Professional and informal mental health support reported by Canadians aged 15 to 24

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by Leanne C. Findlay and Adam Sunderland

The mental health of youth and young adults, including the provision of services targeted to their needs, has been identified as a global public health challenge.^{Note 1,Note 2} In Canada, the prevalence of mood and substance disorders is higher among younger than older people.^{Note 3,Note 4} Mental health disorders often surface during youth and young adulthood, and can have negative lifelong consequences.^Note 5 However, youth/young adulthood is a transitional phase when opportunities for intervention exist.^Note 6

People with mental health issues may seek support from professional sources such as the general medical sector,^Note 7-9 school services,^{Note 10,Note 11} and specialists (psychiatrists, psychologists),^Note 12 and from informal sources such as family, friends, colleagues, self-help groups, and the internet.^Note 13 Evidence suggests that youth are less likely to use professional services,^Note 14  and more likely to discontinue^Note 15 and harbor negative attitudes^Note 16 toward these services than are older individuals. A need for research on youth mental health service use has been recognized,^Note 17 especially for information about its correlates.

According to Andersen’s^Note 18 Behavioral Model of Health Service Use, three sets of determinants affect an individual’s use of health care services:  predisposing characteristics, enabling resources, and needs-related factors. Predisposing characteristics are related to the tendency to use health care services; for example, age, gender, and immigrant status. Enabling resources pertain to the availability of facilities and personnel, and the ability to access them, such as income and urban location. Needs-related factors are directly related to health, such as illness and disability.

Previous research has noted associations between a number of demographic and socio-economic factors and the use of professional mental health care services by young Canadians. Unlike American findings,^Note 19 a Canadian study reported no differences in the use of mental health services between 15- to 18-year-olds and 19- to 24-year-olds.^Note 20 However, young women were more likely than young men to use these services.^{Note 11,Note 20} According to a Nova Scotia study, youth in low-income households were more likely than those in higher-income households to use professional mental health services.^Note 11 The literature has reported relatively less use of mental health services by immigrants in general,^Note 17 but differences for immigrant youth have not been found.^Note 20 As well, rural versus urban location was not a significant predictor of mental health service use by young Canadians.^Note 20 Enrolment in secondary or postsecondary education may be related to mental health service accessibility^Note 21 or use,^Note 22 but little research has examined school attendance as an independent correlate.

Studies of associations between needs-related factors and the use of mental health services reported that only about half of adolescents^Note 12 and young adults^Note 23 with a mental health condition used such services. American adolescents with a mood or behaviour disorder were more likely to use mental health services than were those with anxiety or substance use disorders,^Note 12 which suggests that type of mental health condition may influence service use. As well, individuals with chronic physical conditions were more likely to use mental health services.^Note 24 Distress has also been associated with greater service use.^{Note 25,Note 26} Finally, increased service use has been reported for victims of violence,^Note 13 but most research investigating those with traumatic childhood experiences has examined institutionalized populations^Note 27 or people currently receiving services.^Note 28

The accumulation of risk factors may affect the use of mental health services. For example, mental health problems are relatively common among individuals with chronic physical conditions^Note 29 or who report childhood trauma^Note 30 or abuse.^Note 31-33 Previous work has suggested increased mental health service use among adults with a physical condition in addition to a mental condition,^Note 24 but no population-based studies have investigated the interaction between a mental condition and general childhood trauma.

Based on the results of the 2012 Canadian Community Health Survey―Mental Health (CCHS–MH), the present  study describes the use of professional mental health services for problems with emotions, mental health, or substance use by Canadians aged 15 to 24. Sources of informal support for such problems are also examined. The analysis explores associations between risk factors and help-seeking, including the cumulative effect of risk factors, such as chronic physical conditions, distress, traumatic childhood experiences, and mental or substance disorders.

Methods

Sample

This study pertains to a subsample of respondents to the 2012 CCHS–MH, a cross-sectional survey that provides national estimates of major mental disorders and the use of mental health services.^Note 34 The total sample was selected using a multi-stage stratified cluster strategy in which the provinces were the strata. The survey targeted the household population aged 15 or older in the 10 provinces. Residents of Indian reserves and other Aboriginal settlements, full-time members of the Canadian Forces, and the institutionalized population were excluded. Computer-assisted telephone and in-person interviews were conducted. The present analysis is based on data collected from 4,013 respondents aged 15 to 24, representing 4.4 million young Canadians (Appendix Table A).

Measures

All respondents were asked if, during the past 12 months, they had seen or talked on the telephone about problems with their emotions, mental health, or use of alcohol or drugs with various professional and informal sources of support. Professional sources were:  psychiatrists, family doctors and general practitioners, psychologists, nurses, and social workers/counselors/psychotherapists. Informal sources were: family members, friends, co-workers/supervisors/bosses, teachers/school principals, employee assistance programs, internet resources (online diagnoses, finding help, discussing with others/online therapy/other), self-help groups, telephone help-lines, and other. For ease of reference, in this analysis, “mental health problems” encompasses “problems with emotions, mental health, or use of alcohol or drugs.” Two dichotomous variables were derived to identify if a respondent had contacted: 1) at least one professional health care provider, and 2) at least one informal source of support. Additional information was obtained from those who consulted professional providers, including the number and duration of consultations in the past year.

Correlates

Predisposing characteristics for seeking mental health support were: sex, age group (15 to 17 versus 18 to 24), and immigrant status. Respondents born outside Canada without Canadian citizenship were identified as immigrants.

Enabling resources were: enrolment in secondary or postsecondary education, household income, and population centre/rural residence. The ratio ofhousehold income to the low-incomecut-off^Note 35 was divided into quintiles.Residents of communities of1,000 or more with a density ofat least 400 persons per square kilometrewere classified as living in a populationcentre (versus a rural area).

Needs-related factors were: mental and substance disorders, diagnosed chronic physical conditions, psychological distress, and traumatic childhood experience. The CCHS–MH administered five modules of the World Mental Health—Composite International Diagnostic Interview 3.0 (WMH-CIDI), based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition^Note 36 to detect six mental disorders: depression; bipolar disorder; generalized anxiety disorder; and alcohol, cannabis, and substance abuse or dependence. Diagnostic algorithms identified respondents meeting the criteria for each disorder. Consistent with the reference period for contacting professional and informal sources of support, this analysis considers only disorders experienced in the previous 12 months. Dichotomous variables were created to identify respondents with a mental disorder (depression, bipolar disorder, or generalized anxiety disorder) or a substance disorder (alcohol, cannabis, and/or substance abuse or dependence).

Respondents were categorized as having been diagnosed by a health professional with 0, 1, 2, or at least 3 chronic physical conditions: asthma, arthritis, back problems, high blood pressure/hypertension, migraine headaches, COPD, diabetes, epilepsy, heart disease, cancer, side effects of stroke, bowel disorder, Alzheimer’s Disease/dementia, Chronic Fatigue Syndrome, multiple chemical sensitivities, learning disability, Attention Deficit Disorder, and any other chronic condition.

Distress was measured using the K6 scale.^Note 37 Although values of 13 or more have been shown to predict severe mental illness,^Note 37 a dichotomous variable was determined by a tertile split, with K6 values of 4 or greater representing higher distress.

Based on the Childhood Experiences of Violence Questionnaire,^Note 38 respondents aged 18 or older reported the number of times they had experienced a traumatic childhood event before age 16 (witnessed physical abuse, experienced physical abuse, experienced sexual abuse).^Note 31 Although  a more conservative definition of child abuse has been conceptualized based on this measure, for the current study, the measure was dichotomized as having or not having had a traumatic childhood experience.

Analysis

The prevalence of contact with each type of professional and informal source of support was calculated. Contact with at least one professional or one informal source was examined based on predisposing (age group, sex, immigration status), enabling (student enrolment, household income, population centre/rural location), and needs-related (childhood trauma, chronic physical condition(s), distress, mental disorder, substance disorder) factors. Contact with professional and informal sources in relation to the co-occurrence of a mental or substance disorder and at least one chronic physical condition, elevated distress, or traumatic childhood experience was also explored.

Logistic regression analyses examined associations between the needs-related factors and reporting professional or informal mental health support. Multivariate models controlled for sex, age group, immigration status, student enrolment, household income, and population centre/rural location.

Separate models were used to examine associations with traumatic childhood experiences among respondents aged 18 to 24 (the question was not asked of respondents younger than 18). Interaction terms based on the cumulative effect of a mental or substance disorder and at least one chronic physical condition, elevated distress, or a traumatic childhood experience were added in separate models. Contrast comparisons between levels of each risk factor (the presence of a mental disorder or a substance disorder) were conducted between those with and without a traumatic childhood experience to determine significant interaction effects.

SAS 9.2 was used for all analyses. Survey sampling weights were applied so that the results would be representative of the Canadian population aged 15 to 24. Bootstrap weights were applied using SUDAAN 11.0 to account for the underestimation of standard errors due to the complex survey design.^Note 39

Results

In 2012, 12% of Canadians aged 15 to 24 reported that, in the past 12 months, they had seen or talked on the telephone to a health professional about problems with their emotions, mental health, or use of alcohol or drugs (Table 1). More than twice as many—27%—had consulted informal sources about such problems.  Just over 9% of young Canadians reported seeking both professional and informal support; 3% used professional services only; and 17%, informal support only (data not shown). The majority of 15- to 24-year-olds—71%—reported that they had not sought professional or informal support for mental health problems in the past year.

Professional services

An estimated 6% of young Canadians reported that they had consulted a family doctor/general practitioner; 5% had consulted a social worker/counselor/psychotherapist; 3% reported a psychologist; and 3%, a psychiatrist (Table 1). Two-thirds of those who used a professional service reported just one; 20% reported using two services; and 15%, three or more (data not shown).

Those who consulted a family doctor/general practitioner did so an average of 6 times in the previous 12 months, with an average duration of 23 minutes per consultation (Table 1). Social workers/Counselors/Psychotherapists were consulted an average of 15 times, with sessions averaging 49 minutes. Those who contacted a psychologist or a psychiatrist reported averages of 14 and 11 consultations, respectively, with sessions lasting close to an hour (56 and 51 minutes).

Informal support

One in five (20%) young Canadians had talked to a friend about emotional, mental or substance use problems, and 14% approached a family member (Table 1). As well, some turned to the internet—8% used it for an online diagnosis, 2% to find help, and 2% for discussion forums and social networks.

Factors related to seeking support

The factors related to consulting professional and informal sources about mental, emotional and substance use problems were generally similar (Table 2). For example, females were more likely than males to report contacting professional and informal sources. Immigrants were less likely than people born in Canada to report using professional services, but no differences were apparent for contact with informal sources.

Contrary to earlier research,^Note 17 in this analysis, household income was not significantly related to young Canadians’ use of professional or informal support. As well, student status was not associated with the likelihood of seeking either type of support. And whether they lived in a population centre or a rural area, young Canadians were no more or less likely to seek professional support, although those in rural areas were less likely to contact informal sources.

Among 18- to 24-year-olds who reported a traumatic childhood experience, 19% had talked with a professional, and 40% with an informal source, about mental health problems; this compared with 9% and 21%, respectively, of those who had not had a traumatic childhood experience.

The presence of chronic physical conditions was associated with reporting professional and informal support. For example, 29% of youth and young adults with two chronic conditions had contacted a professional mental health service in the past year, compared with 8% of those who did not have a chronic condition.

Finally, people with higher levels of distress or a mental or substance disorder were more likely to report both types of contact than were people with low distress or who did not have a mental or substance disorder.

The highest prevalence of reporting professional and informal contact was among youth and young adults with multiple needs-related factors (mental or substance disorder, chronic physical condition, distress, traumatic childhood experience)—a cumulative effect (Table 3). For example, 60% of young Canadians with a mental disorder and at least one chronic health condition reported seeking professional support, and 71% sought informal support. This compared with 6% and 19% (professional and informal, respectively) of those who did not have a mental or physical condition, and 35% and 61% of those who had a mental disorder only.

Associations persist

Of course, factors associated with seeking support for mental health problems do not exist in isolation; they may, in fact, be related to each other. Yet even when the confounding influence of other factors was taken into account, several relationships persisted.

Females had higher odds than males, and immigrants had lower odds than non-immigrants, of reporting that they had used professional services (Table 4). Similarly, young Canadians with higher levels of distress, at least one chronic physical condition, or a mental or a substance disorder had higher odds of using professional services than did those with low distress or who did not have a physical health condition, mental disorder, or substance disorder.

As well, females, people with higher distress, with one or more physical condition(s), or a mental or substance disorder had elevated odds of reporting that they had sought help from informal sources.

Results from a set of models pertaining to 18- to 24-year-olds demonstrated that those  who reported a traumatic childhood experience had significantly higher odds of seeking professional (AOR = 1.67, 95% CI: 1.14-2.43) and informal (AOR = 1.81, 95% CI: 1.36-2.41) support, compared with those who had not had such an experience (data not shown).

Models that included interaction terms did not find significant interaction effects between a mental or substance disorder and a chronic physical health condition or distress. However, significant effects emerged between the presence of a mental or substance disorder and a traumatic childhood experience.  Among 18- to 24-year-olds  who had not had a traumatic child experience, those with a mental disorder were significantly more likely to report professional service use (AOR = 7.89, 95% CI: 3.60-17.31). Those who had a traumatic child experience were also significantly more likely to report contact with professional services (AOR = 3.02, 95% CI: 1.65-5.55). However, the interaction between a traumatic child experience and a substance disorder revealed a different pattern. Those who had a traumatic childhood experience were more likely to report professional service use if they also had a substance disorder (AOR = 2.54, 95% CI: 1.43-4.53). By contrast, among 18- to 24-year-olds who did not have a traumatic childhood event, no differences in professional service use were found for those with and without a substance disorder. No significant interactions emerged for informal help-seeking.

Discussion

In 2012, 12% of Canadians aged 15 to 24 reported using professional mental health services in the previous year, and 27% sought help from informal sources. Most who used professional services also reported contact with informal sources.

A GP or family doctor was the most commonly consulted professional, although  a third of those who used professional services reported more than one service. These findings draw attention to the importance of mental health knowledge for GPs and the need for the coordination of care among professional sources.

While family members and friends were the informal sources most frequently cited, many young Canadians reported using the internet. Mental health is an important component of internet health information for youth,^Note 40 but the quality of that information is unregulated.  Consequently, e-health literacy―the ability to use, evaluate and apply internet health information^Note 41―is important for young Canadians. Future research might examine specific internet sources that youth and young adults consult for mental health information.

About half of young Canadians with a mental disorder, and a quarter of those with a substance disorder, reported using professional services. These results are consistent with earlier findings^Note 12 that many young people with a mental health issue do not receive professional mental health care. Identifying characteristics associated with service non-use might be helpful in facilitating access to professional support.

This study provides evidence of the cumulative effect of risk factors on professional service use.  Having more than one needs-related factor (for example, a mental health condition and a chronic physical condition) increased the likelihood of reporting professional service use. Young people may be more likely to talk about mental health problems in the context of a physical health consultation,^Note 42 may feel greater rapport with a doctor that they see regularly,^Note 43 or may not recognize symptoms of poor mental health (for instance, anxiety and depression).^Note 44

For professional support, significant interaction effects emerged between a traumatic childhood experience and a mental or substance disorder. Individuals with a substance disorder were more likely to report using professional mental health services only if they also reported a traumatic childhood event. However, regardless of whether they had a traumatic childhood experience, young people with a mental disorder were more likely to report professional service use than those who did not have a mental disorder. The fact that those with substance disorders were generally less likely to report using mental health services, and that significant interaction effects emerged between a traumatic childhood experience and a mental or substance disorder, suggests that further investigation, in particular, longitudinal analysis, is warranted.

Limitations

The results of this study should be interpreted in light of several limitations. Only certain mental disorders were included in the 2012 CCHS–MH, and the survey did not collect data for the institutionalized population. Mental disorders were identified based on an algorithm, but help-seeking was self-reported. Self-reports of professional service use may differ from administrative records, possibly because of recall or social desirability biases.^Note 45 Also, the self-reported nature of other information warrants caution. Although evidence suggests that retrospective accounts of adverse childhood events can be reliable,^Note 46 this analysis pertained to “at least one” childhood trauma; previous research has found that mental health outcomes worsen as the number of adverse events increases.^Note 30

Because the 2012 CCHS-MH is cross-sectional, causal and temporal relationships between variables cannot be determined. For example, stresses associated with a physical condition may precede a mental health condition, or vice versa. Nor is it possible to identify reasons for seeking support. As well, information about the nature of services is not available.

Finally, seeking professional or informal support for mental health problems is not an indicator of the prevalence of need.^Note 47 Individuals with a need for mental health care may not seek or have access to support,^Note 48 or may report unmet or partially met needs.^Note 49 The current study examines population-based mental health care service use, not perceptions of need for such services, among youth and young adults whose patterns of help-seeking may differ from those of older people.^Note 14-16

Conclusion

A first step in establishing policy priorities in the provision of mental health care to youth and young adults is to determine current service use and correlates of usage. Results from the 2012 Canadian Community Health Survey–Mental Health suggest that many young Canadians seek professional and informal support for problems with their emotions, mental health, and alcohol and drug use. The presence of multiple risk factors generally increased the propensity to seek support, particularly among individuals who reported both a traumatic childhood experience and a substance disorder. Future research could explore these relationships further, especially among those with identified risk factors.