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Perceived Need and Help-Seeking in Adults With Mood, Anxiety, or Substance Use Disorders
Ramin Mojtabai, MD, PhD;
Mark Olfson, MD, MPH;
David Mechanic, PhD
Arch Gen Psychiatry. 2002;59:77-84.
ABSTRACT
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Background A majority of adults with common mental disorders do not seek professional
help. To better understand why not, we examined the correlates of various
stages of help-seeking, including perceived need for professional help, seeking
such help, and from which professionals participants sought help.
Methods The sample for this study comprised 1792 participants in the National
Comorbidity Survey, conducted from 1990-1992, who were diagnosed with a 12-month DSM-III-R mood, anxiety, or substance disorder. In this
sample, we assessed correlates of perceived need for professional help, seeking
professional help among those with a need, and, among those who did seek professional
help, seeking help from mental health professionals.
Results Mood disorders, comorbid mood and anxiety disorders, and mental disorders
associated with impairment in role functioning or suicidality were strong
predictors of perceived need. Psychopathology was also associated with the
decision to seek help from mental health professionals, but not with the decision
to seek professional help overall. After controlling for the nature and severity
of psychopathology, various sociodemographic and attitudinal factors appeared
to be associated with perception of need, help-seeking, and participants'
choices of professionals.
Conclusions Unmet need for mental health care is a serious public health problem.
Meeting this need requires expanding our attention beyond psychopathology
to various evaluations and decisions that affect help-seeking. Our results
suggest the importance of attitude and behavior change strategies in reducing
the gap between need and care.
INTRODUCTION
PSYCHIATRIC epidemiological studies repeatedly find that most adults
with mental disorders receive no treatment.1-2
This finding poses a conceptual problem concerning the relationship between
disorder and need for care and a public health problem concerning the need
to define and address psychological, social, and economic barriers to care.
One commonly used descriptive model,3 which
explains service use in terms of the combined effects of predisposing factors
(eg, gender, education, and health beliefs), enabling factors (eg, income,
insurance, and geographic access), and severity of illness, has only modest
power to predict whether individuals with mental disorders will seek help.4-6
Studies of illness identification and help-seeking generally follow
2 different streams. First, epidemiological surveys, such as the Epidemiologic
Catchment Areas study7 and National Comorbidity
Survey (NCS),8 are based on large representative
samples. They use structured interviews to provide descriptive cross-sections
of how disorder, help-seeking, and other factors are associated. In contrast,
qualitative studies are typically based on limited samples but use more intensive
assessments with less standardized measures.9-10
These studies make clear that the process of help-seeking has multiple stages.9, 11-12 Individuals experience
symptoms; attempt to evaluate the significance of their symptoms and the likely
consequences; determine whether they have a problem that requires intervention
and could benefit from treatment; evaluate the benefits and costs of various
treatments; and choose which health care providers to consult. Different factors
influence each of these evaluations and decisions. The 2 approaches have complementary
strengths and weaknesses but are logistically difficult to combine.13
As previous studies indicate, a key variable when deciding whether to
seek help is the perception of need.14-16
Many who have mental health problems do not think they need treatment because
they believe the symptoms are temporary or not serious. Alternatively, individuals
may not perceive a need because they do not recognize their problem as a mental
health problem, do not know that appropriate help is available, believe that
treatment will not help, do not find services accessible, are embarrassed
about seeking help, fear stigmatization, or, in the case of severe psychotic
disorders, lack insight into the pathological nature of their symptoms. In
short, what appears to be a simple objective report of perceived need is influenced
by the social context and the decisions people make in response to symptoms.
Understanding how perceived need for professional help relates to a constellation
of illness behavior variables helps structure programs that lead to appropriate
care for those who need it most.
In this study, we used data from the NCS8
to examine correlates of different stages in the help-seeking process. We
hypothesized that psychopathology is not the sole determinant of the help-seeking
process and that various psychosocial variables also determine whether individuals
seek help. To test this hypothesis, we examined correlates of perceived need
among participants with psychiatric disorders, correlates of seeking professional
help among those who perceived a need, and correlates of seeking help from
mental health professionals among those who sought professional help.
PARTICIPANTS AND METHODS
SAMPLE
The NCS is a multistage stratified survey of 8089 individuals between
the ages of 15 to 54 years who were selected from the noninstitutionalized
household population of the 48 coterminous states.8, 17
The survey was administered between September 1990 and February 1992 and had
a response rate of 82.4%. Informed consent was obtained from all participants
aged 18 years and older. For participants younger than 18 years, informed
consent was obtained from parents.
The NCS interview was composed of 2 parts. Part 1, administered to all
participants, included core diagnostic questions covering all diagnoses included
in the NCS except for nonaffective psychoses and posttraumatic stress disorder.
Part 2, which included questions about nonaffective psychoses, posttraumatic
stress disorder, and service use, was administered to a probability subsample
of 5877 participants (all those identified as having a lifetime disorder in
part 1, all 15- to 24-year-olds, and a random subsample of other participants
in part 1). In this study, we report data on 1792 participants in part 2 who
met the criteria for at least 1 common mood, anxiety, or substance disorder.
The data were weighted to adjust for differential probabilities of selection
and differential nonresponse, and to approximate the cross-classification
of the population distribution on a range of sociodemographic characteristics.8, 18
ASSESSMENTS
Help-seeking was defined in 2 ways. First, any voluntary contact with
a professional for emotional or substance use problems was considered help-seeking.
Contact was rated separately for different types of professionals, including
formal providers (such as mental health workers, general practitioners, and
other physicians) and informal providers (such as ministers, priests, spiritualists,
and herbalists). However, separate analyses limited to formal health care
providers produced similar results (data not shown). Second, any voluntary
contact with psychiatrists, psychologists, or social workers was considered
help-seeking from mental health professionals, even if the participant also
reported contact with other professionals. The timing of the participant's
last contact with each professional was also noted, and we focused on contact
made within the past 12 months.
We used a procedure described in earlier NCS analyses16, 19
to assess perceived need for professional help. For participants who had not
seen a professional in the past 12 months, perceived need was defined as a
positive answer to the question: "Was there ever a time during the past 12
months when you felt that you might need to see a professional because of
problems with your emotions or nerves or your use of alcohol or drugs?" For
participants who had seen a professional, perceived need was assumed if they
indicated that they had voluntarily contacted the professional. Although reports
of perceived need are subject to memory and other distortions, limiting the
recall period to the past 12 months may have reduced the likelihood of such
errors.
Sociodemographic variables of age, race/ethnicity, and education analyzed
in this study were defined in a similar way as in earlier NCS reports.8, 17 With regard to insurance coverage,
participants were divided into 3 categories: (1) those covered by Medicaid,
welfare, or any other public assistance; (2) those with a health insurance
plan other than Medicaid that covered all or part of the costs for mental
health care outside of a hospital; and (3) those who were not covered by any
plans, did not know if they were covered, or did not know the extent of their
coverage. The categories are a crude indicator of insurance coverage that
do not consider the exact extent of coverage, presence of coinsurance, or
deductible amount, all of which can impose barriers to care. Furthermore,
individuals who had used services may have been more likely to know about
the extent of coverage. Therefore, the effect of insurance on service use
may be a result, rather than a determinant, of utilization.
The diagnoses in NCS were based on a modified version of the World Health
Organization's Composite International Diagnostic Interview (CIDI). Based
on information from these interviews, Diagnostic and Statistical
Manual of Mental Disorders, Revised Third Edition (DSM-III-R)20 lifetime and 12-month diagnoses
were generated with the CIDI diagnostic program. Data presented in this study
are based on the 12-month diagnoses, and 12 such diagnoses, grouped in 3 categories,
were used in this study. The categories were (1) mood disorders, including
major depression and dysthymia; (2) anxiety disorders, including generalized
anxiety disorder, panic disorder, simple phobia, social phobia, agoraphobia
with or without panic, and posttraumatic stress disorder; and (3) substance
use disorders, including alcohol abuse, nonalcohol drug abuse, alcohol dependence,
and nonalcohol drug dependence. These categories are rather broad and heterogeneous,
particularly anxiety disorders, in which self-limited simple phobias are classified
with the more serious panic and posttraumatic stress disorders. To assess
the impact of such categorization, we repeated the analyses for diagnosis
after excluding simple phobia (data not shown). The results of these additional
analyses were quite similar to those reported here.
Bipolar disorder and schizophrenia were not included in this study because
of their low prevalence and uncertain validity in the NCS.21-22
The reliability and validity of the CIDI diagnoses included in this study
have been established in previous field trials23
and in clinical reappraisal studies.24-27
The level of impairment was evaluated by asking participants to indicate
how much their symptoms interfered with their lives and activities on a scale
ranging from "not at all" to "a lot." Participants who stated symptoms caused
"a lot" of interference with their lives and activities were considered severely
impaired. This rating was done separately for every diagnosis, except for
substance disorders and posttraumatic stress disorder.
Suicidality was assessed with 3 sets of questions that asked whether
the participant had ever thought about, planned, or attempted suicide. If
a question was answered affirmatively, follow-up questions assessed the timing
of the event. Only reports of suicide ideation, plans, or attempts in the
past 12 months were used in this analysis.
Physical health status was assessed with 2 ratings. First, participants
were asked: "How would you rate your overall physical health? Is it excellent,
very good, good, fair, or poor?" In this study, "poor" and "fair" self-ratings
were combined and contrasted with the combined "good," "very good," and "excellent"
ratings. The second physical health variable was based on a self-report of
specific health conditions over the past 12 months. Participants were asked
to indicate specific conditions from a list with 14 categories. The list included
musculoskeletal (eg, severe arthritis), respiratory (eg, severe asthma, tuberculosis),
cardiovascular (eg, heart attack), gastrointestinal (eg, ulcer), endocrine
(eg, diabetes), and neurological (eg, multiple sclerosis, epilepsy) disorders
as well as cancer, acquired immunodeficiency syndrome, and other conditions.
Attitudes toward mental health help-seeking were assessed by asking
participants to respond to 3 hypothetical situations: (1) whether the participant
would seek help when faced with a serious emotional problem; (2) how comfortable
he or she would feel talking about personal problems with a professional;
and (3) how embarrassing it would be if friends knew about the professional
help. The answers were ranked on a 4-point Likert scale (highly favorable
to highly unfavorable). The dichotomous rating of attitudes was constructed
by median split on the sum of the item scores.
Supportive relationships were assessed separately for spouse or partner,
relatives, and friends. Each relationship was assessed with a 6-item scale.
Items concerning participants' relationships with their spouses or partners
asked how much the spouse really cared for the participant, understood the
way he or she felt about things, and appreciated him or her; how much the
participant could rely on the spouse or partner for help with serious problems,
could openly talk to the spouse or partner about worries, and could relax
around the spouse or partner. Parallel items asked about supportive relationships
with relatives and friends among participants who had contact with these individuals.
Responses to each item were coded from 1 (not at all) to 4 (a lot). The dichotomous
rating of social support was based on median splits on summed scores.
Parental psychopathology was assessed with questions about symptoms
of depression, anxiety, and substance use disorder. Each parent was addressed
separately, and after each set of questions, participants were asked whether
their parents ever sought professional care or were hospitalized for psychiatric
problems.
DATA ANALYSES
We conducted 3 sets of binary logistic regression analyses. First, we
examined correlates of perceived need. Second, we examined correlates of help-seeking
among participants with a perceived need. Third, we examined correlates of
seeking help from mental health professionals among participants who had sought
professional help. Analyses were conducted once without any covariates (bivariate
analyses) in the model and a second time adjusting for the psychiatric variables
of diagnosis, impairment, and suicidality. A Cronbach  level of P .01 was used for all analyses.
For the analyses reported here, we adopted a design-based approach,
in which frequency weights, strata, and primary sampling units were used to
adjust the parameter estimates and their variances.28
The Taylor series linearlization method, as implemented in the "svytab" and
"svylogit" routines of Stata 6.0 (Stata Co, College Station, Tex), was used
for these computations.
RESULTS
CORRELATES OF PERCEIVED NEED
Of the 1792 participants with one of the 12-month disorders, 32% perceived
a need for professional help in a 12-month period. Distribution of perceived
need was not uniform across diagnoses (Table 1). Participants with comorbid mood and anxiety disorders
with or without comorbid substance disorders were about 3 times more likely
than participants with anxiety disorders alone to perceive a need for professional
help. Substance disorder without comorbidity was associated with the lowest
rate of perceived need. Furthermore, substance disorder comorbidity had different
effects on mood disorders than on anxiety disorders. Participants with comorbid
mood and substance disorders were less likely than participants with noncomorbid
mood disorders to think they needed help. In contrast, participants with comorbid
anxiety and substance disorders were more likely than those with noncomorbid
anxiety disorders to perceive a need.
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Table 1. Perceived Need and Help-Seeking Among Participants With Different
Mental Disorders
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Suicidal ideation, plans, and attempts, and impairment were also strongly
associated with perceived need for help (Table 2). In addition to psychiatric variables, positive attitude
toward mental health help-seeking, physical conditions, marital loss, female
gender, younger age group (15-24 years), maternal psychopathology, and insurance
coverage were positively correlated with perceived need for professional help,
even after controlling for psychopathology (Table 2).
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Table 2. Correlates of Perceived Need and Help-Seeking*
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CORRELATES OF HELP-SEEKING
Of the 571 participants who perceived a need for professional help,
59% sought such help. None of the psychiatric variables that predicted perceived
need were significant correlates of help-seeking. Older age (45-54 years),
having a physical condition, and positive attitudes toward mental health help-seeking
were associated with seeking professional help (Table 2).
CORRELATES OF HELP-SEEKING FROM MENTAL HEALTH PROFESSIONALS
Finally, of the 335 participants who sought professional help, 44% sought
help from mental health professionals. The nature and severity of psychopathology
appeared to be an important predictor of help-seeking from mental health professionals.
Individuals with comorbid anxiety and substance disorders and comorbid mood,
anxiety, and substance disorders were more likely to contact mental health
professionals. The majority of the participants with comorbid mood, anxiety,
and substance disorders who sought professional help sought help from mental
health care providers (Table 1).
In contrast, less than a third of all participants with noncomorbid anxiety
disorders who sought help did so from mental health professionals. For the
analyses of help-seeking from mental health professionals, the number of participants
in some of the diagnostic groups was rather small. Male gender, positive attitudes
toward professional help, and insurance coverage were also associated with
seeking help from mental health professionals among those who had sought professional
help (Table 2).
COMMENT
In interpreting these results, the limitations of this study and the
NCS should be considered. First, for participants who had seen a professional,
perceived need was inferred if they reported that they had voluntarily sought
help. This measure of perceived need may not be as accurate as a direct question.
However, it is reassuring that participants who perceived a need but did not
seek care were indistinguishable from those who sought care with regard to
the nature and severity of psychopathology, the strongest correlates of perceived
need in our study. Second, our analyses were limited to individuals with an
NCS diagnosis of a mental disorder. Another important question is the extent
and correlates of perceived need and help-seeking among individuals who did
not have a diagnosis. Additional analyses indicated that participants without
diagnoses are less likely to perceive a need than participants with diagnoses
(10% vs 32%). After perceiving a need, however, they are as likely to seek
care (61% vs 59%), although they are less likely to seek care from mental
health professionals (28% vs 44%). The correlates of perceived need were similar
in subjects with and without diagnoses (data not shown). Thus, diagnosis is
associated with perceived need and help-seeking from mental health professionals,
but not with help-seeking in general after perceiving need. Third, both the
assessment of perceived need and help-seeking in the NCS were based on 12-month
recall. A shorter recall period might have produced more accurate results.
Previous studies of perceived need and help-seeking provide context
for our findings.29-34
Of these, the Ontario Health Survey29 used
methods similar to the NCS. Comparison of the 2 surveys revealed that more
people in the United States than in Ontario, Canada, perceived a need for
help and used services. After controlling for perceived need, most of the
between-country variations in service use disappeared. Thus, perceived need
explains variations in service use across as well as within settings.
Similar to previous studies, we found higher rates of perceived need
among women30-33;
participants who were divorced, separated, or widowed30-31,33;
participants with physical problems33; and
younger participants.30-31,33
Like previous studies, we found no association between these variables and
help-seeking after need was established30-31
and a higher likelihood of help-seeking after need was felt among the middle-aged.30-32
Few studies, primarily surveys done several decades ago,30-31
have examined perceived need for professional help in the US population. Some
more recent studies of service use have also noted relationships between education
or minority status and the likelihood of mental health visits.35-36
Unlike these studies, we did not find perceived need or help-seeking associated
with education, race, or income. Most previous analyses were based on general
population samples, not specifically persons with psychiatric diagnoses. It
is noteworthy, however, that recent analyses of a 1997-1998 US survey also
revealed educational disparities in service use in a sample of individuals
with mood and anxiety disorders.37
We also found higher rates of perceived need among participants with
a maternal history of mental illness. This finding may reflect increased recognition
of mental illness among the offspring of parents with psychiatric disorders
or less willingness to rely on informal support networks as a result of childhood
experiences.
Interestingly, few of the correlates of perceived need predicted help-seeking
among individuals who perceived a need. The nonsignificant effects of psychiatric
variables are, perhaps, as noteworthy as the significant effects. After the
need for professional help is perceived, the nature and severity of psychopathology
do not affect the decision to seek help. The major determinants of help-seeking
among individuals with a perceived need for professional help are sociodemographic
and attitudinal.
The nature and severity of psychopathology, however, did affect the
choice of care providers. Individuals with more severe comorbid disorders38 were more likely to seek care from mental health
professionals. This suggests progress toward a targeted care system in which
the more severely ill seek help from the more specialized professionals and
the less severely ill from nonspecialized professionals.
One of the explanations proposed for the mismatch between the rates
of mental disorders in the community and rates of help-seeking is that the
rates of disorders are exaggerated and do not reflect the true need for care.39 The results of the present study provide partial
support for this hypothesis. A majority of individuals with less severe or
impairing psychopathology may have recognized the self-limited nature of their
problems and did not perceive a need for professional help.
However, many of the individuals with disorders who do not perceive
a need experience distress and impairment and could potentially benefit from
professional help. In this sample, for example, 26% of participants who met
the criteria for 1 of the disorders in the study but who did not perceive
a need for professional help reported severe impairment in their daily activities.
Furthermore, about 5% reported suicidal ideation, plans, or attempts during
the past year. Thus, experiencing a need for professional help is not a direct
response to distress and impairment, and even after controlling for distress
and impairment, various sociodemographic and attitudinal factors affect both
perceived need and help-seeking. The effects of these sociodemographic and
attitudinal factors reflect the complex evaluations and decisions that characterize
"illness behavior."40
A model of help-seeking as a series of stages,11, 41-42
as illustrated here, can inform interventions that seek to achieve a better
correspondence between need and use of appropriate services. Strategies aimed
at changing attitudes and motivating help-seeking are essential for encouraging
persons with disabling conditions who do not perceive a need for professional
care to use services. There is some limited evidence that screening and targeted
educational campaigns affect attitudes43-45
and help-seeking behavior.46-48
However, we believe that it is essential to go beyond such efforts and seek
to integrate motivational and cognitive aspects of behavior change with specific
instructional plans.49-50
Results from our study also point to some groups that are less likely
to express a need for professional help when experiencing psychiatric problems.
Two such groups that could be the target of educational interventions are
younger individuals and men. Educational programs specifically designed for
schools have had promising results.44, 51
Similar programs could be developed for male-dominated work environments,
such as the military.
For individuals who do perceive a need, a more accepting attitude toward
professional help may facilitate help-seeking. Many of the barriers to care
at this stage, however, are objective barriers such as financial problems
or the time costs of care. Intervention at this stage, therefore, may require
large-scale policy initiatives. Of the NCS participants who had perceived
a need but not sought care, 39% said that professional care was too expensive,
28% that their health insurance would not cover it, and 30% that it would
take too much time or be too inconvenient.
Finally, our results echo earlier general population surveys such as
the Midtown Manhattan Study of the 1950s, which estimated that the majority
of individuals with serious mental health problems were not receiving care
from mental health professionals.52 Although
the rates of professional care for mental illness have increased impressively
since then, unmet need for care still remains a large public health problem.
AUTHOR INFORMATION
Accepted for publication June 26, 2001.
This study was supported in part by a Young Investigator Award from
the National Alliance for Research in Schizophrenia and Depression, Great
Neck, NY (Dr Mojtabai); and grants MH01754 (Dr Mojtabai), MH56490 (Dr Olfson),
and MH43450 (Dr Mechanic) from the National Institute of Mental Health, Bethesda,
Md. The NCS is supported by grants R01 MWDA46376 and R01 MH49098 from the
National Institute of Mental Health; a supplement to grant R01 MWDA46376 from
the National Institute of Drug Abuse, Bethesda; and grant 90135190 from the
William T. Grant Foundation, New York, NY.
The Principal Investigator of the NCS is Ronald Kessler, Harvard Medical
School, Cambridge, Mass. Collaborating NCS sites and investigators are: Addiction
Research Foundation, Toronto, Ontario (Robin Room); Duke University Medical
Center, Durham, NC (Dan Blazer and Marvin Swartz); Harvard Medical School
(Richard Frank and Ronald Kessler); Johns Hopkins University, Baltimore, Md
(James Anthony, William Eaten, and Philip Leaf); Max-Planck Institute of Psychiatry,
München, Germany (Hans-Ulrich Wittchen); Medical College of Virginia,
Richmond (Kenneth Kendler); University of Miami, Miami, Fla (R. Jay Turner);
University of Michigan, Ann Arbor (Lloyd Johnston and Roderick Little); New
York University, New York, NY (Patrick Shrout); State University of New York
at Stony Brook (Evelyn Bromet); Washington University School of Medicine,
St Louis, Mo (Linda Cottler and Andrew Heath).
Corresponding author and reprints: Ramin Mojtabai, MD, PhD, 200 Haven
Ave, Apt 6P, New York, NY 10033 (e-mail: rm322{at}columbia.edu).
From the Department of Psychiatry, College of Physicians and Surgeons,
Columbia University, and the New York State Psychiatric Institute, New York
City (Drs Mojtabai and Olfson); and the Institute of Health, Health Care Policy,
and Aging Research, Rutgers University, New Brunswick, NJ (Drs Mechanic and
Olfson).
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