|Year : 2019 | Volume
| Issue : 2 | Page : 148-154
A study of factors affecting help-seeking behavior in major depressive disorder
Srinivasa Kartik Valipay, Minakshi Nimesh Parikh, Maitri Desai, Bakarali T Nathametha
Department of Psychiatry, B.J. Medical College and Civil Hospital, Ahmedabad, Gujarat, India
|Date of Submission||13-May-2019|
|Date of Decision||01-Jun-2019|
|Date of Acceptance||30-Jun-2019|
|Date of Web Publication||18-Dec-2019|
Dr. Minakshi Nimesh Parikh
Department of Psychiatry, B.J. Medical College and Civil Hospital, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Major depressive disorder (MDD) is among the most common mental disorders. Apart from the high prevalence, depression has been found to contribute to a high degree of impairment in functioning, equalling or exceeding that associated with debilitating medical conditions. Despite this, research shows a large treatment gap and demonstrable benefits on addressing this gap. Hence, it becomes important to study the factors affecting help-seeking behaviors among patients with MDD. Our study aims to assess these factors. Methods: It was a cross-sectional study conducted on 100 consecutive consenting patients of MDD in the department of psychiatry of a tertiary care hospital. The instruments used were semi-structured pro forma for sociodemographic details, Big Five Inventory-10 Scale for personality traits, K10 rating scale for psychological distress, and Depression Stigma Scale to assess the stigma faced. Results: In our study, we found (a) sociodemographic factors such as higher family income, joint family type, and rural locality to be statistically significantly associated with late help seeking and (b) patient-related factors of higher levels of perceived stigma to be statistically significantly associated with late help-seeking behavior. Conclusions: Factors such as family type, stigma, and living in a rural area were significantly associated with late help seeking. Psychoeducation of family members and increased awareness and access to mental health-care professionals may help address these issues. Studying factors affecting help seeking on a larger scale may help with policy formulation in future.
Keywords: Depression, help-seeking behavior, sociodemographic factors, stigma, treatment gap
|How to cite this article:|
Valipay SK, Parikh MN, Desai M, Nathametha BT. A study of factors affecting help-seeking behavior in major depressive disorder. Ann Indian Psychiatry 2019;3:148-54
|How to cite this URL:|
Valipay SK, Parikh MN, Desai M, Nathametha BT. A study of factors affecting help-seeking behavior in major depressive disorder. Ann Indian Psychiatry [serial online] 2019 [cited 2020 Jan 22];3:148-54. Available from: http://www.anip.co.in/text.asp?2019/3/2/148/273374
| Introduction|| |
Major depressive disorder (MDD) is among the most common mental disorders. Apart from being very prevalent, depression has been consistently found across studies to contribute to a high degree of impairment in daily functioning, shown to equal or exceed that associated with debilitating medical conditions such as diabetes mellitus and heart failure. In recent years, this has been studied in terms of YLD (Years Lost due to Disability), with major depression being the leading cause of disability worldwide, as reported by WHO in a Global Health Estimates report in 2017. The high prevalence, the significant impairment it causes in socio-occupational functioning in sufferers, and the impact on the quality of life of patients and their families all contribute to a high economic burden due to the disorder.,,, Despite the availability of effective treatments, a significant fraction of the individuals suffering from depression do not receive help for their condition. Estimates of the number of individuals with depression getting help vary from 17% at worst to 60% at best across various studies. As can be seen from these numbers, there is a significant treatment gap and there are demonstrable benefits in addressing this treatment gap, such as improved social function, increased productivity, and decreased absenteeism. However, to address this, it is crucial to identify factors associated with help-seeking behaviors. Because our study population comprised an exclusively hospital sample, we studied factors associated with early or late help seeking in patients with depression, as opposed to some previous researches which studied factors associated with help seekers and nonhelp seekers in community samples.,
Various factors have been identified to affect help-seeking behavior, and one model which attempted to study them systematically is Andersen's behavioral model of health-care utilization  which put forward three groups of determinants of help seeking:
- Predisposing factors: Factors relating to individuals which exist before their illness, such as age, gender, and other sociodemographic variables
- Enabling factors: Factors which affect access to mental health care, such as number, distribution and location of health-care institutions, costs involved in health care, and financial situation of help seekers
- Need factors: These include “evaluated need for care” and “perceived need for care,” which are the professional opinion regarding an individual's requirement of health-care contact and a person's individual opinion about the need for help seeking, respectively.
There has been extensive research on this topic in the West. Existing literature indicates that predisposing factors are most likely to decrease help-seeking behaviors such as being young or elderly, being male, belonging to certain ethnic groups, and having a lower educational status. There is evidence that severity, duration, and comorbid anxiety are related to more help seeking.
However, there are some unresolved issues and inconsistencies in the existing literature, one of which is the unclear association between a number of variables and help-seeking behaviors. We also noticed a relative lack of Indian studies on the topic; in contrast to Western literature, few studies on the topic have been conducted in India and fewer in Western India, with our literature search yielding no results related to this topic from the state of Gujarat.
Hence, we felt it worthwhile to study factors affecting help-seeking behavior in patients with MDD in our local population and also correlate sociodemographic, illness-related, and patient-related factors with early or late help seeking.
| Methods|| |
The study was approved by an institutional ethics committee. The samples were collected from inpatient and outpatient sections of the department of psychiatry of B. J. Medical College and Civil Hospital, Ahmedabad from October 2017 onward. The first one hundred consenting patients with a diagnosis of MDD made in the past 6 months, as per the DSM-5 criteria, were included in the study. Patients diagnosed with bipolar mood disorder after an initial diagnosis of MDD or those with psychotic features were excluded from the study. A semi-structured pro forma was then filled for each patient. Big Five Inventory-10 (BFI-10) scale, K10 rating scale for psychological distress, and Depression Stigma Scale (DSS) were then applied to each patient. All the instruments including the semi-structured pro forma were applied by the clinician. Participants were divided into groups of early and late help seekers, based on the time duration taken for the first contact with a mental health-care provider after their symptoms started. Patients consulting a mental health-care provider within 3 months of onset of symptoms were considered as early help seekers and those doing so after 3 months were considered late help seekers. The duration of interview was 45–60 min.
- A semi-structured pro forma which was used for recording sociodemographic data, comprising information about age, education, marital sex, status, occupation, family income, and locality. Additional information about duration of symptoms, severity of MDD, presence or absence of a comorbid physical and/or psychiatric illness, whether the patient was an early or late help seeker, and main reason for help seeking were also included in this pro forma
- BFI-10 for the assessment of personality characteristics in terms of the “big five” traits of openness, conscientiousness, extraversion, agreeableness, and neuroticism. It is a 10-item abbreviation of the 44-item Big Five Inventory, with responses on a continuum ranging from 1 to 5, with 1 standing for “strongly disagree” and 5 for “strongly agree.” The abbreviated version has been shown to retain significant levels of reliability and validity of the longer version, which has been translated into various languages and validated ,
- DSS was used to determine stigma associated with major depression and help seeking for the same. It has a 9-item personal stigma subscale and a 9-item perceived stigma subscale, with responses on a continuum ranging from 0 to 4, with 0 standing for “strongly disagree” and 4 for “strongly agree.” Our correspondence with the developer of the scale clarified that the scale was not meant for classification of patients into fixed categories, but rather for a comparison of average scores between groups, with higher scores indicating more stigma. It has been translated and validated and was found to have moderate-to-high internal consistency 
- K10 questionnaire is a 10-item psychological distress scale, with questions regarding various types of psychological distress experienced in the past 1 month. Each question has responses ranging from 1 to 5. Patients with scores <20 are likely to be well, whereas those with scores from 20 to 24, 25–29, and >29 are likely to have a mild, moderate, and severe mental disorder as per the recommended scoring system of this scale, respectively. This scale has been found to be a valid and reliable scale for screening of psychological distress.,,,
Data were entered into Microsoft Excel data sheet and were analyzed using Epi Info version 7.2 software (Epi Info™, Division of Health Informatics & Surveillance (DHIS), Center for Surveillance, Epidemiology & Laboratory Services (CSELS), CDC, USA). Categorical data were represented in the form of frequencies and proportions. Chi-square test or Fisher's exact test (for 2 × 2 tables only) was used as a test of significance for qualitative data. Continuous data were represented as mean and standard deviation. Independent t-test was used as a test of significance to identify the mean difference between two quantitative variables. Graphical representation of the data: MS Excel and MS Word were used to obtain various types of graphs P < 0.05 (probability that the result is true) was considered statistically significant after assuming all the rules of statistical tests.
| Results|| |
Our sample consisted of one hundred patients diagnosed with MDD in the past 6 months at the time of sample collection. Of this, there were 46 males and 54 females. A majority of individuals were married (72), engaged in nonprofessional occupations (56), had school level education (74), belonged to Hindu religion (84), lived in nuclear families (62) and urban localities (74), and did not have any physical (62) or psychiatric (74) comorbidity. The samples were divided into two groups, namely early and late help seekers, and the groups were compared with respect to their association with various variables as mentioned [Table 1].
We did not find a statistically significant association between help-seeking behavior and sex, mean age, education, occupation, and marital status.
Among participants with family income above INR 9797, 28% were early help seekers and 72% were late help seekers. Among participants with family income between INR 2936 and 9797, 50% were early help seekers and 50% were late help seekers. Among participants with family income below INR 2936, 55.6% were early help seekers and 44.4% were late help seekers. We found a statistically significant association between help-seeking behavior and family income (P = 0.046)[Table 2].
|Table 2: Distribution of participants according to help-seeking behavior and family income|
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Sixty-two percent of the study population were living in nuclear families as opposed to 38% in joint families. Among participants living in nuclear families, 53.2% were early help seekers and 46.8% were late help seekers. Among participants living in joint families, 18.4% were early help seekers and 81.6% were late help seekers. A statistically significant association was found between help-seeking behavior and family type, with a negative association between living in a joint family and early help seeking [Table 3].
|Table 3: Distribution of participants according to help-seeking behavior and family type|
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Among rural participants, 19.2% were early help seekers and 80.8% were late help seekers. Among urban participants, 47.3% were early help seekers and 52.7% were late help seekers. We found a statistically significant association between help-seeking behavior and locality, with a negative association between living in a rural area and early help seeking [Table 4].
|Table 4: Distribution of participants according to help-seeking behavior and locality|
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No statistically significant association was found between early and late help seeking and mean personal DSS score. However, there was a statistically significant association between early and late help seeking and mean perceived DSS score, with the scores being higher in late help seekers [Table 5].
|Table 5: Comparison of mean Depression Stigma Scale score among early and late help seekers|
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There was no statistically significant association between help-seeking behavior and main reason for help seeking. As a group, depressive symptoms were the most common reason for help seeking (26%), closely followed by sleep problems (24%) and anxiety and related symptoms (22%). When individual symptoms were considered, sleep disturbance was the most common symptom (24%), followed by anxiety (18%) [Table 6].
|Table 6: Distribution of participants according to help-seeking behavior and main reason for help seeking|
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There was no statistically significant association between help-seeking behavior and religion, symptom severity, comorbid physical/psychiatric illness, level of psychological distress, and any of the “big five” personality traits (openness, conscientiousness, extraversion, agreeableness, and neuroticism).
| Discussion|| |
The aim of this study was to examine factors affecting help-seeking behavior among people with depression, by investigating the relationship of sociodemographic factors, illness-related factors, and patient-related factors with early or late help seeking. In this study, 40% of the population were early help seekers as opposed to 60% who were late help seekers.
Correlation of sociodemographic factors with help seeking
- Sex: In our study, 48.1% of females were early help seekers as opposed to 30.4% of males, and 69.6% of males were late help seekers as opposed to 51.9% of females. Despite no statistically significant association between sex and help seeking, we found the above numbers to be significant. Studies by González et al. and Chartrand et al. found a positive association between female gender and help seeking. This is consistent with previous research, which found that help seeking in males was perceived as a threat to hegemonic masculinity. However, Boerema et al., Lin and Parikh, Coryell et al. found no association between gender and help seeking. The absence of a statistical significance in our study may be due to a small sample size that limits the statistical power
- Mean age: There was no statistically significant association between mean age and help-seeking behavior, as in the study by Boerema et al., whereas Gabilondo et al. found a positive association between middle age and increased help seeking
- Education: No statistically significant association was found between educational level and help-seeking behavior. This finding is consistent with previous studies by González et al. and Coryell et al., but other studies such as the ones by Hailemariam et al. and Gadalla  have found a positive association between higher levels of education and help seeking. A noteworthy finding in our study was that there were more early help seekers than late help seekers in the illiterate group, and vice versa in the participants with graduate-level education and above, which is contrary to most literature on the matter. One possible explanation for this could be the type of center being approached by the study participants, with our center being a government tertiary care hospital. Previous research has shown that individuals with higher education are more likely to use private health-care services than illiterate individuals 
- Occupation: There was no statistically significant association between occupational type/status and help-seeking behavior. This is consistent with the findings of Hailemariam et al., Lin and Parikh, and Kleinberg et al., whereas Gadalla  found a negative association of employment with help seeking, with those who were unemployed or too disabled to work having a higher likelihood of service use in their study
- Marital status: Our study found no significant association between marital status at the time of consultation and help-seeking behavior. This finding was in line with studies by Boerema et al., Sussman et al., and Wang et al., whereas Gagné et al. and Coryell et al. found a negative association of marital status (in individuals married or living as married) with help-seeking behaviors, who found that single individuals were more likely to seek help than individuals who were married or living as married
- Family income: Our study found a statistically significant association between income and help-seeking behavior, with low income (<2936 INR) having a positive association with help seeking and higher income (>9797) having a negative association with early help seeking. This finding is in concordance with a study by Gagne et al., which found a positive association of lower adjusted household income with mental health service use. Conversely, studies by Gabilondo et al. and Diala et al. found a negative association between low income and help seeking, with low income impeding help-seeking behaviors. The finding in our study could possibly be explained by the trend of individuals with lower incomes seeking help more from government-run institutions providing free care and individuals with a higher income seeking help more from private hospitals or practitioners. In our center, it has been our observation that individuals with a higher income usually reach us after a referral, initially having sought help from elsewhere, and usually reach us later than individuals who approach us directly as the first-time help seekers
- Family type: We found a statistically significant association between help-seeking behavior and family type, with living in a nuclear family showing a positive association with early help seeking and living in a joint family showing a negative association with help seeking. This finding was similar to that of Dew et al., who found that receiving social support during the index episode was negatively related to help seeking. On the contrary, Gagne et al. found that social support and help seeking were positively related, but only in women. It has been shown in previous research that a desire to handle the problem on one's own delays help seeking, and in our experience, this is a common practice in joint families in our setting, where family members attempt to address the issue within the family, and only when that fails, help is sought
- Locality: Our study found a statistically significant association between help-seeking behavior and locality of residence, with a negative association found between living in a rural area and early help seeking. Most previous studies have not found an association in this aspect.
The urban location of our center coupled with the observation that most of our rural clientele come from low-income households and find it financially challenging to commute to our center for help, could possibly explain the above finding.
- Religion: Our study did not find any significant association between religion and help-seeking behavior. Previous research has focused on differences in help seeking between various ethnicities and found that ethnic minorities had lower rates of help seeking, possibly due to the families need to deal with the problem on their own and within the community, before help seeking.
Correlation of illness factors with help seeking
- Severity of illness: No statistically significant association was found between severity of illness and help-seeking behavior in our study. This is consistent with studies by Boerema et al. and Lin and Parikh, whereas other studies by Kleinberg et al., Coryell et al., and González et al. found a positive association between increasing severity of symptoms and the use of mental health-care services. The direction of results in our study is in line with previous findings, but the lack of statistical significance may be because of the small sample size which limits statistical power
- Comorbid physical illness: There was no statistically significant association between the presence of comorbid physical illness and help-seeking behavior in our study. This is in line with the findings of Boerema et al. and Lin and Parikh, whereas studies by Gadalla  and Gagne et al. found a positive association between the presence of a chronic somatic disorder and help seeking
- Comorbid psychiatric illness: No statistically significant association was found between the presence of comorbid psychiatric illness and help-seeking behavior in our study. This is in line with studies by Wang et al. and Lin and Parikh  and contrary to the findings of Gabilondo et al. Although the direction of our result is consistent with the latter, our sample size may have been a limiting factor for statistical power
- Psychological distress: There was no significant association between psychological distress and help seeking in our study. This finding is consistent with the findings of Boerema et al. Previous research has shown higher psychological distress to be associated with earlier help seeking. The population in our study was an exclusively hospital sample of individuals who had approached us for help, and this may be a limiting factor, as psychological distress levels in a community sample would possibly have been a more accurate measure
- Main reason for help seeking: Our study did not find a statistically significant association between help-seeking behavior and any of the specific reasons for help seeking. However, it is noteworthy that the most common individual symptom that clients sought help for was insomnia followed by anxiety, and the most common group of symptoms was core depressive symptoms (including anhedonia, depressed mood, reduced concentration, and fatigue/weakness), followed by anxiety and related symptoms and psychosomatic symptoms. Dew et al. found a positive association between symptoms such as depressed mood/anhedonia, reduced concentration, insomnia, and help seeking.
Correlation of patient-related factors with help seeking
- Stigma: We found a statistically significant association between higher perceived stigma scores and help-seeking behavior, with mean higher scores negatively associated with early help seeking. There was no significant association between personal stigma and help seeking. These findings are contrary to ones from a study by Boerema et al., who found no association between personal stigma and help seeking, but found a negative association between higher personal stigma and help seeking. This difference may possibly be explained by the variations in societal makeup in both the places. In our observation, the fear that others might get to know of their problem commonly serves as a deterrent for help seeking in our center, where many clients approaching the first time would not have told even their immediate families about their problem or about the visit
- Personality traits: There was no significant association between any of the “big five” personality traits, namely openness, conscientiousness, extraversion, agreeableness and neuroticism, and help-seeking behavior, in our sample. Boerema et al. studied an association between neuroticism and help seeking and found no association, although some previous researches suggest a positive association between neuroticism and late help seeking.
| Conclusions|| |
Based on the Andersen's model, we mainly found predisposing factors such as family type and stigma to be significantly associated with help-seeking behaviors in patients with MDD, and contrary to some previous studies, the enabling factor of income was found to be negatively associated with help-seeking behaviors. The contextual factor of living in a rural area was also found to correlate negatively with help-seeking behavior. Psychoeducation of family members and increased awareness may help address the delay in help seeking we observed in individuals living in joint families; increased access to a mental health-care professional, which our authorities are actively working toward, may help address the delay in help seeking we observed in rural areas.
Limitations and future scope
- Statistical power is limited by the small sample size. Studying the topic with a bigger sample size of the study may increase the statistical power
- Only some aspects of help seeking have been assessed in this study. More aspects of help seeking may be studied for a more comprehensive view
- This study was conducted in a hospital sample. The study may be replicated in a community setting for a more accurate representation of nonhelp-seeking behavior in the general population.
I would like to offer my sincerest gratitude to my teachers Dr. Rajesh Kumar, (Additional Professor) Dr. Mehul Brahmbhatt (Associate Professor), Dr. Hemang Shah (Assistant Professor), and Dr. Pragna Sorani (Assistant Professor) who gave me their valuable advice and guidance. I am indebted to the Department of Psychiatry for providing equipment, the technical support, resources, such as online databases and library, without which compilation of this thesis would have been extremely complicated. I am also grateful to my fellow residents for their timely help throughout this study.
This study was approved by Institutional Ethics Committee with reference number IEC/Certi/194/18 obtained on 29th September 2016.
Declaration of Patient Consent
Patient consent statement was taken from each patient as per institutional ethics committee approval along with consent taken for participation in the study and publication of the scientific results / clinical information /image without revealing their identity, name or initials. The patient is aware that though confidentiality would be maintained anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]