Help Seeking and Mental Health Service Utilization Among College Students With a History of Suicide Ideation

Suicide remains a leading cause of death among young adults in the United States (1), particularly among college students. One in ten college students contemplated suicide during the previous year, and between 1% and 2% made an attempt (2,3). Suicide ideation is sometimes regarded as a transitory phenomenon in youths (4), yet epidemiologic evidence indicates that adolescent suicide ideation often recurs in adulthood (5). Directors of campus counseling centers have observed recent increases in the number of college students exhibiting severe mental health problems (6), including suicidality (7).

Unfortunately, only 28% of U.S. adolescents who reported suicide ideation received counseling in the past year (8). Help-seeking rates are similarly low among college students with suicide ideation (3,9), who typically cite a preference to manage the problem on one's own, fears about what others might think (10), negative attitudes and beliefs about mental health services, and stigma (11) as barriers to treatment.

Help seeking can include both formal professional treatment and informal help, such as help from friends, parents, and informational resources. Few studies have explored informal help seeking by young adults. Australian researchers asked youths about recent problems that caused them “considerable distress” and found that students sought help more readily from informal sources than from professionals (12).

This study used a novel life history interview method to examine a broad range of help-seeking behaviors among college students with a lifetime history of suicide ideation. We also explored the degree of continuity between precollege and college experiences of psychological distress and help seeking, examined the sociodemographic correlates of service utilization, and described barriers to treatment among students with an unmet need for help.

Methods

This study was a supplement to the College Life Study (CLS), a longitudinal study of health risk behaviors by 1,253 students assessed annually beginning in their first year in college (13). CLS participants (N=182) who reported suicide ideation at least once on the Beck Depression Inventory (BDI) in years 1 through 4, lifetime suicide ideation in year 4, or both were invited to participate in a 30-minute interview sometime during 2009. The University of Maryland Institutional Review Board granted approval for the study, and written informed consent was obtained.

The interview consisted of questions developed and piloted for this study to assess lifetime episodes of psychological distress and help-seeking behavior. Participants were asked about times in their lives when they felt in need of any type of help or treatment for problems with their emotions, nerves, or mental health, broadly defined as episodes of psychological distress. [A chart outlining the format of the interview and a description of the interview procedure are included in an online appendix to this report at ps.psychiatryonline.org.]

Summary variables were computed for total number of episodes of psychological distress, age at first episode, and the presence or absence of an episode before the start of college and after the start of college. Analyses were conducted in Stata 10.

Lifetime help-seeking data were consolidated into two binary variables representing any use of informal help or formal treatment, respectively. Formal treatment included services provided by health professionals, counselors, campus- or community-based health or counseling centers, hospitals or other facilities, law enforcement officials, support groups, rehabilitation clinics, or hotlines. Informal help was defined as talking to friends, family members, significant others, or other trusted adults or clergy; conducting Internet research; reading self-help books; or engaging in prayer.

The average BDI score from the four annual CLS assessments was used as an indicator of depression severity. Possible scores range from 0 to 63, with higher scores indicating more depressive symptoms. The BDI has good psychometric properties when used with young adults (14).

Data about demographic characteristics collected in the parent study included gender and self-reported race. Socioeconomic status was approximated by the mean adjusted gross income for the zip code of the participant's permanent residence (publicly available data).

Results

A total of 158 of the 182 (87%) eligible students, ranging in age from 21 to 24, completed the 30-minute interview assessment; 102 were female, 97 were white, and ten were Hispanic. According to their BDI responses from the CLS, 94 individuals had had suicide ideation since starting college; the remaining 64 had ideation sometime in their lives, but of indeterminate timing. Of the 94 with ideation in young adulthood, 25 (27%) sought treatment in both adolescence and young adulthood, and another 28 (30%) sought treatment for the first time in young adulthood. The remaining 41 (44%) did not seek treatment during young adulthood. Of those, 31 (76%) had never sought treatment in their lifetimes, and ten had sought treatment in adolescence.

Most participants (N=151, 96%) reported at least one lifetime episode of psychological distress. Almost two-thirds (N=94, 62%) had their first episode in adolescence. A majority (N=138, 91%) experienced an episode after starting college, and more than half (N=81, 54%) experienced an episode in both college and adolescence. Thus of the 138 students who reported an episode of psychological distress in college, 81 (59%) also experienced at least one earlier episode in adolescence.

Of the 151 individuals who ever experienced an episode, 110 (73%) received formal treatment, 131 (87%) received informal help, 92 (61%) received both types of help, 39 (26%) received only informal help, 18 (12%) received only formal help, and two (1%) neither sought nor received any type of help. The likelihood of seeking treatment was similar regardless of whether the distress occurred in adolescence or young adulthood (66% versus 65% of individuals, respectively). Of the 81 individuals who reported episodes in both adolescence and young adulthood, those who received formal treatment in adolescence were significantly more likely to receive treatment for a later episode compared with those whose adolescent episode was untreated. Of the 51 who received formal treatment for the earlier episode, 42 (82%) received formal treatment in young adulthood, compared with 14 of the 30 (47%) individuals who did not receive formal treatment as an adolescent (p=.001).

Correlates of obtaining treatment were examined by comparing characteristics of the 39 individuals who sought only informal help with those of the 110 individuals who obtained treatment (Table 1). Obtaining treatment was associated with more lifetime episodes of psychological distress (3.1 versus 2.5, p=.05) and younger age at first episode (15 versus 18, p<.01). Stressful life events were the most commonly cited reason for episodes by those who did and did not obtain treatment (71% and 80%, respectively). Both depression and anxiety were positively associated with obtaining treatment; depression was reported by 66% of those who sought treatment compared with 33% of those who received only informal help (p<.05). Anxiety was reported by 21% of those who sought help compared with 5% of those who did not (p<.05). Neither involvement with alcohol or drugs nor average BDI score in college was related to treatment seeking.

Of the 149 individuals who sought any help, 97 (65%) sought help from family, 81 (54%) from friends, 56 (38%) from private psychiatrists, and 49 (33%) from private psychologists. Despite the popular notion that the Internet is often a resource for young adults, few used Internet research (N=14, 9%) or participated in an Internet group (N=1, 1%). Other informal resources mentioned were a significant other (N=34, 23%), trusted adult (N=20, 13%), self-help books (N=9, 6%), clergy (N=6, 4%), prayer or religion (N=5, 3%), and book research (N=2, 1%). Other formal resources accessed were private medical doctor (N=16, 11%), private social worker (N=15, 10%), hospital (N=14, 9%), other private professional (N=13, 9%), emergency room (N=9, 6%), support group (N=8, 5%), guidance counselor (N=5, 3%), law enforcement (N=4, 3%), drug or alcohol clinic (N=3, 2%), mental health clinic (N=3, 2%), hotlines (N=1, 1%), and residential treatment (N=1, 1%).

Of the 138 individuals who experienced an episode after starting college, fewer than half (N=56, 41%) accessed campus-based resources.

A total of 67 (44%) individuals who ever experienced an episode felt they needed more treatment than they received. The barrier cited most commonly for not getting the treatment they needed was uncertainty about the need for help, treatment effectiveness, or importance of treatment. Examples of this barrier were thinking they could handle the problem without treatment (N=39, 58%), not having time (N=28, 42%), and thinking that treatment would not help (N=24, 36%). Stigma-related barriers, such as a fear that getting treatment might cause people to have a negative opinion of the young adult (N=26, 39%), and logistical barriers, such as not knowing where to get treatment (N=16, 24%), were also common. One-third (N=22, 33%) cited financial barriers.

Discussion

In this retrospective study of college students with a history of suicide ideation, 73% obtained formal treatment at least once for an episode of psychological distress. Two major findings emerged. First, there was a large degree of continuity in psychological distress experiences between adolescence and young adulthood, given that 59% of young adults who reported episodes of psychological distress in college also experienced psychological distress in adolescence. For college mental health providers, this finding underscores the importance of conducting careful lifetime assessments rather than attributing problems to more immediate environmental or social circumstances.

Second, 44% of individuals who experienced suicide ideation since the start of college did not seek treatment for the problem at that time, a finding that points to a significant unmet need for services in the college population. Although it is encouraging that 73% of the young adults obtained treatment at least once in their lives, it is apparent that services were not accessed every time they were needed. Of particular concern are the ten individuals who sought treatment as adolescents but for some reason did not access treatment later when they experienced suicide ideation in young adulthood.

One implication of the findings is that adolescents and young adults who have accessed care in the past might benefit from outreach activities over time to facilitate an ongoing connection to a source of help should the need arise. The finding that treatment seeking in college was more likely if the individual had had some experience before college with treatment comports with research linking previous mental health care to future treatment-seeking intentions (11). Although the link between previous and future mental health care might reflect differences in severity, help-seeking propensity, or other factors, it is equally plausible that early experiences with professional treatment could facilitate future help seeking—especially if those experiences were positive.

As others have found (10,11), the most frequently cited barriers to receiving treatment were attitudes and beliefs, such as a desire to self-manage the problem, time pressures, and stigma-related fears. Many of these attitudes reflect an apparent lack of urgency of perceived need, an absence that is especially concerning considering the presence of suicide ideation. Educational efforts to raise awareness might help to change such beliefs in the general population of college students, but targeted approaches might also be warranted. For example, providers could perform proactive outreach to high-risk young people previously in care and support parents interested in fostering ongoing, open discussions with their high-risk child about treatment-related beliefs and reinforcing positive, accepting attitudes toward treatment.

Participants accessed a wide range of formal and informal helpers—parents, friends, significant others, and health care providers all had opportunities to recognize students' unmet needs and facilitate treatment access. Findings highlight the need to bolster the capacity of these potential gatekeepers to assist students with locating resources and undertaking an appropriate course of treatment. Perhaps the most important gatekeepers are parents, whose unique understanding of their child's mental health history equips them to encourage proper continuation of care over time, such as by encouraging periodic mental health “check-ups.”

Yet parents need more evidence-based information about what to expect from a child who has experienced suicide ideation in adolescence and how best to exercise vigilance during stressful times. They might benefit from innovative methods like the American Foundation for Suicide Prevention's interactive screening program to identify students at risk for suicide (9). Even when their child is away at college and has attained legal adult status, parents can maintain open lines of communication and assist their child in identifying and accessing appropriate resources on or off campus.

Limitations of this study include uncertain generalizability and insufficient sample size for some comparisons, for example, between individuals with transient versus recurrent suicide ideation or early versus late onset of psychological distress. Future research should evaluate the predictive value of episodes of psychological distress and treatment experiences during adolescence on outcomes in college. Because BDI scores were obtained independently of treatment, we cannot make inferences about treatment-related changes in depressive symptoms.

Conclusions

Among this cohort of college students with a lifetime history of suicide ideation, episodes of psychological distress in young adulthood were often part of a recurring pattern of distress that had its onset in adolescence. Among students experiencing suicide ideation in college, nearly half had an unmet need for services during that time. It is important to recognize and respond to signs of psychological distress during adolescence and assess the need for continued treatment among college students.

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