EMPIRICAL RESEARCH

Adolescents’ Suicidal Thinking and Reluctanceto Consult General Medical Practitioners

Coralie J. Wilson Æ Frank P. Deane ÆKellie L. Marshall Æ Andrew Dalley

Received: 28 April 2009 / Accepted: 1 July 2009 / Published online: 15 July 2009

� Springer Science+Business Media, LLC 2009

Abstract Appropriate help-seeking is widely recognized

as a protective factor, and vital for early treatment and

prevention of mental health problems during adolescence.

General medical practitioners (GPs), that is, family doctors,

provide a vital role in the identification of adolescents with

mental health problems and the provision of treatment as

well as access to other specialists in mental health care

services. The current study examined the association

between suicidal ideation and intentions to seek help from

a GP for suicidal thoughts, emotional problems and phys-

ical health problems, using a sample of 590 Australian high

school students that was 56.7% female and aged 13–18

years (M = 15.56 years, SD = .66 years). Higher levels of

suicidal ideation and general psychological distress were

related to lower intentions to seek help from a GP for

suicidal and physical problems. The results suggest that

even at subclinical levels, increases in suicidal ideation or

psychological distress may lead to help avoidance. School

personnel and other gatekeepers need to be aware of this

trend in order to be more assertive in encouraging and

supporting appropriate help-seeking for mental health

problems. School health promotion programs should con-

sider including information to explicitly address the help-

negation process.

Keywords Suicidal ideation � Psychological distress �Help-seeking � Primary health care � Barriers

Introduction

Mental illness and substance use disorders are highly pre-

valent among adolescents. If left untreated, they can cause

distress and disability that last for decades (McGorry et al.

2007). Worldwide, up to 20% of children and adolescents

experience a disabling mental illness (Belfer 2008), with

approximately 50% of all adult mental health disorders

starting by age 14, and three quarters starting before age 24

(Belfer 2008; Kessler et al. 2005). Within Australia, the

statistics are higher with approximately one in four young

people aged 13–24 years experiencing a mental health

problem (Sawyer et al. 2000). These are mostly anxiety

disorders (15.4%), followed by substance use disorders

(12.7%) and affective disorders (6.3%) (Australian Bureau

of Statistics 2008). Internationally, suicide is the third

leading cause of death in the 15–24 year age group and

remains the focus of worldwide concern (Belfer 2008). In

2005, approximately 10% of deaths amongst American

15–24 year olds were by suicide. Between 2004 and 2006,

C. J. Wilson � F. P. Deane

Illawarra Institute for Mental Health, Wollongong,

NSW, Australia

F. P. Deane

e-mail: Frank_Deane@uow.edu.au

C. J. Wilson (&)

Graduate School of Medicine, University of Wollongong,

Building 28, Wollongong, NSW 2522, Australia

e-mail: Coralie_Wilson@uow.edu.au; cwilson@uow.edu.au

F. P. Deane

School of Psychology, University of Wollongong, Wollongong,

NSW, Australia

K. L. Marshall � A. Dalley

Illawarra Division of General Practice, Wollongong,

NSW, Australia

K. L. Marshall

e-mail: kmarshall@idgp.org.au

A. Dalley

e-mail: adalley@idgp.org.au

123

J Youth Adolescence (2010) 39:343–356

DOI 10.1007/s10964-009-9436-6

suicide accounted for 20% of all Australian deaths in the

16–24 age group (ABS 2008), and has resulted in a ‘‘state

of emergency’’ being declared in Australia’s youth mental

health (News Release, October 2008). Together, these

statistics underscore the need for mental health research to

focus on factors involved in protecting against the dis-

ability of mental illness, and specifically, against the

development of acute suicidality.

Help-Negation for Suicidal Thoughts

Appropriate help-seeking can successfully reduce the long-

term impact of many mental health problems and is partic-

ularly important when adolescents are suicidal and need

accurate advice (Rickwood et al. 2007). However, epide-

miological studies indicate that only about a quarter of young

people with a mental health problem seek professional care

(Sawyer et al. 2000), and many prefer no help for depressive

and suicidal symptoms (e.g., Gould et al. 2004; Sen 2004).

Thus, despite the benefits of seeking and receiving profes-

sional psychological help, these studies suggest that up to

75% of young people with a mental health problem do not

seek appropriate mental health care for their problem. These

epidemiological studies also raise the possibility that, in this

population group, a trend towards help avoidance occurs in

response to symptoms of psychological distress.

Help-negation is defined as ‘‘the refusal to accept or

access available helping resources’’ (Rudd et al. 1995,

p. 499). It has been found in acutely suicidal inpatient

samples (Rudd et al. 1995) and non-clinical (i.e., non-

acutely suicidal) adolescent and university student samples

(Carlton and Deane 2000; Deane et al. 2001; Gould et al.

2004; Saunders et al. 1994; Wilson et al. 2005a). While

help-negation in acutely suicidal samples is not too sur-

prising in that those who are acutely suicidal are known to

feel pessimistic and think that nothing can help (Belfer

2008; Rudd et al. 1995), reasons for why the help-negation

process occurs in non-clinical samples are unclear.

Two Australian studies, one with first-year university

students (Deane et al. 2001) and one with high school

students (Wilson et al. 2005a), found an inverse relation-

ship between suicidal ideation and help-seeking intentions.

Suicidal ideation refers to people’s thoughts and ideas

about death, suicide, and serious self-injurious behaviors

(Reynolds 1988). It is both a proxy measure for suicide

(Martin 2002) and an independent estimate of risk for

suicide completion (Brown et al. 2000). Intentions were

measured because they proximate behavior (Webb and

Sheeran 2006). In both samples as levels of suicidal idea-

tion increased intentions to seek help from a range of

informal and formal help-sources decreased. Conversely,

as levels of ideation increased, intentions to seek help from

no-one increased simultaneously. Both studies also tested

whether hopelessness would explain the help-negation

process, but neither study found support for this hypothesis.

These findings raise both concern and opportunity. The

concern is that the help-negation process might prevent

young people from seeking help when it is needed. It is

generally agreed that suicidal behaviors have develop-

mental pathways. It is also agreed that these pathways

typically begin with emotional and/or psychological dis-

tress that develops into ideation, continues to attempt, and

ends with suicide completion (e.g., Cole et al. 1992; Felner

et al. 1992; Pfeffer et al. 1993; Schweitzer et al. 1995;

Yung and McGorry 1996). Despite methodological issues

and evidence suggesting that reported rates of ideation may

underestimate actual rates by as much as two-thirds

(Beautrais 1998; Madge and Harvey 1999; Wagner 1997),

suicidal ideation appears relatively common in young

people. Australian and non-Australian studies converge to

suggest that up to 62.6% of young people report suicidal

ideation at some point in their lifetime (e.g., Martin et al.

1997; Meehan et al. 1992; Smith and Crawford 1986), up

to 43% of young people report suicidal ideation within the

previous year (e.g., Centers for Disease Control and Pre-

vention 1991; Rudd 1989; Schweitzer et al. 1995), and up

to 23.4% of young people report current and/or recurrent

suicidal ideation (e.g., Goldney et al. 1989; Reinherz et al.

1995; Swanson et al. 1992). This suggests that, at any point

in time, up to 23.4% of young people worldwide are

potentially at risk to act on their suicidal thoughts. Findings

of help-negation suggest that compared to those without

ideation, these high-risk young people are those who are

most likely to avoid seeking help for their potentially lethal

thoughts. The opportunity is for suicide prevention

research to identify factors that can explain and potentially

reverse adolescents’ help-negation for suicidal thinking.

General Medical Practitioners’ (GPs) Role

in Adolescent Suicide Prevention

GPs provide primary health care that is both clearly rec-

ognized by the general public and generally accessible for

adolescents in need of care (Veit et al. 1996). Interna-

tionally, GPs are known as family doctors or family phy-

sicians because they provide broad-based health care for

adults and children in a family. In Australia, GPs provide

comprehensive and coordinated medical care that is not

focused on a particular illness or treatment type. They are

often the first point of contact for young people seeking

health care and thus, can provide a vital role in the iden-

tification of adolescents with mental health problems. They

can also provide treatment and access to other specialist

mental health care services (Stanistreet et al. 2004).

However, the extent to which GPs have the capacity

to contribute to young peoples’ mental health care,

344 J Youth Adolescence (2010) 39:343–356

123

particularly suicide prevention, is impeded by the natural

underrepresentation of young people among GP attenders.

Young people, as a population group, do not have the same

need to consult a GP as often as other population groups

(e.g., older age groups with chronic diseases, such as car-

diovascular disease, that need regular monitoring). Even

though young Australians make up about 13% of the

population (ABS 2006), less than 1 in 10 of all consulta-

tions are made by those aged 15–24 and they mainly attend

for coughs and colds. Only 1 in 12 specifically request help

for psychological problems (Britt et al. 2008). This means

that young people do not provide the same natural oppor-

tunity for GPs to identify and treat their mental health

needs as other groups. Unless a young person specifically

seeks a GP’s help for a mental health problem, the GP’s

capacity to provide mental health care is limited largely by

circumstance.

These statistics reinforce the need for prevention strat-

egies to consider more effective ways to encourage young

people to consult GPs, particularly when they are experi-

encing suicidal ideation and other indications of psycho-

logical distress (Stanistreet et al. 2004). It is noteworthy

that in both studies that have examined the help-negation

effect for formal and informal help sources (Deane et al.

2001; Wilson et al. 2005a), the young people in both

samples were least reluctant to seek help from a GP

compared to other formal sources such as counselors and

psychologists, and to informal sources such as friends and

family. This suggests that the help-negation process might

interfere less with help-seeking from a GP than other

sources. If so, it also suggests that strategies to specifically

target variables involved in the help-negation process for

GPs might promote higher rates of proactive consultation

for mental health problems, which may subsequently result

in lower rates of acute lifelong mental health problems and

suicide completion.

There are several factors that may have a role in the

help-negation process for a GP. Firstly, it is possible that

the help-negating effect of suicidal ideation can be

explained by co-occurring psychological distress symp-

toms. Since suicidal ideation without other psychological

disturbance is rare in adolescents (Belfer 2008; Marttunen

et al. 1991), even when levels of suicidal ideation are not

acute, an adolescent might experience increased levels of

general psychological distress that subsequently reduce

their intentions to seek help for suicidal thoughts.

Secondly, it is possible that perceived barriers to health

care seeking will explain aspects of the help-negation

process for GPs. Variables that inhibit the utilization and

success of health care are commonly described as ‘‘barri-

ers’’. These are broadly categorized as ‘‘person-related’’

(perceived or belief-related) and ‘‘treatment-related’’ (e.g.,

service imposed cost) (Saunders et al. 2006). The

predominance of perceived barriers over treatment-related

barriers is highlighted in both quantitative and qualitative

research (e.g., Sawyer et al. 2000; Wilson and Deane

2001). Several categories of perceived barriers relate spe-

cifically to seeking help from a GP. These include: limited

knowledge about the types of help GPs provide; perceived

difficulties in the doctor-patient relationship; fears about

both the process and content of a GP consultation; and

developmental processes such as individuation (see Wilson

et al. 2008, for a review). In adolescents, perceived barriers

to seeking professional psychological help have explained

the help-negating effect of suicidal ideation on help-seek-

ing intentions for a mental health professional (Wilson

et al. 2005a). A similar pattern of results might also be

found for seeking help from a GP.

Thirdly, according to the belief-desire-intention (BDI)

model of practical reasoning (Bratman 1987), an individ-

ual’s beliefs represent their knowledge and way of repre-

senting the world. Beliefs lead to desires (goals), which

subsequently predict intentions to perform a behavior or

activity. Put another way, based on an individual’s beliefs,

their desires motivate their prospective behavioral inten-

tions. Conversely, having no desire to perform an activity

reduces behavioral intentions (Elliot 1999). This suggests

that adolescents with no current or existing desire to con-

sult a GP for a mental or physical health problem will

report lower intentions to consult a GP than those whose

current desire is high. It also suggests that desire will have

a role in explaining the help-negation effect for a GP for

different types of health problems.

Study Aims

The first aim of the current study was to examine the

help-negation effect on three types of problems that a GP

might help an adolescent manage: thoughts about suicide,

an emotional problem, and a physical health concern.

Consistent with earlier studies, the help-negation effect

in this study is represented by an inverse relationship

between suicidal ideation and help-seeking intentions. We

hypothesized that an inverse relationship would be found

between adolescents’ levels of suicidal ideation and their

intentions to seek help from a GP for all three problem-

types.

The second study aim was to identify and examine the

role of potentially modifiable variables on the help-nega-

tion process for a GP. We hypothesized that higher levels

of general symptoms of psychological distress, perceived

barriers to engaging in treatment with a GP, and current

desire would explain the help-negating effect of suicidal

ideation for suicidal thoughts, emotional problems and

physical health concerns.

J Youth Adolescence (2010) 39:343–356 345

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Method

Participants

Five hundred and ninety participants (approximately 70%

of the available participant pool) were recruited from Years

10 and 11 in three unstreamed public high schools in the

Illawarra region of New South Wales (NSW), Australia.

The schools served students coming from a range of

socioeconomic backgrounds with the majority coming

from what would be characterized as ‘‘middle class’’ and

‘‘blue-collar’’ families. (Additional information on the

family structure or parent employment status of students

attending each school was not available.) Eighty-five per-

cent (n = 501) of the sample described their cultural

affiliation as Australian and 1% as Indigenous (n = 3).

Additional sample characteristics are reported in Table 1.

Results focusing on different measures and hypotheses

from a subset of the current sample have been reported

elsewhere (Wilson et al. 2008).

Procedure

Study approvals were provided by the University of Wol-

longong Human Ethics Committee and the NSW Depart-

ment of Education and Training Strategic Research

Directorate. The current cross-sectional study comprised

two parts. The first part comprised an anonymous survey

that included the eight critical items of the Suicidal Idea-

tion Questionnaire (SIQ; Reynolds 1988). The second part

comprised a non-anonymous survey that involved students

rating the eight critical items for a second time as a suicide

screen. Both parts of the study were described in an

information sheet that was posted to parents. Students were

provided with written and verbal information regarding the

study during school classes. Parental and student consent

was required for both parts of the survey prior to partici-

pation. Participants completed the research survey indi-

vidually under the supervision of the first author. Twelve

students scored higher than four on three of the eight items

and received additional assessment using individual inter-

views with a school counselor or registered psychologist.

All 12 students had been previously identified by school

welfare staff as having mental health needs.

Measures

Intentions

Intentions to seek future help from a GP were measured by

items adapted from the General Help-Seeking Question-

naire (GHSQ; Wilson et al. 2005b). The items have been

used in other studies with adolescents (Deane et al. 2007;

Wilson et al. 2003). There were three items with the same

general structure ‘‘If you have [problem-type], how likely

are you to talk to a GP about it?’’ The three problem-types

were ‘‘a physical health concern’’, ‘‘an emotional problem,

like being depressed or stressed out’’, and ‘‘thoughts about

suicide’’. (In Australia, national television and radio

advertisements define what is meant by ‘‘GP’’ and explain

the types of help a GP can provide.) Each item is rated on a

scale from 1 = ‘‘Extremely unlikely’’ to 7 = ‘‘Extremely

Table 1 Sample characteristics

a 89.3% (n = 528) of the total

sample was aged 15–16 years

Sample characteristics Total sample Level of suicidal ideation

Minimal Moderate Critical

ntotal (% total sample) 590 (100%) 529 (89.7%) 49 (8.3%) 12 (2.0%)

nfemale (% total sample) 335 (56.7%) 292 (49.4%) 35 (5.9%) 8 (1.3%)

nmale (% total sample) 251 (43.3%) 233 (39.5%) 14 (2.4%) 4 (1.0%)

M(SD)age in years 15.56 (.66) 15.59 (.66) 15.27 (.73) 15.55 (.73)

Rangeage in years 13–18a 13–17 14–18 15–16

M(SD)SIQ-CI 3.38 (7.38) 1.34 (2.06) 16.14 (6.60) 41.33 (5.14)

RangeSIQ-CI scores 0–48 0–8 9–32 34–48

Level of general psychological distress

Minimal Moderate Severe

ntotal (% total sample) – 455 (77.1%) 125 (21.2%) 10 (1.7%)

nfemale (% total sample) – 239 (40.5%) 91 (15.4%) 4 (1.0%)

nmale (% total sample) – 213 (36.1%) 34 (5.8%) 5 (1.0%)

M(SD)age in years – 15.59 (.66) 15.45 (.67) 15.78 (.67)

Rangeage in years – 14–18 13–17 15–17

M(SD)HSCL-21 35.39 (10.11) 31.06 (5.41) 48.22 (5.84) 71.60 (7.06)

RangeHSCL-21 scores 21–84 21–40 40–63 64–84

346 J Youth Adolescence (2010) 39:343–356

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likely’’, with 4 = ‘‘Not sure’’. These items have demon-

strated acceptable reliability and validity in research with

adolescents and university students (e.g., Deane et al. 2001;

Wilson et al. 2005a, b). They have also been related to

prospective consultations with a GP (Wilson et al. 2008),

suicidal ideation, depression, and hopelessness (Wilson

et al. 2005b, 2007), and perceived barriers to help-seeking

mental health care and engaging in treatment with a GP

(e.g., Deane et al. 2007; Wilson et al. 2005a).

Desire

Current desire to receive help from a GP was measured by

three items that were developed for the current study and

that ask participants ‘‘Would you like to receive help from

a doctor for…’’ (a) ‘‘a physical problem’’, (b) ‘‘an emo-

tional problem’’, and (c) ‘‘suicidal thoughts’’. Participants

replied to each of the items selecting from 1 = ‘‘No’’,

0 = ‘‘Yes’’. Wording for the stem question is consistent

with recommendations made elsewhere for conceptualizing

and measuring the desire construct (Grantham and Gordon

1986; Tinsley 1992; Tinsley and Westcott 1990).

Perceived Barriers

Perceived barriers to engaging in treatment with a GP were

measured by the 11 items comprising the Barriers to

Engagement in Treatment Screen (BETS; Wilson et al.

2008). All items assess adolescents’ perceived knowledge-

and belief-based barriers to consulting a GP. Example

items include: ‘‘I know what to expect when I go to see a

GP’’, ‘‘I feel comfortable talking to a GP who I don’t

know’’, ‘‘I believe a GP can understand my thoughts and

feelings’’, and ‘‘I’m not embarrassed to talk about my

problems’’ (see Wilson et al. 2008, for a full list of items).

Each item is rated on a 4-point scale from 0 = ‘‘Agree’’ to

3 = ‘‘Disagree’’. The average of all 11 items was used to

obtain a total barrier score. Higher scores represent higher

perceived barriers to engaging in treatment. The BETS has

satisfactory reliability and validity in adolescent samples.

In adolescent samples it has been negatively correlated

with intentions to consult a GP for psychological and

physical problems, as well as subsequent self-reports of

consultations with a GP (Deane et al. 2007; Wilson et al.

2008). In the current study, a Cronbach alpha coefficient

of .81 was obtained and indicates acceptable internal

consistency.

Suicidal Ideation

Suicidal ideation was measured by the 8 critical items of

the Suicidal Ideation Questionnaire (SIQ; Reynolds 1988):

(1) ‘‘I thought about killing myself’’; (2) ‘‘I thought about

how I would kill myself’’; (3) ‘‘I thought about when I

would kill myself’’; (4) ‘‘I thought about what to write in a

suicide note’’; (5) ‘‘I thought about writing a will’’; (6) ‘‘I

thought about telling people I plan to kill myself’’; (7) ‘‘I

thought about how easy it would be to end it all’’; (8)

‘‘I thought if I had the chance I would kill myself’’. These

items examine the intensity and lethality of current suicidal

thoughts (e.g., ‘‘I thought about killing myself’’ and ‘‘I

thought if I had a chance I would kill myself’’), together

with the specificity and availability of a suicide plan (e.g.,

‘‘I thought about how I would kill myself’’ and ‘‘I thought

about when I would kill myself’’), in the last month. The

eight items were selected due to their ability to discrimi-

nate between suicidal and non-suicidal psychiatric adoles-

cents (Pinto et al. 1997). A Cronbach alpha coefficient of

.98 was obtained for the eight items in the current sample

showing good internal consistency. The eight items are

rated on a 7-point scale (0–6). In the current study, scores

of 0 (‘‘I never had this thought before’’) or 1 (‘‘I had this

thought before but not in the last month’’) indicated a

minimal level of current suicidal ideation, scores of 2

(‘‘About once a month’’) to 4 (‘‘About once a week’’)

indicated a moderate level of suicidal ideation, and scores

of 5 (‘‘A couple of times a week’’) or 6 (‘‘Almost every

day’’) indicated thoughts at a critical level of frequency

that should be investigated (Reynolds 1988).

Psychological Distress

Symptoms of general psychological distress were measured

by the 21-item Hopkins Symptom Check-List (HSCL-21;

Green et al. 1988). The measure has satisfactory concurrent

and construct validity in clinical and non-clinical samples

(Deane et al. 1992). It has been related to prior help-seeking

experience, gender, treatment fearfulness, and higher levels

of suicidal ideation in non-patient adolescents (Carlton and

Deane 2000), and higher levels of depression and anxiety

in non-patient university students (Harari et al. 2005).

A Cronbach alpha coefficient of .92 was obtained for the

current sample. The 21 items examine the degree to which

general psychological symptoms (e.g., self-blame, feeling

blue), performance distress (e.g., difficulty speaking,

remembering things), and somatzsation (e.g., back pain, hot/

cold spells) have affected individuals in ‘‘the past 7 days,

including today’’. The items are self-rated on a 4-point scale

(1–4) that can be summed to obtain a psychological distress

score ranging from 21 to 84 where higher scores indicate

greater degrees of psychological distress. In the current

study, scores of 1 (‘‘Not at all’’) were nominated as indi-

cating a minimal level of psychological distress, scores of 2

(‘‘A little’’) and 3 (‘‘Quite a bit’’) as indicating a moderate

level, and scores of 4 (‘‘Extremely’’) as indicating a severe

level of current psychological distress.

J Youth Adolescence (2010) 39:343–356 347

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Results

Preliminary Analyses

Prior to analysis, the raw data were examined through

SPSS programs for the extent to which they met the

assumptions of the analyses conducted. For intentions to

seek help for a physical problem, 100 students (16.9% of

the sample) reported that they were unlikely to seek help

with a score of 1, 2 or 3; whereas, 425 students (71.9% of

the sample) reported they were likely with scores of 5, 6 or

7 (M = 4.99, SD = 1.57). For an emotional problem, 357

students (60.5% of the sample) were unlikely to seek help

and 124 (21.0% of the sample) were likely (M = 3.09,

SD = 1.65). For suicidal thinking, 326 students (55.3% of

the sample) were unlikely to seek help; whereas, 140 stu-

dents (23.7% of the sample) were likely (M = 3.21,

SD = 1.97). As shown by the frequencies reported in

Table 1, SIQ and HSCL-21 scores indicated that these

variables were also skewed in that most cases had low

levels of suicidal ideation (M = 3.38, SD = 7.38) and

psychological distress (M = 35.39, SD = 10.11). Conse-

quently, before use as continuous variables, loglinear

transformation was applied to all GHSQ, SIQ and HSCL-

21 scores to correct for skew. For ease of expression, Log

GHSQ, Log SIQ, and Log HSCL-21 are referred to as

intentions, suicidal ideation and psychological distress

when described in the results.

Being younger was related weakly but significantly to

both higher levels of suicidal ideation (r = -.10; p = .015)

and general psychological distress (r = -.09; p = .025).

Being female was also related weakly but significantly to

higher levels of suicidal ideation (r = -.14; p = .001) and

psychological distress (r = -.16; p = .000), higher per-

ceived barriers to consulting a GP (r = -.14; p = .001), and

higher help-seeking intentions to consult a GP for physical

problems (r = -.08; p = .041). Being male was related

weakly but significantly to higher intentions to consult a GP

for suicidal thoughts (r = .11; p = .009). To guard against

the possibility of age and sex effects, both variables were

controlled in the following analyses.

Help-Negation from a GP for Suicidal, Emotional

and Physical Problems

To examine differences between groups with different

levels of clinically relevant suicidal ideation and psycho-

logical distress, a series of one-way analyses of variance of

the help-seeking intention measures (dependent variables)

was conducted. Due to the very small sample sizes in the

critical suicidal ideation and severe psychological distress

groups (Table 1), these groups were combined with the

moderate groups for each distress-type before conducting

the analyses of variance. Table 2 provides mean intention

ratings by problem-type for the new suicidal ideation and

psychological distress groups in the study (moderate-criti-

cal for suicidal ideation, moderate-severe for psychological

distress). Significant differences were found between

groups with varying levels of suicidal ideation and psy-

chological distress for intentions to seek help for suicidal

thoughts and physical problems. Help-seeking intentions

for suicidal thinking were significantly lower for those with

moderate-critical levels of suicidal ideation compared to

those with minimal scores. For those experiencing mod-

erate-severe levels of psychological distress, help-seeking

intentions for suicidal thoughts and physical problems were

also significantly lower than for those experiencing mini-

mal levels (Table 2).

The trends and levels of significance found in the

analyses of variance were confirmed by the correlations

between the continuous suicidal ideation and help-seeking

intentions scores, as well as between the psychological

distress and intentions scores (see Table 3). With trans-

formations applied, the negative associations between

intentions to seek help for an emotional problem and both

suicidal ideation and psychological distress became sig-

nificant (non-parametric correlations conducted with raw

data prior to transformation had magnitudes and levels of

significance that were consistent with each association

reported in Table 3). As predicted, for all problem-types,

there were small to moderate but negative and significant

correlations between levels of suicidal ideation and inten-

tions, and between levels of psychological distress and

Table 2 Mean intentions to seek help from a GP by problem-type

and current level of suicidal ideation or psychological distress

Problem-type Suicidal ideation

Minimal Moderate-critical Fa pa

M SE M SE

Suicidal thoughts 3.31 .09 2.26 .25 15.53 .000

Emotional 3.09 .07 2.72 .22 2.59 .108

Physical 5.09 .07 4.24 .20 16.15 .000

Psychological distress

Minimal Moderate-severe M SE

M SE

Suicidal thoughts 3.37 .09 2.55 .18 16.53 .000

Emotional 3.10 .08 2.86 .15 1.97 .161

Physical 5.10 .07 4.59 .14 10.27 .001

a Means differ according to level of suicidal ideation or psycholog-

ical distress in the same row at the listed F and p values with gender

and age controlled for. Note. Intentions were rated on a 7-point scale

(1 = ‘‘Extremely unlikely’’, 4 = ‘‘Unsure’’, 7 = ‘‘Extremely likely’’)

and higher scores indicate higher help-seeking intentions

348 J Youth Adolescence (2010) 39:343–356

123

intentions. There were also moderate positive and signifi-

cant correlations between barriers to engaging in treatment

and suicidal ideation, psychological distress, and no current

desire to receive help from a GP. Significant positive

correlations were found between no desire for help and

levels of both suicidal ideation and psychological distress.

For each type of problem, there were moderate negative

correlations between barriers and intentions. A consistent

finding was the significant negative and moderate correla-

tions between no desire for help and intentions to seek

future help from a GP for suicidal, emotional and physical

problems.

We explored the possibility that adolescents contem-

plating suicide might avoid future help from a GP as a

function of psychological distress, no desire to receive

help, or because they perceive barriers to consulting a GP.

Three regression analyses were run, one for seeking help

from a GP for each problem-type: suicidal thoughts,

emotional problems, and physical problems. For each

regression model, suicidal ideation and psychological dis-

tress were entered in Step 1, desire for help in Step 2, and

barriers to engaging in treatment in Step 3. The results of

the regression analyses are presented in Table 4. To control

for Type 1 error, p was set to .01.

When predicting help-seeking intentions for suicidal

thoughts, both suicidal ideation and psychological distress

were unique predictors in Step 1. Entering desire in Step 2

and barriers to treatment in Step 3 failed to eliminate the

significant relationship between suicidal ideation and

intentions found in Step 1. However, desire together with

barriers increased the variance explained in intentions at

Step 3 from approximately 9–27% (Step 3: F(6,561) = 35.52,

p = .000, Adj, R2 = .27). For help-seeking intentions for

emotional problems, at Step 1 there were no significant

predictors. However, entering desire for help at Step 2 and

barriers at Step 3 increased the variance explained for help-

seeking intentions for emotional problems from approxi-

mately 2–18% (Step 3: F(6,564) = 21.55, p = .000, Adj,

R2 = .18). For intentions to seek help for physical prob-

lems, at Step 1, the only unique predictor was suicidal

ideation, and entering desire then barriers into the model at

Steps 2 and 3 could not eliminate the significant relationship

between suicidal ideation and intentions found at Step 1. As

for the other models, barriers together with desire for help

increased the variance explained in intentions at Step 3 from

approximately 6–16% (Step 3: F(6,563) = 18.47, p = .000,

Adj, R2 = .16).

The regression analyses were repeated to examine the

possibility that adolescents with high levels of psycholog-

ical distress might negate future help from a GP because

they have no desire for help, because they perceive barriers

to consulting a GP, or because they are experiencing sui-

cidal ideation. Psychological distress and desire for help

were entered in Step 1, barriers to engagement in treatment

in Step 2, and suicidal ideation in Step 3 (see Table 5).

When predicting help-seeking intentions for suicidal

thoughts, psychological distress and no desire for help were

both unique predictors at Step 1. Entering barriers to the

model at Step 2 resulted in the relationship between psy-

chological distress and intentions for suicidal thinking

becoming non-significant, indicating that barriers explained

the help-negating effect of psychological distress symp-

toms, in regards to suicidal problems. Entering suicidal

ideation at Step 3 improved the variance explained in the

model by about 1% but the significance of relationships in

Step 2 was not altered (Step 3: F(6,561) = 35.52, p = .000,

Adj, R2 = .27). For help-seeking intentions for emotional

problems, desire for help was the only predictor at Step 1

and suggests that not having a desire for the help of a GP

explains the help-negating effect of psychological distress

Table 3 Intercorrelations between measures

Measure 2 3 4 5 6 7 8 9

1 Suicidal ideation (SIQ-CI) .51*** .34*** -.20*** -.12** -.29*** .02 .07 .13**

2 General distress (HSCL-21) .39*** -.17*** -.09* -.24*** .08 .02 .14***

3 Barriers (BETS) -.29*** -.35*** -.45*** .12** .19*** .26***

Intentions (GHSQ)

4 Physical problem .37*** .28*** -.22*** -.10* -.17***

5 Emotional problem .62*** -.09* -.28*** -.29***

6 Suicidal thinking -.02 -.25*** -.33***

No desire for help

7 Physical problem .33*** .41***

8 Emotional problem .65***

9 Suicidal thinking

n = 590. SIQ-CI, Suicidal Ideation Questionnaire-Critical Items; HSCL-21, Hopkins Symptom Checklist-21 item version; GHSQ, General Help-

Seeking Questionnaire; BETS, Barriers to Engaging in Treatment

*** p \ .001; ** p \ .01; * p \ .05

J Youth Adolescence (2010) 39:343–356 349

123

Ta

ble

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iera

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ical

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ress

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ith

suic

idal

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n,

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eral

dis

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eral

dis

tres

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4

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eral

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.03

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rier

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sto

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ing

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p,

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idal

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om

a

gen

eral

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2

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eral

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tres

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0-

.19

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**

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ire

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on

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p\

.01

;*

p(F

Change)\

.01

350 J Youth Adolescence (2010) 39:343–356

123

symptoms for emotional problems. Entering perceived

barriers at Step 2 increased the variance explained by

approximately 8%. Entering suicidal ideation at Step 3

failed to significantly increase the variance explained in the

model and made no difference to the significance of the

other relationships in the model (Step 3: F(6,562) = 21.27,

p = .000, Adj, R2 = .18). Finally, when predicting inten-

tions to seek help for physical problems, at Step 1, psy-

chological distress and no current desire for help were both

unique predictors. However, Step 3 suggests that barriers to

engaging in treatment make a significant contribution to

seeking help from a GP. Entering barriers into the model

resulted in non-significant relationships between psycho-

logical distress and intentions and between no desire and

intentions, increasing the variance explained by approxi-

mately 6%. Entering suicidal ideation at Step 3 increased

the variance explained in intentions by approximately 1%,

but again, the significance of relationships in Step 2

remained the same in Step 3 (Step 3: F(6,563) = 14.61,

p = .000, Adj, R2 = .13).

As a precaution, all analyses were again repeated with

the order of entry for desire for help and barriers reversed

for each model to examine whether this made any differ-

ence to the analyses. In the first set of regressions

(Table 4), with barriers entered in Step 2 and desire for

help in Step 3, for each problem-type no current desire to

receive help from a GP still contributed significant variance

over and above barriers when predicting intentions (Desire:

p = .000 in Step 3 for suicidal and emotional problems,

and p = .002 in Step 3 for physical problems). In the

second set of regressions (Table 5), this pattern was repe-

ated for barriers entered in Step 1 and desire in Step 2

(Desire: p = .000 in Step 2 for suicidal and emotional

problems and p = .017 in Step 2 for physical problems).

For both sets of regressions, the significant inverse asso-

ciations between suicidal ideation and intentions and

between psychological distress and intentions remained

unchanged.

Finally, we conducted the same analyses as above but

with the high scorers in the top 2% (n = 12) (equivalent to

a suicidal attempter, Reynolds 1987) extracted from the

sample. With the reduced sample, the analyses replicated

the results described above, and suggest that consistent

with Deane et al. (2001) and Wilson et al. (2005a), the

current results apply to adolescents at both acute and sub-

clinical levels of suicidal ideation.

Discussion

The current study found that, as levels of suicidal ideation

and psychological distress increase, adolescents’ intentions

to seek help from a GP for suicidal and physical problems

decrease. These results were confirmed by differences

between groups (based on levels of suicidal ideation and

psychological distress) and in correlational analyses.

Adolescents who reported moderate-critical levels of sui-

cidal ideation or moderate-severe levels of psychological

distress also reported help-seeking intentions that were at

the unlikely end of the response spectrum for suicidal

thoughts and emotional problems and intentions that were

unsure for physical problems (Table 2). Similarly, higher

levels of both suicidal ideation and psychological distress

were associated significantly with greater numbers of

adolescents reporting they had no desire to receive help

from a GP for any of the three problem-types (Table 3),

and higher levels of suicidal ideation and psychological

distress together predicting lower intentions for suicidal

and physical problems (Tables 4, 5).

The current study has confirmed the help-negating effect

of suicidal ideation and extended the effect to the symptoms

of general psychological distress. In so doing, it replicates a

trend found in earlier studies of 269 high school students

(mean age = 15.86 years) (Wilson et al. 2005a) and 302

first year university students (mean age = 20.58 years)

(Deane et al. 2001). In the earlier studies, bivariate corre-

lations between suicidal ideation (measured by the full

version of the SIQ) and help-seeking intentions for a GP

were r = -.23 for personal-emotional problems (Wilson

et al. 2005a), and r = -.15 (Wilson et al. 2005a) and r =

-.13 (Deane et al. 2001) for suicidal thoughts. In the cur-

rent study (mean age = 15.56), the correlations were r =

-.12 for emotional problems and r = -.29 for suicidal

thoughts. Thus, the results converge to suggest that adoles-

cents and young adults with the highest, and most likely

clinically relevant, levels of suicidal ideation and psycholog-

ical distress are least likely to intend to seek help from a GP.

The help-negating effect of suicidal ideation and general

psychological distress suggests that there may be common

processes occurring that lead young people to reject help.

Referred to as ‘‘automatic processing’’, adolescents’ first

response to a problem is to do what they have done in the

past and often what is easiest (Black and Frauenknecht

1990). This suggests that since most adolescents have not

consulted a GP for mental health problems in the past, it is

unlikely they would automatically consider consulting a

GP for mental health problems in the future. However,

since most adolescents have previously received help from

a GP for physical health problems, automatic processing

does not explain why suicidal or psychologically distressed

adolescents would be reluctant to seek help from a GP for

physical problems.

The constricted cognitive-affective state associated pri-

marily with suicidal ideation, but also other forms of

psychological distress (e.g., depressive symptoms), may

play a role. Applying new problem solution strategies

J Youth Adolescence (2010) 39:343–356 351

123

requires both the ability to recognize that automatic strat-

egies are not sufficient to solve the problem and the ability

to consider a broader range of problem solutions than have

been used in the past. Cognitive constriction might inter-

fere with these abilities. General problem identification is

defined as the adolescent’s primary means of recognizing

that a problem exists and usually includes attitudinal,

affective, behavioral and/or physiological cues (Fra-

uenknecht and Black 2003). While it might seem reason-

able to expect that higher levels of suicidal ideation and

other forms of psychological distress would assist adoles-

cents to recognize their distress symptoms and need for

help, the current results do not support this hypothesis.

Either high distress does not increase problem identifica-

tion or there may be other processes that interfere with

help-seeking intentions. Cognitive constriction might lead

to normal problem cues becoming distorted or overlooked.

Similarly, when the help of a GP is not an automatic prob-

lem solution, cognitive constriction might interfere with

the adolescent’s capacity to consider a GP’s help for

managing mental and physical health problems. It is pos-

sible that help-negation is a function of distressed adoles-

cents’ difficulty recognizing and responding to problem

cues, or their difficulty recognizing that consulting a GP

provides a new and valuable solution option. Further

research needs to examine each of these possibilities, as

these factors may be useful in interventions to inhibit the

help-negation process and facilitate more effective health

care seeking from primary health care clinicians.

Based on previous findings (e.g., Marttunen et al. 1991;

Wilson et al. 2005a), we investigated whether general

psychological distress, current desire for help from a GP

and perceived barriers to engaging in treatment with a GP

might contribute to the help-negating effect of suicidal

ideation (Table 4). The results suggest that none of these

variables had a role in decreasing help-seeking intentions

for suicidal thoughts and physical problems over and above

suicidal ideation itself. Although psychological distress

was also inversely related to help-seeking intentions, when

psychological distress was controlled it could not fully

account for the help-negation effect for suicidal thoughts or

physical problems. Neither could a lack of current desire

for help or perceived barriers to consulting a GP. These

results provide further evidence that suicidal ideation itself

acts as a substantial barrier to help-seeking for suicidal and

physical problems (Deane et al. 2001; Saunders et al.

1994).

In contrast, for emotional problems such as ‘‘feeling

depressed or stressed out’’, the help-negating effect of

suicidal ideation was explained by symptoms of general

psychological distress. This suggests that when adolescents

identify their problem as ‘‘emotional’’, general psycho-

logical distress symptoms may have a greater role in

explaining their reluctance to seek help from a GP than

when they identify their problem as ‘‘suicidal’’ or ‘‘physi-

cal’’. It is possible that it is the type of problem that an

adolescent identifies as theirs, and perhaps the meaning

they associate with their problem-type, that promotes their

help-seeking reluctance. Stigma associated with different

types of mental health problems has been widely associated

with professional psychological help-seeking as a barrier to

health service use (e.g., Barney et al. 2006; Samargia et al.

2006; Vogel et al. 2007a). The extent to which stigma has a

role in explaining the help-negation effect for GPs, for at

least some types of mental and physical health problems, is

unknown and requires further research.

Other variables that are worthy of investigation include

those linked to troubled or challenging family and peer

contexts, which are also linked to helplessness in

achievement situations and psychological distress in young

people (Haddad 2000; Ryan et al. 2000). For example,

healthy achievement motivation and independent help-

seeking are promoted through positive and supportive

interactions within the family (e.g., Hokoda and Fincham

1995), whereas troubled or unsupportive family relation-

ships can inhibit the development of autonomy and might

promote help-seeking avoidance through processes of

learned helplessness (Haddad 2000). Variables associated

specifically with the primary health care setting are also

important to consider. Many studies report that GPs under-

diagnose and under-treat psychological disorders in

patients (MaGPIe Research Group 2006). Emerging evi-

dence also suggests that while GPs’ identification of

symptoms of psychological distress may not be inade-

quate, at least some capable GPs choose not to diagnose

and treat mental ill-health (MaGPIe Research Group

2004); this can be because of time and other resource

constraints experienced in primary care (Kang et al. 2003;

Launer 2004; Vandana and Ambelas 2004). More research

is needed on this issue. Similarly, research is also needed

to examine the impact of failed past attempts to access

treatment from health care professionals and the role of

learned helplessness on the help-negation relationship. In

the meantime, help-seeking promotion programs should

include strategies to improve GPs’ capacity to work

effectively with young people and reduce stigma associ-

ated with mental health problems (Wilson et al. 2005b;

Rickwood et al. 2006).

We assessed whether a desire to seek help from a GP

would contribute to the help-negation effect. Adding desire

to consult a GP significantly improved the variance

explained in intentions to seek help for suicidal thoughts,

emotional problems and physical problems over and above

the contribution of suicidal ideation and general psycho-

logical distress (Table 4). Consistent with the BDI model

of practical reasoning (Bratman 1987), this result supports

352 J Youth Adolescence (2010) 39:343–356

123

the hypothesis that having adolescents focus on their desire

to consult a GP is a change agent that contributes to their

prospective help-seeking intentions. Future research is

needed to clarify the relationship between beliefs, desire

and help-seeking intentions in relation to suicidal ideation

and general psychological distress.

Finally, we examined whether perceived barriers to

engaging in treatment and desire to receive help from a GP

would together explain the negative relationship between

psychological distress symptoms and help-seeking inten-

tions for emotional problems. The results suggest that

having no desire for help independently predicts lower

intentions to seek help for emotional problems, and

explains the help-negating effect of psychological distress

symptoms for emotional problems. In comparison, per-

ceived barriers independently explained the help-negating

effect of distress symptoms for physical problems, whereas

the effect for suicidal problems was explained by no desire

in conjunction with perceived barriers (Table 5). The

results suggest that while suicidal ideation independently

acts as a help-seeking barrier for suicidal and physical

health problems, perceived barriers together with desire

have a strong combined influence on adolescents’ reluc-

tance to consult a GP for suicidal problems. The results

also suggest that perceived barriers have a strong inde-

pendent influence on adolescents’ reluctance to consult a

GP for physical problems. Barrier items included beliefs

that talking to an unfamiliar GP would be uncomfortable, a

GP would not understand adolescent’ thoughts and feel-

ings, and talking to a GP would be embarrassing. Future

research needs to identify variables that influence specific

beliefs adolescents have about seeking help from a GP for

different problem-types, as well as the specific role these

beliefs have in the help-negation process for different

health care practitioners.

As an adjunct to the main results, the current study

revealed that, in this Australian high school sample, 10.3%

of the students who took part reported that they were

experiencing moderate to critical levels of suicidal ideation

and almost 23% of the sample reported that they were

experiencing moderate to severe symptoms of psycholog-

ical distress. The presence of these vulnerable adolescents

highlights the need for school personnel to be sensitive to

the signs of young people who are struggling. In schools, it

is important that all personnel are aware that, statistically, 1

in 10 of the students they interact with could be experi-

encing moderate-critical levels of suicidal ideation and

approximately 1 in 5 of their students might be experi-

encing moderate-severe levels of psychological distress.

Teachers and other school personnel need ongoing pro-

fessional development in symptom recognition, referral

and strategies for supporting distressed students in the

educational environment.

Finally, with implications for policy and directions in

prevention and early intervention, it is notable that most of

the acutely distressed adolescents in the current study were

aged 15–17 years. Within Australia, the legal age for

obtaining a Medicare Card that is independent of parents is

15 years. However, cost may still be a barrier to adoles-

cents consulting a GP because few have their own Medi-

care card and many believe that they cannot access a GP

without payment or without their parents finding out

(Chown et al. 2008). This means that, although capacity for

self-referral develops over adolescence alongside inde-

pendence from parents and the need for autonomy (Vogel

et al. 2007b; Wilson and Deane 2001), at least some ado-

lescents who are most in need of professional health care

might be additionally hindered from consulting a GP

because of perceived financial dependence on their parents.

Again, further research is needed on this issue. In the

meantime, the current results highlight the need for the

Government to revisit the legal age for obtaining a Medi-

care card or to consider an alternative method of financial

support that is independent of parents, with the aim of

facilitating greater access for younger adolescents to pri-

mary health care.

Limitations

There are several limitations to the current study that

should be noted. Firstly, given that we used a convenience

sample that was drawn from three high schools in the same

geographical area, the extent to which these results gen-

eralize to samples from rural or remote locations or to

adolescents who are not at school is unknown. Secondly, in

our sample, students with minimal levels of suicidal idea-

tion and other psychological distress symptoms were over-

represented because this was a non-clinical sample. Thus,

the results may not generalize to groups of young people

with moderate-critical/-severe symptom levels who are

identified in other ways (e.g., at risk groups such as

unemployed young people or youth who drop out of high

school). Further research is needed to replicate the results

of the current study in larger samples of moderately to

critically/severely psychologically distressed adolescents.

Recruiting larger representative samples might be achieved

by using a combination of cross-sectional and targeted

sampling. Thirdly, the results were based solely on self-

report measures and biases in reporting may be present

(e.g., minimizing problems and levels of suicidal ideation;

Madge and Harvey 1999). Further research might include

more in-depth suicide screening and measurement of lon-

gitudinal help-seeking behavior. Finally, intentions were

measured by single items for each problem-type. To

improve reliability, future research might include multiple

items for each problem-type.

J Youth Adolescence (2010) 39:343–356 353

123

Conclusions

The current study found that help-negation occurs for sub-

clinical levels of suicidal ideation and general psycholog-

ical distress in adolescents. Higher levels of both suicidal

ideation and general psychological distress were associated

significantly with lower intentions to seek help from a GP

for suicidal and physical problems. Findings of help-

negation in sub-clinical samples suggest that young people

who are most in need of receiving help early are also those

who are most likely to avoid seeking help. The opportunity

remains for suicide prevention research to identify factors

that can explain and potentially reverse adolescents’ help-

negation for suicidal thinking for all help sources. In the

meantime, school personnel and other gatekeepers need to

be aware of the help-negation trend in order to be more

assertive in encouraging and supporting appropriate help-

seeking for mental health problems. School health pro-

motion programs should consider including information to

explicitly address the help-negation process.

Acknowledgments The authors wish to thank the following people

for their contribution to project coordination and data collection.

From the Illawarra Division of General Practice: Beth Bignell and

Janette Ellis. From the New South Wales Department of Education

and Training: Helen Clancy, Dianne Young, Kathy Russell, Fiona

Kyle, and Greg Hand together with the School Counsellors and

welfare staff who provided follow-up student support. From the

University of Wollongong: the intern clinical psychologists and

clinical supervisors who also provided follow-up student support. Our

thanks also go to Professor John Bushnell who reviewed an earlier

draft of this manuscript, and the Australian Commonwealth Depart-

ment of Health and Ageing and University of Wollongong who

provided infrastructure funding for this research.

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Author Biographies

Coralie J. Wilson is a Behavioral Health Scientist and Academic

Leader for the Professional and Personal Development Curriculum

Theme and Behavioral Health Science Curriculum in the Graduate

School of Medicine at the University of Wollongong. She received

her PhD in clinical psychology research from the University of

Wollongong and has major research interests in help-seeking and

psychological medicine.

Frank P. Deane is a Clinical Psychologist, Professor of Psychology

and Director of the Illawarra Institute for Mental Health at the Uni-

versity of Wollongong. He received his PhD from Massey University

and has major research interests in the areas of mental health and drug

and alcohol service use, medication alliance, the use of homework in

clinical practice and help-seeking.

Kellie L. Marshall is a Clinical Psychologist and Deputy CEO of the

Illawarra Division of General Practice. She received her DPsyc in

Clinical Psychology from the University of Wollongong and has

research interests in mental health care in general practice.

Andrew Dalley is a General Practitioner and CEO of the Illawarra

Division of General Practice. He received his DPH from the Uni-

versity of Wollongong and has research interests in service delivery in

general practice.

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