOI: 10.1371/journal.pone.0176730] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 04/14/2017] [Indexed: 11/01/2022] Open
Abstract
Psychological models can help to understand why many people suffering from major depression do not seek help. Using the 'Behavioral Model of Health Services Use', this study systematically reviewed the literature on the characteristics associated with help-seeking behaviour in adults with major depression. Articles were identified by systematically searching the MEDLINE, EMBASE and PsycInfo databases and relevant reference lists. Observational studies investigating the associations between individual or contextual characteristics and professional help-seeking behaviour for emotional problems in adults formally diagnosed with major depression were included. The quality of the included studies was assessed, and factors associated with help-seeking behaviour were qualitatively synthesized. In total, 40 studies based on 26 datasets were included. Several studies investigated predisposing (age (N = 17), gender (N = 16), ethnicity (N = 9), education (N = 11), marital status (N = 12)), enabling (income (N = 12)), need (severity (N = 14), duration (N = 9), number of depressive episodes (N = 6), psychiatric comorbidity (N = 10)) and contextual factors (area (N = 8)). Socio-demographic and need factors appeared to influence help-seeking behaviour. Although existing studies provide insight into the characteristics associated with help seeking for major depression, cohort studies and research on beliefs about, barriers to and perceived need for treatment are lacking. Based on this review, interventions to increase help-seeking behaviour can be designed.
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Affiliation(s)
- Julia Luise Magaard
- Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
| | - Tharanya Seeralan
- Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Schulz
- Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Levke Brütt
- Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- Department of Health Services Research, Carl von Ossietzky University, Oldenburg, Germany
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15
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Chesin M, Interian A, Kline A, Benjamin-Phillips C, Latorre M, Stanley B. Reviewing Mindfulness-Based Interventions for Suicidal Behavior. Arch Suicide Res 2016; 20:507-27. [PMID: 26983364 DOI: 10.1080/13811118.2016.1162244] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This article describes the rationale for using mindfulness-based interventions (MBIs) to prevent suicidal behavior in high suicide-risk individuals. A narrative review of studies testing the feasibility of MBIs with individuals at risk for suicidal behavior and the effectiveness of MBIs for reducing suicidality was conducted. Studies testing the effectiveness of MBIs for reducing deficits specific to suicide attempters among depressed individuals were also reviewed as were studies examining moderators of MBI treatment adherence and effectiveness to the extent that these might suggest possible limitations to using MBIs with high suicide-risk individuals. Findings from the handful of available studies support targeting suicidal ideation with MBI. Additional studies show deficits associated with suicide attempt, namely attentional dyscontrol, problem solving deficits, and abnormal stress response, are improved by MBI and thus strengthen the rationale for using MBIs with high suicide-risk individuals.
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16
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Sung YK, La Flair LN, Mojtabai R, Lee LC, Spivak S, Crum RM. The Association of Alcohol Use Disorders with Suicidal Ideation and Suicide Attempts in a Population-Based Sample with Mood Symptoms. Arch Suicide Res 2016; 20:219-32. [PMID: 25933091 PMCID: PMC5728356 DOI: 10.1080/13811118.2015.1004489] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Using population-based data, we examined associations between alcohol use disorders (AUD) and suicidality, assessing effect modification by mood disorders, and mediation by drinking level. Suicidality was assessed among current drinkers with 2-weeks of low mood (n = 9,173) in the National Epidemiologic Survey on Alcohol and Related Conditions. Independent of mood disorder, alcohol dependence, was associated with suicidal ideation (adjusted odds ratio [AOR] = 1.64; 95% confidence interval [CI] = 1.25-2.14), and suicide attempts (AOR = 2.02; CI = 1.43-2.85) relative to those without AUD. Findings indicate partial mediation by consumption. Associations between AUD and suicidality among those with low mood are not explained by comorbid mood disorder, but are partially mediated by drinking level. Future studies should evaluate transitions in suicidality with change in consumption.
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17
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Hasin DS, Grant BF. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings. Soc Psychiatry Psychiatr Epidemiol 2015; 50:1609-40. [PMID: 26210739 PMCID: PMC4618096 DOI: 10.1007/s00127-015-1088-0] [Citation(s) in RCA: 274] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/28/2015] [Indexed: 01/12/2023]
Abstract
PURPOSE The NESARC, a "third-generation" psychiatric epidemiologic survey that integrated detailed measures of alcohol and drug use and problems has been the data source for over >850 publications. A comprehensive review of NESARC findings and their implications is lacking. METHOD NESARC was a survey of 43,093 participants that covered alcohol, drug and psychiatric disorders, risk factors, and consequences. Wave 1 of the NESARC was conducted in 2001-2002. Three years later, Wave 2 follow-up re-interviews were conducted with 34,653 of the original participants. Scopus and Pubmed were used to search for NESARC papers, which were sorted into topic areas and summarized. RESULT The most common disorders were alcohol and posttraumatic stress disorders, and major depression. Females had more internalizing disorders and males had more externalizing disorders, although the preponderance of males with alcohol disorders (the "gender gap") was less pronounced than it was in previous decades. A race/ethnic "paradox" (lower risk among disadvantaged minorities than whites) remains unexplained. Younger participants had higher risk for substance and personality disorders, but not unipolar depressive or anxiety disorders. Psychiatric comorbidity was extensive and often formed latent trans-diagnostic domains. Since 1991-1992, risk for marijuana and prescription drug disorders increased, while smoking decreased, although smoking decreases were less pronounced among those with comorbidity. A nexus of comorbidity, social support, and stress predicted transitions in diagnostic status between Waves 1 and 2. Childhood maltreatment predicted psychopathology. Alcohol and drug use disorders were seldom treated; attitudinal barriers (little perceived need, perceived alcoholism stigma, pessimism about efficacy) were more important in predicting non-treatment than financial barriers. CONCLUSIONS Understanding comorbidity and the effects of early stressors will require research incorporating biologic components, e.g., genetic variants and brain imaging. The lack of treatment for alcohol and drug disorders, predicted by attitudinal rather than financial variables, suggests an urgent need for public and professional education to reduce the stigma associated with these disorders and increase knowledge of treatment options.
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Affiliation(s)
- Deborah S Hasin
- Department of Psychiatry, College of Physicians and Surgeons, New York, NY, 10032, USA
- Mailman School of Public Health, Columbia University, New York, NY, 10032, USA
- New York State Psychiatric Institute, New York, NY, 10032, USA
| | - Bridget F Grant
- Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, 5635 Fishers Lane, Room 3077, Rockville, MD, 20852, USA.
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18
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Choi NG, DiNitto DM, Marti CN. Mental health treatment use and perceived treatment need among suicide planners and attempters in the United States: between and within group differences. BMC Res Notes 2015; 8:305. [PMID: 26179170 PMCID: PMC4502636 DOI: 10.1186/s13104-015-1269-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 07/02/2015] [Indexed: 12/19/2022] Open
Abstract
Background Despite many previous studies of suicidal ideation and/or attempts, little research has examined mental health treatment use and perceived treatment need among and within groups of ideators and/or attemptors. We examined mental health treatment use and perceived treatment need in four groups of US adults who had serious suicidal ideation: (1) no suicide plan/no attempt; (2) planned/no attempt; (3) no plan/attempted; and (4) planned/attempted. Methods We compared ideators and nonideators using the 154,923 U.S. residents aged 21 and older who participated in the 2008–2012 National Survey on Drug Use and Health (NSDUH). We then employed logistic regression analyses to discern factors associated with treatment use and perceived treatment need among and within the four groups of ideators (N = 7,348). Results More than 30% of ideators who made suicide plans and/or attempted suicide received no treatment before or after planning or attempting. Racial/ethnic minorities had lower odds of treatment use in all four groups, but major depression significantly increased the odds in all but the no plan/attempted group. Treatment use and substance use disorder increased the odds of perceived need in all four groups. Conclusions The four groups have different rates of treatment access and perceived treatment need that do not appear to be commensurate with their risk level. The findings underscore the importance of treatment access for all those at-risk of suicide, especially racial/ethnic minorities and those of lower SES.
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Affiliation(s)
- Namkee G Choi
- University of Texas at Austin School of Social Work, 1925 San Jacinto Blvd, D3500, Austin, TX, 78712, USA.
| | - Diana M DiNitto
- University of Texas at Austin School of Social Work, 1925 San Jacinto Blvd, D3500, Austin, TX, 78712, USA.
| | - C Nathan Marti
- University of Texas at Austin School of Social Work, 1925 San Jacinto Blvd, D3500, Austin, TX, 78712, USA.
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19
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Integration of peer support and computer-based CBT for veterans with depression. COMPUTERS IN HUMAN BEHAVIOR 2014. [DOI: 10.1016/j.chb.2013.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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