literature review help seeking behaviour

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Research Article

Factors associated with help-seeking behaviour among individuals with major depression: A systematic review

* E-mail: [email protected]

Affiliation Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany

Affiliations Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany, Department of Health Services Research, Carl von Ossietzky University, Oldenburg, Germany

• Julia Luise Magaard, 
• Tharanya Seeralan, 
• Holger Schulz, 
• Anna Levke Brütt

• Published: May 11, 2017
• https://doi.org/10.1371/journal.pone.0176730
• Reader Comments

Psychological models can help to understand why many people suffering from major depression do not seek help. Using the ‘Behavioral Model of Health Services Use’, this study systematically reviewed the literature on the characteristics associated with help-seeking behaviour in adults with major depression. Articles were identified by systematically searching the MEDLINE, EMBASE and PsycInfo databases and relevant reference lists. Observational studies investigating the associations between individual or contextual characteristics and professional help-seeking behaviour for emotional problems in adults formally diagnosed with major depression were included. The quality of the included studies was assessed, and factors associated with help-seeking behaviour were qualitatively synthesized. In total, 40 studies based on 26 datasets were included. Several studies investigated predisposing (age (N = 17), gender (N = 16), ethnicity (N = 9), education (N = 11), marital status (N = 12)), enabling (income (N = 12)), need (severity (N = 14), duration (N = 9), number of depressive episodes (N = 6), psychiatric comorbidity (N = 10)) and contextual factors (area (N = 8)). Socio-demographic and need factors appeared to influence help-seeking behaviour. Although existing studies provide insight into the characteristics associated with help seeking for major depression, cohort studies and research on beliefs about, barriers to and perceived need for treatment are lacking. Based on this review, interventions to increase help-seeking behaviour can be designed.

Citation: Magaard JL, Seeralan T, Schulz H, Brütt AL (2017) Factors associated with help-seeking behaviour among individuals with major depression: A systematic review. PLoS ONE 12(5): e0176730. https://doi.org/10.1371/journal.pone.0176730

Editor: Ali Montazeri, Iranian Institute for Health Sciences Research, ISLAMIC REPUBLIC OF IRAN

Received: November 23, 2016; Accepted: April 14, 2017; Published: May 11, 2017

Copyright: © 2017 Magaard et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This study was not funded and part of the dissertation of Julia Luise Magaard (JLM). However, JLM, Anna Levke Brütt (ALB) and Tharanya Seeralan (TS) received grants from the German Research Foundation for a pilot study about help-seeking behavior of patients with depression (DFG BR4859/3-1). The German Research Foundation had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper.

Competing interests: The authors declare that they have no competing interests.

Introduction

Major depression is a common mental disorder and one of the leading causes of health impairment worldwide [ 1 ], resulting in serious impairment of functioning and decreased quality of life [ 2 , 3 ]. To treat major depression depending on severity, American and European guidelines (e.g. [ 4 , 5 ]) recommend treatment options as psychotherapy, pharmacotherapy, or a combination of both. Despite the availability of effective treatment options, researchers continue to find that a significant number of individuals suffering from major depression do not seek professional help. Using studies on service utilization rates for major depression in community-based surveys, Kohn, Saxena [ 6 ] reported that the percentage difference between number of people needing treatment for major depression and number of people seeking professional help ranged between 15.9% (12 month, Florence) [ 7 , 8 ] and 83.9% (current, UK) [ 9 ]. They estimated that the median untreated rate for depression is 56.3% worldwide [ 6 ].

Various psychological models have been used to explain variations in help-seeking behaviour among populations, such as the Self-Regulation Model [ 10 ], the Health Belief Model [ 11 ] and the Theory of Planned Behavior [ 12 ]. From the sociological perspective models like the Pescosolido’s Network Episode Model [ 13 ], Kadushin’s theory about why people go to psychiatrists [ 14 ] and the Behavioral Model of Health Services Use [ 15 ] were specifically constructed to explain help-seeking behaviour. The ‘Behavioral Model of Health Services Use’ suggests that people’s predisposition to use services, factors which enable or impede the use of services and people’s need of care predict and explain health behaviours like use of health services [ 15 ]. According to the model, all health behaviours influence health related outcomes. The model includes feedback loops to demonstrate that outcomes can affect health behaviours, predisposing, enabling and need factors and health behaviours can influence predisposing, enabling and need factors. In the current version of his ‘Behavioral Model of Health Services Use’, Andersen [ 15 ] distinguishes between contextual and individual characteristics influencing service utilization and health-related outcomes ( Fig 1 ). The model asserts that contextual and individual characteristics consist of predisposing, enabling and need factors [ 15 ]. Individual characteristics are measured at the individual level, whereas contextual characteristics are measured at an aggregate level (e.g., families, communities, national health care system). Contextual characteristics include health organizations and provider-related factors as well as community characteristics [ 15 ]. At the individual level, a person’s beliefs (e.g., attitudes towards health services), demographic characteristics (e.g., age) and social factors (e.g., education) define his or her predisposition to use health services. Additionally, the availability of financial resources to pay for services as well as organizational factors (e.g., regular source of care, means of transportation to care) enable or impede the use of health services at the individual level. In the “Behavioral Model of Health Service Use” it is not clearly defined if social relationships and social support are considered as predisposing or enabling factors. We agree with Andersen’s argumentation that social support can facilitate or impede help-seeking behaviour and therefore serves as an enabling resource [ 15 ] whereas the social structure including family situation predisposes help-seeking. Furthermore, perceived and evaluated need influences help-seeking behaviour. Professional judgement about people’s health and need for treatment is represented by evaluated need whereas perceived need includes people’s perspective on their own health [ 15 ]. The model has frequently used in studies and systematic reviews (e.g. [ 16 , 17 , 18 ]). According to validity, associations between different individual characteristics and services use were found empirically. However, causal conclusions cannot be drawn from analyses on the basis of mainly cross-sectional data (e.g. [ 16 ]). Individual characteristics of the current model can be expanded to include predictors of help-seeking behaviour like treatment and illness beliefs [ 10 ], perceived susceptibility and severity of symptoms as well as perceived expectations regarding treatment and self-efficacy [ 11 , 12 ] and motivational factors [ 12 ].

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https://doi.org/10.1371/journal.pone.0176730.g001

The current review focusses on contextual and individual characteristics as well as use of personal health services and relations between characteristics and use of personal health services (printed in bold).

In recent years, several quantitative studies have used Andersen’s model to investigate the factors influencing professional help-seeking behaviour among individuals suffering from depression (e.g. [ 17 , 18 ]). Additional quantitative studies on this subject have been conducted without referral to Andersen’s model (e.g. [ 19 ]). However, a systematic review of these findings has not been performed. The only existing review [ 20 ] was published 14 years ago and focused on studies using heterogeneous definitions of depression or depressive symptoms and help-seeking behaviour, finding that the help-seeking behaviour of individuals with depression or depressive symptoms was influenced by age, ethnicity, social support and clinical and psychiatric factors. Further studies focussed on specific populations [ 21 ] or specific factors associated to help-seeking [ 22 , 23 ]. Recently, a qualitative synthesis of interview studies about help-seeking behaviour among people with depression was published [ 24 ].

The purpose of this review was to apply a theoretical framework to investigate the individual and contextual characteristics associated with professional help-seeking behaviour for emotional problems in adults with major depression. Therefore, the current review addresses two questions: (1) Which characteristics associated with help-seeking behaviour in adults suffering from major depression are investigated in the literature? (2) How are these characteristics related to help-seeking behaviour in adults suffering from major depression?

In addition to including new literature, this review expands upon previous reviews in two ways: first, it embeds the findings within the ‘Behavioral Model of Health Services Use’ framework and integrates aspects of different models. By systematically reviewing observational studies using standardized diagnostic instruments to assess major depression, this review aims to synthesize the results of studies assessing help-seeking behaviour in a homogeneous population.

To the extent that they were applicable to observational studies and to the qualitative synthesis of results, the methods and results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [ 25 ] ( S1 Appendix ) and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement [ 26 ]. No review protocol exists.

Search strategy

Two researchers (JLM, ALB) searched the MEDLINE, EMBASE and PsycInfo electronic databases in February 2017 (09.02.2017) using key words and a standardized vocabulary (e.g., MeSH) presented in S2 Appendix . These terms aimed to represent the concepts of ‘Depression’ and ‘Help-Seeking’. The search was restricted to ‘human’ and ‘English or German’. Additionally, the EMBASE search was restricted to ‘article’, and the search in PsycInfo to ‘all journals’.

Study selection

After excluding double hits, the title and abstracts of all articles (published in English or German) identified through the electronic search were screened to exclude clearly irrelevant articles. Two researchers (TS, JLM) independently screened the title and abstracts of 150 records. If at least moderate agreement was achieved (Kappa ≥ .41) [ 27 ], the remaining records were screened by JLM. Additionally, the reference lists of the relevant studies and reviews identified in the electronic search were manually examined.

In the second step, the full texts of all potentially relevant studies were independently reviewed by two researchers (TS, JLM). The decision to include studies was based on a priori defined inclusion criteria (IC) ( S3 Appendix ).

Study design

To identify the factors associated with help-seeking behaviour, we relied on observational quantitative studies because randomization of these influencing factors is not possible. Therefore, cohort, case-control and cross-sectional studies were included (IC 1), but intervention studies were excluded unless they retrospectively assessed help-seeking behaviour at baseline.

To investigate the factors of interest in a population with a comparable depression status, studies reporting on the help-seeking behaviour of individuals with a major depressive episode or major depression disorder were included (IC 2). To ensure the validity of the diagnoses, a sample or subsample with formally diagnosed major depression disorder or a major depression episode according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), International Statistical Classification of Diseases (ICD) or Research Diagnostic Criteria (RDC) was required (IC 3). We included studies investigating adult populations (IC 4) with depressive subsamples of population-based datasets to ensure that the samples included individuals not seeking care (IC 5).

Based on the guidelines and in accordance with other reviews on help-seeking [ 16 , 23 , 28 ], we defined professional help-seeking as contacting a health practitioner or service for mental health reasons at least once or receiving therapy including primary care and specialized care in outpatient and inpatient settings in a defined time period (IC 6). To ensure the homogeneity of our outcome, we decided to exclude studies assessing lifetime help seeking. Studies had to include results on the factors influencing help-seeking behaviour (IC 7).

We included studies if they fulfilled all of the inclusion criteria. If there were disagreements about the in- or exclusion of a study, the decision was discussed until consensus was reached (JLM, TS, ALB).

Data extraction and synthesis

The study characteristics, factors associated with help seeking, results and methodological quality were extracted by JLM and TS. Qualitative data synthesis was performed to illustrate which influencing factors were investigated and to discuss heterogeneous findings (e.g., adjusted and unadjusted results) from samples in heterogeneous contexts (e.g., countries, health care systems). Therefore, JLM and TS classified all investigated variables into individual and contextual predisposing, enabling and need factors according to the ‘Behavioral Model of Health Service Use’ [ 15 ]. Data synthesis was performed by vote counting because of the heterogeneity of settings, measures, adjustments and the number of investigated variables. Therefore, measures (e.g., odds ratios, chi-square, and regression coefficients) of the association between each variable and help seeking were grouped into significant positive, significant negative and non-significant results and were listed for each variable. Any disagreements between JLM and TS were discussed until agreement was reached. We documented if and which potential confounding variables were adjusted for in the analyses.

Assessment of methodological quality

Two researchers (JLM, TS) evaluated the methodological quality of all of the included studies. Because of the high level of homogeneity in study design, we considered only criteria with variance between studies. Consequently, three criteria were used ( S4 Appendix ). Two criteria of 14 from the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies [ 29 ] were selected to examine internal validity (Q1 and Q2, S4 Appendix ). We added one criterion about the recruitment of a cohort from the Critical Appraisal Skills Programme [ 30 ] to focus on external validity (Q3, S4 Appendix ). A score of 1 was awarded for each criterion adequately fulfilled, with a potential score ranging from 0 (poor) to 3 (excellent). No studies were excluded because of poor quality rating.

Study characteristics

Altogether, 40 studies based on 26 datasets were included in the systematic review (see Fig 2 for an overview of the search process). The study characteristics are summarized in S5 Appendix . The 26 included datasets comprised 24 cross-sectional studies, one case-control study [ 31 ] and one cohort study [ 32 ]. The years of publication for these studies ranged from 1987 [ 33 ] to 2016 [ 34 ]. In 24 of the 26 datasets, the help-seeking behaviour of individuals with major depression was assessed in population-based samples within a certain region or country. The exceptions included a study investigating white-collar professionals from a specific corporation [ 35 ] and a study investigating the relatives and spouses of people seeking treatment for mental disorders and matched controls [ 31 ]. Most datasets were collected in the US (N = 10) and Canada (N = 8). The other datasets were collected in Finland (N = 3), Ethiopia (N = 1), Mexico (N = 1), Estonia (N = 1), Netherlands (N = 1) and Europe (N = 1). The sample sizes ranged between 102 and 18,927 participants with major depression [ 36 ].

https://doi.org/10.1371/journal.pone.0176730.g002

Quality of studies

The study quality was rated as ‘good’ (60%) for more than half of the studies, ‘excellent’ for one study [ 32 ], ‘fair’ for 35% of the studies, and ‘poor’ for one study [ 35 ]. S5 Appendix displays the ratings of methodological quality.

Individual predisposing factors

Thirty-nine studies and all 26 datasets reported results on individual characteristics, as shown in S6 Appendix .

Five studies assessed stigma and help-seeking beliefs; feeling comfortable with seeking help [ 37 , 38 ] and having the intention to seek help [ 38 ] were positively associated with help-seeking behaviour. Negative attitudes towards antidepressants were negatively related to help-seeking behaviour [ 39 ]. Lin and Parikh [ 38 ] reported no significant associations between help seeking and beliefs about improving through or without professional care and feeling embarrassed about seeking help. This finding is inconsistent with Diala, Muntaner [ 37 ], who found that participants who said they would be embarrassed if their friends knew they were getting mental health care were less likely to use it than others. Aromaa, Tolvanen [ 39 ] found no association between help-seeking behaviour and prejudices against mentally ill people. However, they found that a stronger desire for social distance was negatively related to help seeking. Boerema, Kleiboer [ 34 ] reported that own negative attitudes towards people with depression are negatively related to help-seeking, whereas participants’ beliefs about how other people think about depression was unrelated to help-seeking.

Kleinberg, Aluoja [ 19 ] found that a higher external locus of control was associated with increased help seeking.

Demographic factors

The associations between gender and help seeking were analysed in 16 datasets. In three US samples [ 18 , 32 , 40 ] and one Finish sample [ 39 ], being female was positively related to help-seeking behaviour. Sussman, Robins [ 33 ] reported the same association only among white Americans, not among black Americans. An association between gender and help-seeking was not found in Spanish [ 41 ], Ethiopian [ 42 ], Canadian [ 38 , 40 , 43 – 45 ], American [ 31 , 35 ], Finnish [ 46 , 47 ], Netherlands [ 34 ] or Mexican [ 48 ] samples.

The association between age and help seeking was analysed in 17 different datasets and was mainly computed comparing different age groups. In eight datasets, age was significantly associated with help-seeking behaviour. Two of these studies reported a positive association between age in years and help seeking [ 31 , 39 ]. In the other five datasets, being middle-aged was significantly related to higher help-seeking rates [ 32 , 41 , 49 – 51 ].

Social factors

The associations between help-seeking behaviour and social factors are shown in S6 Appendix . Results were available for educational status (N = 11 datasets), ethnicity (N = 9 datasets), family and living situation (N = 15 datasets) and employment (N = 4 datasets)

The associations between help seeking and education in individuals with major depression were significantly positive or non-significant in the eleven datasets. For example, in three datasets, more years of education and a higher degree were positively associated with help-seeking behaviour after adjusting for clinical and socio-demographic variables [ 32 , 42 , 44 , 52 ]. After adjusting for clinical and socio-demographic variables, this positive association remained significant only in the Canadian dataset [ 40 ] and the US dataset [ 53 ].

Differences between help seeking by ethnic group were assessed in four Canadian and five US datasets. Belonging to a different ethnic group was defined differently between the studies. Differences in help-seeking between different ethnic groups were reported in seven studies [ 18 , 32 , 33 , 37 , 40 , 54 , 55 ]. For example, black Americans [ 55 ], African Americans [ 18 , 37 ], Mexican Americans [ 18 ], and ethnic minorities [ 40 ] had lower rates of seeking help compared to whites. No differences were reported between the help-seeking behaviours of people born in Canada and of Canadian migrants [ 44 ], except that lower rates of help-seeking were observed in a group of Chinese immigrants compared to a group of Canadians born in Canada [ 52 , 54 ]. The results from the ‘National Survey of American Life’ (NSAL) showed that although African Americans reported higher rates of seeking help than Caribbean Blacks, this difference was only significant in a sample of adults with severe or very severe symptoms [ 56 ] and was not significant in a sample of adults with mild to moderate symptoms [ 56 ] or in a subsample of mothers [ 57 ]. Sussman, Robins [ 33 ] reported that blacks had lower odds of seeking help than whites only in people with less severe depression.

Eight [ 33 , 34 , 38 , 40 – 42 , 44 , 52 ] out of 15 datasets found no association between help-seeking behaviour and marital status or living as married. In addition, no significant associations were reported for cohabitation [ 19 , 47 ], household size [ 19 ] or pregnancy [ 58 ]. However, four studies showed that being married or living as married was negatively associated with help-seeking behaviour [ 17 , 31 , 35 , 59 ]; in contrast, Chartrand, Robinson [ 32 ] found the opposite relationship. Gadalla [ 52 ] reported that single mothers with adult children had the lowest odds of seeking treatment in comparison to other women.

Individual enabling characteristics

Financial aspects were addressed in ten datasets, focusing mainly on income or household wealth. In Spanish respondents from the ‘European Study of the Epidemiology of Mental Disorders’ (ESEMeD), the low to average income group was negatively related to help seeking compared to the highest income group [ 41 ]. Diala, Muntaner [ 37 ] found a similar association in respondents from the ‘National Comorbidity Survey’ (NCS). Conflicting results were found in male respondents from the CCHS 1.2, in which help-seeking was positively related to a lower adjusted household income [ 17 ]. All other studies reported non-significant results regarding this association [ 18 , 31 , 32 , 38 , 40 , 42 , 44 , 52 , 53 ]. In the ‘Collaborative Psychiatric Epidemiology Survey’ (CPES), health insurance coverage doubled the odds of any use of depression therapy in the past year [ 18 ], while in the American samples in the ‘Joint Canada/United States Survey on Health’, this association lost significance in the multivariate model [ 40 ].

Regarding the influence of organizational factors on help-seeking behaviour, findings on the availability, accessibility and acceptability of care were available from the CCHS 1.2 [ 17 ]. Additionally, findings on the influence of having a regular medical doctor were available in the ‘Joint Canada/United States Survey on Health’ [ 40 ]. Availability, including waiting times and help not available in the area, was positively related to help-seeking among female Canadian respondents, whereas accessibility and acceptability were not related to help-seeking [ 17 ].

Social support was addressed in three datasets. In the CCHS 1.2, social support and help seeking were positively related in women only [ 17 , 52 ]. Although social support was not directly associated with help-seeking behaviour in the Estonian health survey, emotional loneliness was associated with increased help seeking among depressed persons with an external locus of control [ 19 ]. Dew, Bromet [ 35 ] found that receiving social support during the index episode was negatively related to help seeking, whereas receiving recommendations from others to seek professional help was positively related to help seeking.

Individual need characteristics

Studies on the need factors influencing help-seeking behaviour often focused on the severity of depression (14 datasets), psychiatric comorbidity (11 datasets), duration of episode (9 datasets), subjective disability (5 datasets), number of depressive episodes (6 datasets), somatic comorbidity (6 datasets), and presence of certain depressive symptoms (7 datasets) ( S6 Appendix ). Illness and symptom based need factors were assessed through structured interviews or questionnaires and were defined as professional judgements about people’s mental health status and therefore can be allocated to evaluated need, according to the “Behavioral Model of Health Services Use” [ 15 ]. Specifically, severity of depression was positively related to help-seeking in seven of the 16 datasets [ 31 , 39 , 40 , 46 , 47 , 60 , 61 ]. In addition, a longer duration of illness was positively related to help-seeking behaviour in six datasets [ 31 , 34 , 35 , 40 , 46 ] and was non-significantly related in three datasets [ 33 , 38 , 53 ]. After adjusting for socio-demographic and clinical variables, having more than one major depressive episode was no longer significantly associated with help seeking in the ‘Ontario Health Study’ (OHS) [ 38 , 53 ]. Furthermore, in three other datasets, no significant association occurred [ 31 , 35 , 53 ]. However, in the group of black US participants [ 33 ] and female Canadians [ 52 ], there was a significant positive association. Having trouble concentrating [ 31 , 35 , 46 ] and suicidal thoughts or ideation [ 31 , 35 , 46 , 52 ] were positively related to help-seeking behaviour. Conversely, three studies found no significant results for the latter association [ 32 , 38 , 53 ].

Psychiatric comorbidity was assessed in eleven datasets, and somatic comorbidity in seven ( S6 Appendix ). Having comorbid generalized anxiety disorder [ 17 , 44 , 47 ] or a panic disorder [ 31 , 62 ] was positively related to help-seeking behaviour. Interestingly, after adjusting for several clinical and socio-demographic factors, having a generalized anxiety disorder, agoraphobia or panic disorder in the previous 12 months was significantly related to higher help-seeking rates in OHS respondents but not in NCS respondents [ 53 ]. In contrast with the findings from the Ontario study, Lin and Parikh [ 38 ] found no significant differences analysing the same dataset. Moreover, comorbid phobic disorders were not related to help-seeking behaviour [ 31 ].

Chen, Crum [ 36 ] showed that people suffering from major depression and substance dependence were more likely to seek help than people suffering from major depression only. Other findings indicate no significant difference in help-seeking behaviour with comorbid substance dependence disorder [ 17 , 38 , 44 , 63 ] or alcohol or drug abuse [ 31 ]. Having any additional mental disorder was positively related to help-seeking behaviour in one [ 41 ] of four relevant studies [ 38 , 44 , 64 ].

Suffering from chronic somatic disorders was significantly associated with higher help-seeking rates in two datasets [ 17 , 44 , 52 , 65 ]. However, in five datasets, this association was non-significant [ 34 , 38 , 40 , 41 , 60 ]. Demyttenaere, Bonnewyn [ 65 ] found that people with depression who had comorbid painful physical symptoms had lower rates of help seeking than those without these comorbid symptoms. In older people from the same dataset, this association was not significant [ 66 ].

Contextual characteristics

Studies on the contextual characteristics of help seeking in individuals with major depression have focused on region or different countries. Living in an urban or rural area was not related to help-seeking behaviour in Spanish [ 41 ], Ethiopian [ 42 ], Canadian [ 38 , 44 ] or American [ 32 ] samples. Additionally, no differences in help-seeking behaviour were found between the American and Canadian samples [ 40 ] or between the Francophone Canadian and European samples [ 67 ]. Differences in individuals’ help-seeking behaviour between different regions of the US were found in one [ 32 ] of two studies [ 31 ].

This paper aimed to systematically review the individual and contextual characteristics associated with professional help-seeking behaviour in adults suffering from major depression based on the ‘Behavioral Model of Health Service Use’. Several studies investigated the association between help-seeking behaviour and individual characteristics, such as socio-demographic predisposing factors (e.g., age, gender, ethnicity, education, and family status), enabling factors (financial situation/income) and need factors (e.g., severity of depression, comorbidity, and duration and number of episodes). Some studies focused on beliefs (n = 4) (predisposing factors), social support (n = 4), organization (n = 3) (enabling factors), and context (n = 8) (e.g., urban vs. rural, country) and help-seeking behaviour. No study focusing on need for mental health treatment was included. Similarly, studies investigating help-seeking behaviour for different diseases based on the ‘Behavioral Model of Health Services Use’ examined characteristics similar to those of the studies included in our review [ 16 ].

Based on the current review, it appears that several factors may influence the likelihood that an individual suffering from major depression will seek professional help.

Predisposing factors that seem most likely to decrease help-seeking behaviour in individuals with major depression are, being young or elderly, being male, belonging to certain ethnic groups and having a lower educational status. Although these groups may be at a higher risk for not seeking professional help for major depression, the reasons for this higher risk need to be clarified. Certain structural or attitude-related barriers to seeking care among individuals in these groups may explain the findings. For instance, synthesizing qualitative studies, Doblyte and Jiménez-Mejías [ 24 ] identified attitudinal barriers for help seeking among depressed man, ethnic minorities and young adults: They concluded that help seeking is a threat to hegemonic masculinity, that the fear of disclosure and being judged was strongest among young adults and that ethnic minorities were more willing to keep depression within family [ 24 ]. Apart from attitudinal barriers, structural barrier like cultural inappropriateness of interventions could explain lower help-seeking rates among ethnic minorities [ 24 ].

The majority of studies reported no association between income and help-seeking behaviour. A possible explanation for this finding might be that income as an indicator is not sensitive enough to detect socioeconomic differences in the use of health care services [ 68 ]. Regardless, accounting for the financing of health care systems it is necessary to interpret these associations [ 15 ].

There is some evidence that the severity of depression, longer and more depressive episodes and the presence of anxiety disorders are related to higher help-seeking rates. These findings are consistent with those on help-seeking behaviour in individuals with depressive symptoms or depressive disorder [ 20 ]. However, as these findings were mainly based on retrospective cross-sectional studies, it remains unclear whether individuals affected by more severe depression are more likely to seek help. It is possible that individuals receiving treatment perceive their condition to be more severe than individuals without treatment. Qualitative findings indicate that the first hypothesis is more likely, because professional help-seeking is seen as the “final step”, because it “damages one’s self-definition” [ 24 ].

Based on the reviewed literature, the effects of additional individual predisposing factors such as attitudes on help-seeking behaviour and enabling factors like social support remain unclear. These psychosocial variables are mentioned in the ‘Behavioral Model of Health Service Use’, but which factors influence help-seeking behaviour in what way is not specified. Nonetheless, the initial findings show that social support might be associated with help-seeking behaviour [ 17 , 35 , 52 ]. Therefore, it might be worth distinguishing between informational social support (e.g., recommending seeking care) and emotional social support and investigating the interactions with other psychological concepts such as locus of control. Although the former could facilitate help seeking (e.g. [ 35 ]), the latter may only be associated with help seeking in certain populations (e.g., in individuals with an external locus of control [e. g. 19]). Regarding the influence of beliefs, feeling comfortable seeking care [ 37 , 38 ] was positively associated with help-seeking, whereas having negative beliefs about antidepressants and having a stronger desire for social distance from people who are mentally ill [ 39 ] and having negative attitudes towards them [ 34 ] might have a negative impact on help-seeking behaviour. Within the ‘Health Beliefs Model’ [ 11 ], these beliefs could be considered the perceived benefits and barriers to taking action. Henshaw and Freedman‐Doan [ 69 ] conceptualised help-seeking for mental illnesses using this model and examined the role of fears about treatment and stigma as psychological barriers. The desire for social distance from mentally ill people is known to be an indirect measure of stigmatizing beliefs towards people belonging to this group, and a dissonance between these negative stereotypes and the preferred self can impede help-seeking for mental health problems [ 23 ]. Fears about antidepressant treatment could be a particular problem if practical or psychological barriers to seeking psychotherapy exist.

As evidenced by the findings presented in the results section, several factors of the ‘Behavioral Model of Health Service Use’ seem to be not validated through the systematic review. For instance, mainly no associations between certain predisposing factors (e.g. employment status), enabling factors (e.g. income, organisation), need factors (e.g. somatic symptoms, general health) and help-seeking were identified.

Practical implications

The studies included in this review revealed that men, young and elderly adults, and people of certain ethnicities as well as individuals with a lower educational status with major depression are at risk of not seeking help, and these populations could be addressed in individually tailored interventions to increase help-seeking. In a review of randomized controlled trials, the majority of help-seeking interventions for depression, anxiety and psychological distress targeted young people [ 28 ]. In that review, Gulliver, Griffiths [ 28 ] provided some evidence that mental health literacy interventions (e.g., delivering destigmatisation information and/or providing information about help-seeking sources) can be effective in improving help-seeking attitudes. Mental health literacy is defined as “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” [ 70 ]. However, this positive association could not confirmed for help-seeking behaviour for these interventions [ 28 ]. According to Doblyte and Jiménez-Mejías [ 24 ] who stressed out the role of hegemonic masculine identity and its influence in limiting men’s help seeking behaviour, educational campaigns for primary care providers can facilitate communication between male patients and GPs. Additionally a slighter entrance into care can be achieved. In this spirit, trainings which increase GPs intercultural competence and awareness of cultural differences regarding e.g. illness definition should also be considered [ 24 ]. However, further research on interventions that increase help-seeking intentions and behaviour among individuals suffering from major depression is needed.

Limitations

The results of this review should be considered in light of several limitations. First, the vast majority of the studies reviewed were conducted in the US and Canada, which reduces the external validity of the findings. Second, the synthesis of results was limited because of the heterogeneity of the studies. Although the samples were homogenous regarding the formal diagnosis of major depression, the studies differed in terms of the samples’ age, gender and ethnicity as well as the health care systems affecting the participants. According to the ‘Behavioral Model of Health Service Use’, these contextual characteristics directly influence service utilization and indirectly influence service utilization through individual characteristics [ 15 ]. In addition, the results included different levels of adjustment. Third, reliable conclusions concerning whether a factor causes help-seeking behaviour were not possible, because the large majority of the studies used cross-sectional designs and retrospective data. Fourth, there was a lack of studies that quantitatively investigated the influence of individuals’ beliefs and perceptions on their help-seeking behaviour. Finally, because of the heterogeneous measures and adjustment methods used, a quantitative synthesis was not appropriate.

Plea for consideration of the subjective perspective in help-seeking behaviour

The focus on socio-demographic and clinical variables in the reviewed literature is understandable, as the majority of the studies utilized secondary datasets, thus limiting the variables available for analysis. Nevertheless, it is important to obtain information on the subjective perspective to better understand the complex process of help seeking. Furthermore, including this perspective could provide insight into the associations between certain socio-demographic variables and help seeking. For instance, several studies have already been conducted to shed light on depressed men’s lower help-seeking rates (for review see [ 21 ]) and on men’s delays in medical and psychological help-seeking (for review see [ 71 ]). Specifically, embarrassment, distress or anxiety related to using health care services, need for emotional control, the perception of symptoms as minor and poor communication with health professionals were identified as barriers for help-seeking among men [ 71 ]. Although the ‘Behavioral Model of Health Service Use’ [ 15 ] does not focus on this subjective perspective, it is explicitly included in the predisposing contextual individual beliefs and implicitly included in perceived need . Psychological models such as the Self-Regulation Model of Illness Behavior [ 10 ], the Health Belief Model [ 11 ] and the Theory of Planned Behavior [ 12 ] focus on the individual’s perspective in the help-seeking process. According to these models, illness beliefs [ 10 ], perceived susceptibility and severity of symptoms as well as perceived expectations regarding treatment and self-efficacy [ 11 , 12 ] and motivational factors [ 12 ] influence help-seeking behaviour. For instance, a qualitative analysis using the Self-Regulation Model found that primary care patients with depression who did not seek treatment believed that the treatment would not be effective, that depression would be short-lived and that it would not affect their daily lives [ 72 ]. Accordingly, it is promising to focus on psychological variables that affect the decision-making process of seeking help to better predict behaviour.

Future directions for research

We suggest that future quantitative research on help-seeking behaviour among individuals suffering from major depression should focus more on the individuals’ perspective and include psychological theories as a framework for understanding the help-seeking process. Additionally, the influence of illness beliefs, treatment beliefs, anticipated stigmatization and perceived need for mental health care on help seeking may be worth investigating. Future research should provide insight into the associations between predisposing, enabling and need factors to improve the understanding of the complex process of help seeking. Therefore, the characteristics identified in the literature should be further considered.

Future prospective cohort studies on the causal relations between predisposing, enabling and need factors and help-seeking behaviour among individuals suffering from major depression should also be conducted. Measuring predisposing beliefs, perceived barriers, clinical variables, and perceived need prior to assessing help-seeking behaviour is important because these characteristics can change due to treatment and over time.

This review found that the associations of help-seeking behaviour with socio-demographic predisposing (e.g., age, gender, ethnicity, education, and family status), enabling (financial situation/income), need (e.g., severity of depression, comorbidity, and duration and number of episodes) and contextual factors were investigated in several studies. Gender, age, education, ethnicity, marital status, severity of depression, duration and number of depressive episodes, and comorbid anxiety disorders appeared to influence help-seeking behaviour. Further research investigating the influence of these characteristics on help-seeking behaviour by individuals suffering from major depression in prospective cohorts and research specifically focused on beliefs, social support, organizational factors and perceived need for treatment would address a significant gap in the literature. A better understanding of the process of help-seeking by individuals suffering from major depression and improved knowledge of the factors that influence this process are important for identifying groups at risk of failing to seek adequate professional help and for improving their access to depression care.

Supporting information

S1 appendix. prisma checklist..

https://doi.org/10.1371/journal.pone.0176730.s001

S2 Appendix. Search strategy.

https://doi.org/10.1371/journal.pone.0176730.s002

S3 Appendix. Inclusion criteria (IC).

https://doi.org/10.1371/journal.pone.0176730.s003

S4 Appendix. Quality characteristics.

Q1 and Q2 from the ‘Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies” [ 29 ] Q3 from the Critical Appraisal Skills Programme [ 73 ].

https://doi.org/10.1371/journal.pone.0176730.s004

S5 Appendix. Summary of the main characteristics of the published articles.

ws = whole sample; MDE = major depressive episode; MDD = major depressive disorder; NR = not reported; DIS = Diagnostic Interview Schedule; WHO-CIDI / CIDI = World Health Organization’s composite international diagnostic interview; SFMD = Short form for major depression; SF = Short form; UM = Short Form (University of Michigan) ESEMeD = European Study on the Epidemiology of Mental Disorders; CCHS = Canadian Community Health Study; NESARC = National Epidemiologic Survey on Alcohol and Related Conditions; CPES = Collaborative Psychiatric Epidemiology Survey; NSAL = National Survey of American Life; NCS = National Comorbidity Survey; NCS-R = National Comorbidity Survey–Replication; NLAAS = National Latino and Asian American Study; JUCSH = Joint Canada/US Survey of Health; NSDUH = National Study on Drug Use and Health; OHS = Ontario Health Study; ENHS = Ethiopian National Health Survey; NPHS = National Population Health Survey; ENHS = Ethiopian National Health Survey.

https://doi.org/10.1371/journal.pone.0176730.s005

S6 Appendix. Summary of results of the systematic review.

If adjusted and unadjusted results were reported in the same study for the same variable, only the adjusted results were listed in the table. + = significant positive association between characteristic and help-seeking behaviour;— = significant negative association between characteristic and help-seeking behaviour; Ø = no significant association between characteristic and help-seeking behaviour; x = significant differences between different groups; ESEMeD = European Study of the Epidemiology of Mental Disorders; CCHS = Canadian Community Health Survey on Mental Health and Well Being; NESARC = National Epidemiologic Survey on Alcohol and Related Conditions; NSDUH = National Survey on Drug Use and Health; NCS = National Comorbidity Survey; OHS = Ontario Health Study; EHS = Estonian Health Survey; CPES = Collaborative Psychiatric Epidemiology Survey.

https://doi.org/10.1371/journal.pone.0176730.s006

Acknowledgments

This study as not funded and part of the dissertation of Julia Luise Magaard (JLM). However, Anna Levke Brütt (ALB), Tharanya Seeralan (TS) and JLM received grants from the German Research Foundation for a pilot study about help-seeking behavior of patients with depression. The German Research Foundation had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper. The authors declare that they have no competing interests. The authors wish to thank Mr. PD Dr. Levente Kriston for valuable and constructive comments on conduction of systematic reviews. We thank American Journal Experts (AJE) for English language editing.

Author Contributions

• Conceptualization: ALB HS JLM.
• Data curation: JLM TS.
• Formal analysis: ALB JLM TS.
• Funding acquisition: ALB.
• Investigation: JLM TS ALB.
• Methodology: JLM ALB HS TS.
• Project administration: ALB HS JLM.
• Resources: HS ALB.
• Supervision: HS.
• Validation: JLM ALB TS.
• Visualization: JLM TS.
• Writing – original draft: JLM.
• Writing – review & editing: ALB HS TS.
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• Open access
• Published: 09 August 2022

Explaining adults’ mental health help-seeking through the lens of the theory of planned behavior: a scoping review

• Claire Adams   ORCID: orcid.org/0000-0002-0667-8088 2   nAff1 ,
• Eyal Gringart 1 &
• Natalie Strobel 2  

Systematic Reviews volume  11 , Article number:  160 ( 2022 ) Cite this article

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Despite evidence-based efficacy, mental health services are underutilized due to low rates of help-seeking, leaving unmet mental health needs a global concern. The Theory of Planned Behavior (TPB) has been applied to understand the help-seeking process and in the development of behavior change interventions. The aim of this scoping review was to map the literature on the TPB as applied to mental health help-seeking in adults aged >18 years.

This scoping review was conducted based on the methodology presented by Arksey and O’Malley (2005). Six databases (CINAHL, PsycINFO, MEDLINE, ProQuest Health and Medicine, ProQuest Dissertations and Theses, Web of Science) and two grey literature sources (OpenGrey, Google Scholar) were systematically searched in February 2018 and updated in March 2020. Studies that explicitly discussed the TPB in the context of mental health help-seeking were initially selected; only studies that explored formal help-seeking for mental health problems and were published in English were retained. Data were extracted using Microsoft Excel.

Initially, 8898 records were identified. Of these, 49 met the selection criteria and were included: 32 were journal articles and 17 were theses. Forty-three papers reported on non-intervention studies and seven articles reported on TPB-based interventions. Most studies ( n = 39) identified predictors of help-seeking intentions. Attitudes and perceived behavioral control were significant predictors of intentions in 35 and 34 studies, respectively. Subjective norms were a significant predictor of intentions in 23 studies. Few studies aimed to predict help-seeking behavior ( n = 8). Intentions and perceived behavioral control were significant predictors of behavior in seven and six studies, respectively. Only six TPB-based interventions were identified, all used digital technology to influence help-seeking, with mixed results.

Conclusions

The present scoping review identified a considerable evidence base on the TPB for predicting mental health help-seeking intentions. Attitudes and perceived behavioral control were frequently found to be significant predictors of help-seeking intentions. Knowledge on the TPB for predicting mental health help-seeking behavior, and on TPB-based interventions, is limited. Thus, the role of the TPB in developing help-seeking interventions remains unclear. Recommendations are presented to address such research gaps and inform policy and practice.

Peer Review reports

Mental health problems are a major public health concern. Recent prevalence estimates indicate 10.7% of the world’s population live with a mental health disorder, and the number of years lived with a mental health disorder has increased by 13.5% from 2007 to 2017, which is likely to be a reflection of increasing prevalence rates and greater life expectancy [ 1 , 2 , 3 ]. Associated with the rising prevalence rates of mental health problems is a high level of unmet mental health needs. Unmet mental health needs not only extend the period in which someone lives with the burden of ill mental health, but are also associated with greater levels of disability, reduced quality of life, and an increased likelihood of suicidal ideation and suicide attempts [ 4 , 5 ].

Pervasive unmet mental health needs have been reported in prominent and large-scale studies of mental health such as the World Health Organization (WHO) and World Mental Health Surveys and are reflected in low rates of service utilization [ 6 , 7 , 8 , 9 ]. For example, results of the World Mental Health Surveys conducted across 21 countries revealed only 27.6% of people with anxiety disorders received treatment over the course of one year, and less than one in 10 received adequate treatment [ 10 ]. People in low- and middle-income countries were the least likely to receive treatment (13.1%). Furthermore, national data from Australia and Canada indicate a little over half of the people who experienced emotional distress in 2013 and 2016 received treatment; however, many people (37% in Australia and 30% in Canada) reported that they did not want treatment [ 11 ].

Individual and social factors, such as perceived need for treatment, poor mental health literacy, and low rates of help-seeking have been shown to influence rates of service utilization. Researchers have noted that many people with mental health problems go undiagnosed and untreated, often due to a lack of knowledge about mental health disorders and their treatments, as well as a lack of help-seeking for mental health problems [ 12 , 13 ]. This has led to a widely recognized mental health treatment gap, whereby more individuals are diagnosed with mental health problems than those who receive treatment [ 14 , 15 ]. This treatment gap continues to exist even with the growing evidence base on effective mental health treatments.

The literature indicates that despite the effectiveness of evidence-based mental health treatments, most people do not seek help, or delay seeking help, which has significant personal, social, and economic costs [ 14 , 16 ]. There are many factors that influence help-seeking including stigma, attitudes, knowledge, financial resources, perceived need, and structural barriers/facilitators [ 12 , 17 , 18 , 19 ]. Understanding these factors and addressing the disparity between the need for mental health services and their use are critical to understanding and addressing mental health outcomes. Still, most of the research on mental health help-seeking has been exploratory and devoid of a theoretical orientation, which has been identified as a gap in the body of knowledge. A clear theoretical framework would greatly improve our ability to understand, explain, predict, and address maladaptive behaviors such as refraining from seeking professional mental health support.

In recent years, researchers have attempted to address this gap [ 20 , 21 , 22 ], and a number of theories have been applied to mental health help-seeking [ 23 ]. One such theory is the Theory of Planned Behavior (TPB). The TPB is an extension of Ajzen and Fishbein’s Theory of Reasoned Action (TRA) and suggests people make conscious decisions to act, or not act, based on their attitudes, subjective norms, and perceived behavioral control [ 24 ]. The theory posits that attitudes towards a behavior influence a person’s plan or intention to act, and subsequently, the action or behavior itself [ 25 ]. Subjective norms, defined as perceived social pressures from significant others to perform a behavior, also influence a person’s intentions and behavior [ 26 ]. Perceived behavioral control, which is the perceived opportunities, skills, and resources needed to perform a behavior, can influence behavior directly or indirectly as it affects intentions [ 24 ]. The inclusion of perceived behavioral control as an antecedent to intentions and behavior is the main difference between the TPB and the TRA. By considering the role of perceived behavioral control, the TPB includes non-motivational factors that influence behavior, thereby overcoming criticisms of the TRA [ 26 , 27 ]. Thus, the TPB proposes that attitudes, subjective norms, and perceived behavioral control influence behavioral intentions, which predict behavior [ 24 ].

The utility of the TPB to explain factors that contribute to decision-making, and how behavior change occurs, is thought to be particularly useful in understanding mental health issues, the help-seeking process, and developing interventions to facilitate mental health behavior change [ 28 , 29 , 30 ]. Whilst there is no commonly accepted definition of professional help-seeking, Cornally and Mccarthy [ 31 ] defined help-seeking as “a problem focused, planned behavior, involving interpersonal interaction with a selected health-care professional”. Seeking help from a professional, also known as formal help-seeking, involves seeking help from professional sources who can provide appropriate care [ 16 ]. Seeking help from a professional is considered optimal for the receipt of evidence-based treatments [ 23 , 32 ]. The conceptualization of help-seeking as a planned behavior aligns well with the TPB, as it suggests seeking help involves a conscious or planned decision to seek or not seek support. There is also evidence supporting attitudes and intentions as influential to mental health help-seeking behavior, further substantiating the relevance of the TPB in this area [ 33 ]. Applying theories that encompass attitudes and intentions when investigating behavior, such as the TPB, is recommended by scholars and has been a major focus of research across fields [ 34 ].

Whilst there is no universally accepted theory or model in the area of mental health help-seeking [ 23 ], the body of research applying the TPB to understand mental health help-seeking continues to gain momentum, and the TPB has been favored as the most common approach to frame help-seeking in the literature [ 16 ]. Studies on the TPB have identified predictors of mental health help-seeking intentions as well as behavior. For example, Tomczyk et al. [ 29 ] found attitudes, subjective norms, and self-efficacy (a component of perceived behavioral control), significantly influence intentions, and intentions significantly predict behavior, among people with untreated depressive symptoms in Germany. Moreover, Zorrilla et al. [ 35 ] explored predictors of help-seeking intentions among young adults in the USA and found attitudes was a strong, significant predictor of help-seeking intention for mental health services, followed by perceived behavioral control and subjective norms. Conversely, Bohon et al. [ 36 ] found partial support for the influence of TPB variables on help-seeking, with attitudes and perceived behavioral control significantly predictive of intentions to seek help, but not subjective norms.

There is a need to synthesize what is known about the TPB in the context of mental health help-seeking, to facilitate the identification of factors related to mental health help-seeking, which may provide viable targets for intervention to encourage mental health service utilization and potentially reduce the treatment gap. Recent research has attempted to improve rates of mental health help-seeking through TPB-based interventions [ 37 , 38 , 39 ], however these are yet to be reviewed. It is important to understand what efforts have been made to improve mental health help-seeking to progress the effectiveness of interventions and inform future directions.

The aim of the current scoping review was to map the literature on the TPB when applied to mental health help-seeking. Given the favorable results of the TPB in the health field, and logical expansion of the TPB to mental health help-seeking, this theory provides an important evidence base from which mental health help-seeking can be understood and improved. A scoping review allowed the identification of different types and sources of evidence on this topic, as well as gaps in them, which limit our understanding. The purpose of this scoping review was to:

Identify how the TPB has been applied to mental health help-seeking

Identify and summarize the theoretical factors, which influence help-seeking intentions and behavior

Explore the current state of knowledge on TPB-based interventions designed to improve mental health help-seeking

Highlight how this understanding can inform future research and practice on mental health help-seeking in adult populations.

The current scoping review was based on the methodology outlined by Arksey and O’Malley [ 40 ]. Arksey and O’Malley proposed a five-stage process, which includes (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarizing, and reporting the results. This process was followed, and the scoping review is reported based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist (see Additional file 1 ) [ 41 ].

Review protocol

The scoping review protocol was drafted using Arksey and O’Malley’s five-stage process and was published on the Open Science Framework on 9th November 2017 ( https://osf.io/73c5a/ ).

Identifying the research question

The research question for this scoping review was: What is known about the application of the TPB to mental health help-seeking in adults?

Criteria for study inclusion

Table 1 summarizes the study eligibility criteria.

Types of studies

All studies, which explicitly discussed the TPB in the context of mental health help-seeking, independently of the TRA, were included in the current review. Studies that utilized mediation, moderation, and extended models of the TPB were included only if they examined all variables in the TPB model, and these variables were examined independently (attitudes, subjective norms, perceived behavioral control, intentions and, where applicable, behavior). For the purposes of this study, we defined traditional TPB models as models which included only the aforementioned TPB variables and extended TPB models as those which included any additional predictor(s).

Intervention studies were included if they utilized the TPB model in the design and development of the intervention. Editorials, opinion pieces, and conference abstracts were excluded. Qualitative studies were also excluded as these tended to be formative research, which use the TPB as an exploratory framework rather than apply the TPB constructs to mental health help-seeking.

Participants

This review included papers focused on adults aged >18 years. Samples with and without mental health problems were included, as well as samples restricted to specific sociodemographic criteria (such as age, gender, and occupation). Populations with cognitive deficits such as dementia, intellectual disabilities, and head injuries were excluded, as a person’s cognitive ability directly affects their capacity to seek help as well as process the TPB variables. Studies specific to people diagnosed with schizophrenia, drug users, and survivors of cancer were also excluded due to the cognitive impairments often found in these populations resulting from their treatments or drug use.

Only papers focused on formal mental health help-seeking were included in the current review. Formal help-seeking has been defined as seeking help from professional sources who can provide appropriate care [ 16 ]. In the context of mental health help-seeking, a professional source may include a primary health care provider (general practitioner, nurse, medical specialist) or mental health specialist (psychologist, social worker, counselor, psychiatrist). Formal mental health help-seeking may be face-to-face or online (e.g., e-counseling) as long as it was from a professional source. Self-help programs and resources were excluded, and papers which did not distinguish between formal and informal sources of support were also excluded.

Studies were included if the reason for seeking help was for mental health problems or concerns. For the purposes of the current review, a mental health problem included any symptoms of emotional distress or psychological disturbance, to ensure all studies relevant to mental health were encompassed. The mental health problem did not have to be formally diagnosed as a mental disorder or meet established criteria for a mental disorder.

Some mental health problems such as substance abuse and eating disorders have been considered health-related behaviors in previous research [ 42 , 43 ]. In the present review, these conditions were excluded, as our aim was to examine how the TPB has been applied to mental health problems beyond the traditional application of the TPB to health-related behaviors.

Additionally, studies which focused on secondary help-seeking (seeking help for someone else such as a peer, family member, or friend) were excluded as we sought self-agency over help-seeking behavior, in line with the TPB assertion that behavior must be under volitional control [ 24 ].

Standardized quantitative measures of the TPB are scarce, and therefore, all questionnaires and tools that measure TPB variables were included.

The primary outcomes founded in the TPB framework were (1) attitudes: attitudes toward seeking help for mental health problems; (2) subjective norms: beliefs about whether others approve or disapprove of help-seeking; (3) perceived behavioral control: beliefs about one’s own ability to seek help for mental health problems; and (4) help-seeking intentions: conscious decision to seek or not seek help.

The secondary outcome was help-seeking behaviors, defined as actual help-seeking from a health professional.

Identifying relevant studies

Searches were conducted across six databases (CINAHL, PsycINFO, MEDLINE, ProQuest Health and Medicine, ProQuest Dissertations and Theses, and Web of Science) and two gray literature sources (OpenGrey and Google Scholar). Only papers published in English were included. The searches were run during February 2018 and updated in March 2020. With the help of an experienced subject librarian, keywords were selected, which allowed for breadth of coverage (see Table 2 ).

The above search strategy was used for each database search, and keywords from this search strategy were used to search the gray literature sources. Multiple combinations of the keywords were used to conduct the Google Scholar searches, and the first 50 pages (representing 1000 results) were screened using Google search engines relevancy ranking to order the results [ 44 ]. Reference list searches were also conducted from articles selected for inclusion to identify other relevant studies, which may have been absent in the electronic searches.

Study selection

All titles and abstracts retrieved through the literature searches were reviewed independently by two researchers to identify studies that met the inclusion criteria. The reviewers met during the title and abstract screening and at the conclusion of this stage to discuss and resolve conflicts regarding the inclusion of articles. The inclusion criteria at the title and abstract level were limited to any paper that utilized the TPB or any of its primary variables (attitudes, subjective norms, perceived behavioral control) in relation to mental health problems. Studies excluded at this stage were those including children under the age of 18 exclusively, people with cognitive deficits, and studies not published in English. The covidence systematic review platform was used for title and abstract screening [ 45 ].

Once the relevant studies had been selected, the full-text was retrieved and read independently by two researchers to determine eligibility for inclusion, based on the criteria described above. A third senior reviewer was consulted to resolve conflicts regarding the inclusion of articles, and a final decision was reached once a consensus was achieved.

Charting the data

A standard data charting form was developed and pilot-tested in Microsoft Excel before data extraction. Data collected from each study were organized according to key information: basic descriptors (title, first author, year of publication, publication type, country), eligibility information (aim/purpose of the paper, reason for seeking help, source of help), study population (population group, mental health status, sample size, setting, method of recruitment, sociodemographic information), research methods (study design, measures used, analysis, intervention details if applicable), primary and secondary outcome measures (attitudes, subjective norms, perceived behavioral control, intentions, behavior), and description of key findings.

Collating, summarizing, and reporting the results

Descriptive tables were used to outline the key information from each paper. Based on the content of the articles and the present research question, the studies were organized according to non-interventions and interventions. Tables were used to highlight the pertinent information from the non-intervention and intervention studies according to our review objectives.

A PRISMA flow diagram is presented in Fig. 1 , which outlines the process of selecting studies. There were 8898 records identified through the literature searches. After the removal of duplicates, 5626 records were screened for eligibility. There were 5436 records excluded at the title and abstract stage, 143 articles excluded after full-text screening and three articles excluded after data extraction. The reasons for exclusion are provided in Fig. 1 . A further 5 articles were identified through reference list searches and screened. This process resulted in the inclusion of 49 articles.

Flow diagram of study selection

Characteristics of studies

The 49 articles that were chosen were published between 1998 and 2020; 32 (65%) were journal articles and 17 (35%) were theses. Of these, 42 (86%) were non-intervention studies, six (12%) were intervention studies, and one paper (2%) reported on both cross-sectional data and an intervention (Fig. 2 ).

Stacked histogram of the number of studies published per year

Most studies were conducted in North America ( n = 27, 55%), followed by Europe ( n = 9, 19%), Asia ( n = 8, 16%), Oceania ( n = 4, 8%), and Africa ( n = 1, 2%). In terms of the populations, most targeted college students ( n studies = 16, 33%; n participants = 6048), followed by community samples ( n studies = 12, 25%; n participants = 7305), both students and community samples ( n studies = 1, 2%; n students = 320; n community adults = 208), armed forces or emergency service workers ( n studies = 8, 16%; n participants = 1910), older adults ( n studies = 2, 4%; n participants = 568), and other specific populations ( n studies = 10, 20%; n participants = 3137).

Most studies included all participants with and without symptoms of mental health problems ( n studies = 42, 86%; n participants = 17371), three studies (6%; n participants = 1542) only included participants with psychological symptomatology, two studies (4%; n participants = 160) targeted people who screened positive for a mental disorder, one study (2%; n participants = 400) included dysphoric individuals only, and an intervention design paper ( n studies = 1, 2%; n participants = 23) only included young adults with experience in seeking help for mental health issues.

TPB-based non-intervention studies

Forty-three articles reported on non-intervention studies [ 21 , 29 , 35 , 36 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 ]. Of these, 28 (65%) were journal articles and 15 (35%) were theses. A summary of the final selected non-intervention articles is given in Additional file 2 , Supplementary Table 1 .

Two journal articles reported on the same sample [ 77 , 79 ], and one thesis reported pre-intervention cross-sectional data and intervention data and thus was included in both sections [ 58 ]. One study reported on post-intervention data only and was included under non-intervention studies as the intervention was not based on the TPB [ 62 ]. The results of the study are not reported due to the study design.

Most of the non-intervention studies were conducted in North America ( n = 23, 53%), followed by Europe ( n = 9, 21%), Asia ( n = 8, 19%), Oceania ( n = 2, 5%), and Africa ( n studies = 1, 2%). The most commonly targeted populations were students ( n studies = 14, 33%; n participants = 5588), followed by armed forces or emergency service workers ( n studies = 7, 16%; n participants = 1900) and community samples ( n studies = 10, 23%; n participants = 7231).

Of the 43 non-intervention papers, 38 were cross-sectional studies that aimed to identify predictors of mental health help-seeking intentions and/or behaviors. Five of the cross-sectional papers included a psychometric study or elicitation study, which designed and/or evaluated measures to assess TPB variables, for use in the main cross-sectional study [ 36 , 50 , 53 , 54 , 59 ]. Three papers were solely psychometric evaluations, which examined the validity and reliability of attitudinal mental health help-seeking scales. Two centered on the reliability and validity of the Inventory of Attitudes towards Seeking Mental Health Services (IASMHS) [ 49 , 84 ]. The third paper developed and tested the Mental Help-Seeking Attitudes Scale (MHSAS) [ 76 ]. One psychometric study also reported on predictors of help-seeking intentions [ 84 ].

In addition, one paper was an experimental between-group design, which aimed to influence intentions to seek help for depression through evoking positive emotions using nostalgic messages [ 62 ], and one paper presented baseline data from a randomized controlled trial examining students’ intentions to seek help and actual counselling usage [ 58 ].

The type of mental health problem was rarely defined in the literature, most commonly referred to as a psychological problem or mental health problem/concern ( n studies = 21, 49%). Other terms used included psychological stress/distress, personal and/or emotional problems, psychological difficulties, mental health conditions, persistent issues, and common concerns. Some studies gave examples of mental health problems, for example, Mo and Mak [ 21 ] used the term mental health problems and provided a definition to include low mood, tense, anxious, and problems sleeping. Stecker et al. [ 55 ] used the term mental health concerns and defined these to include major depressive disorder, panic disorder, generalized anxiety, post-traumatic stress disorder, and/or alcohol abuse disorder. Some studies presented a list of symptoms or problems such as depressed mood, anxiety, relationship difficulties, personal concerns, memory loss, and alcohol or drug abuse [ 50 , 51 , 59 ].

Depression was the only mental health problem to be examined independently, with eight studies (19%) focusing only on help-seeking for depression, and one study (2%) focusing on depression and suicidal thoughts [ 35 , 36 , 48 , 53 , 58 , 60 , 62 , 72 ]. These studies included all participants irrespective of their mental health status, with the exception of one paper which included only dysphoric individuals [ 60 ]. Additionally, three studies (7%) explored help-seeking for suicidality as well as other emotional or mental health problems [ 54 , 66 , 80 ].

As only formal mental health help-seeking was included, most studies reported the source of help as mental health services, psychological/psychiatric help, mental health professional, or a combination of these terms ( n studies = 27, 63%). Additional terminology included counseling ( n studies = 7, 17%), treatment ( n studies = 5, 12%), cyber-counseling ( n studies = 1, 2%), therapy for depression ( n studies = 1, 2%), psychotherapy ( n studies = 1, 2%), and prison psychologist ( n studies = 1, 2%). Of the studies that defined the type of service, common examples included social workers, counselors, psychologists, and psychiatrists. Six studies (14%) also specified physicians/general practitioners within their definition [ 49 , 55 , 57 , 67 , 71 , 75 ].

Factors which influence help-seeking intentions and behavior

The theoretical factors, which predict help-seeking intentions and behavior, are summarized in Tables 3 and 4 , respectively. Some studies ( n = 13, 33%) used traditional models of the TPB to explore help-seeking, whereby only the original TPB variables (attitudes, subjective norms, perceived behavioral control, intentions, and where applicable, behavior) were included in the model. Other studies ( n = 19, 49%) used extended models of the TPB, in which the original TPB variables and additional variables were included in the model (either as predictors or control variables), to identify further predictors of mental health help-seeking relevant to the population. Seven studies (18%) explored both traditional and extended models.

Overall, 39 studies identified predictors of mental health help-seeking; 31 studies identified predictors of mental health help-seeking intentions only, and eight studies identified predictors of intentions and behavior.

From the 39 studies that identified predictors of mental health help-seeking intentions, attitudes was a significant predictor of intentions in 35 (90%) studies, perceived behavioral control was a significant predictor of intentions in 34 (87%) studies, and subjective norms was a significant predictor of intentions in 23 (59%) studies. The variance in mental health help-seeking intentions explained by the TPB ranged from 7 to 93% for both the traditional and extended models.

There were eight articles that examined factors, which influence mental health help-seeking behavior. Seven of the eight articles (88%) found intentions to be a significant predictor of mental health help-seeking behavior, and six of the eight (75%) articles found perceived behavioral control to be a significant predictor of behavior. Two of the articles (25%), which did not support perceived behavioral control as a predictor of help-seeking behavior only examined one component of this construct, control factors, which may account for the insignificant findings [ 55 , 64 ]. Furthermore, two articles (25%) found perceived behavioral control to be a significant predictor of behavior in the traditional TPB model, but not when the model was extended to include other variables [ 47 , 83 ].

An additional paper examined help-seeking behavior but did not utilize the full TPB model [ 60 ]. In this paper, intentions were found to be a significant direct predictor of prospective help-seeking, and direct relationships were also found between attitudes and prospective help-seeking, and subjective norms and current help-seeking.

Overall, the variance in mental health help-seeking behavior explained by the TPB ranged from 3 to 61% for the traditional models and 10 to 63% for the extended models.

TPB-based interventions

Seven articles were identified on TPB-based interventions; four were journal articles and three were theses [ 30 , 37 , 38 , 39 , 58 , 85 , 86 ]. The seven articles comprised six unique interventions, which used the TPB model to improve intentions or behavior to seek professional help. A summary of the final selected intervention articles is given in Additional file 2 , Supplementary Table 2.

Three of the interventions were evaluated in randomized controlled trials, two were evaluated in pre-post studies, and one was assessed using a randomized post-test-only design. All six interventions used digital technology: two interventions were short videos on seeking counseling services, three were web-based tools, and one was a theory-guided multimedia presentation. The target population were mainly young adults ( n studies = 5, n participants = 704), one study targeted USA war veterans ( n participants = 10), and one study focused on adolescent mothers with a mean age of 18 ( n participants = 289).

The findings from each study were mixed. One study demonstrated improvements in mental health help-seeking intentions and behavior after intervention. Logsdon et al. [ 39 ] employed a pre-post design to evaluate an Internet-based depression intervention encouraging adolescent mothers to seek depression treatment and found a statistically significant increase in both intentions to seek treatment and actually receiving treatment over time in the intervention group compared to the control group. Another study that designed a web-based psychoeducational tool for USA veterans reported an increase in willingness to consider mental health treatment post-intervention [ 30 ].

Two studies, both using video interventions on attending counseling, demonstrated significant improvements in all three TPB predictor variables (attitudes, subjective norms, and perceived behavioral control) immediately after the intervention [ 58 , 85 ]. Chang [ 58 ] also conducted a follow-up and found sustained improvements in subjective norms and perceived behavioral control at 4-weeks post-intervention. In both studies, changes in predictor variables did not translate to improvements in intentions or behavior. Furthermore, Lindsley’s [ 86 ] guided multimedia presentation on treatment seeking reported findings consistent with overall improvements in TPB predictor variables after intervention; however, this declined over time and no differences between the experimental and control group were found. Finally, an online navigation tool for young adults designed to match participants with appropriate services did not demonstrate improvements in help-seeking intentions; changes in other TPB variables were not assessed [ 37 , 38 ].

The current scoping review mapped existing literature on the TPB when applied to mental health help-seeking. Of the 49 articles included, the earliest paper identified was published in 1998, with a rise in the number of studies since 2008, indicating growing interest in this field. Most studies were conducted in western countries (North America and Europe), with college students and community samples the most common populations targeted. Participants with and without mental health problems were typically included, which aligns with an early intervention approach to mental health care [ 87 ].

This body of research typically applied the TPB to predict mental health help-seeking intentions ( n = 39). Most studies found the TPB accounted for a large amount of variance in intentions; however, the range in variance explained was large. Of the theoretical factors, which influence mental health help-seeking intentions, attitudes and perceived behavioral control were frequently found to be significant predictors of help-seeking intentions, and subjective norms were found to be a significant predictor in more than half of the studies. This indicates that across population groups, a person’s favorable or unfavorable evaluation towards using mental health-related services, and their perceived resources, skills, and opportunities to access services, influence their intentions to seek help. For example, the belief that seeing a mental health professional will be helpful, and beliefs regarding potential costs of mental health consultations, influence help-seeking intentions [ 53 ]. The influence of subjective norms on intentions, that is, perceived social pressures to seek help, was less consistent, which may be due to differences in cultural norms and beliefs. For example, western cultures are typically individualistic and therefore, people from these cultures may be more motivated to act according to their own goals and beliefs [ 88 ]. In the present review, we found subjective norms were not statistically significant predictors of help-seeking intentions in some studies conducted in the USA [ 36 , 55 ]. In studies conducted in non-western cultures such as South Asia and among Chinese populations, social pressures were found to significantly predict help-seeking intentions [ 21 , 73 ]. This may be reflective of the collectivistic nature of these societies, which traditionally encourage interconnectedness with others [ 88 ].

Indeed, cultural factors such as race, ethnicity, and religion have been shown to influence help-seeking intentions and behavior. For example, mental health problems are commonly stigmatized in Chinese societies, which hinders people’s intentions to seek help for fear of social rejection [ 50 , 64 ]. In some extended and modified models of the TPB, variables such as adherence to Asian values, shame/izzat, and a Strong Black Woman ideal were included and were shown to significantly predict help-seeking intentions [ 22 , 47 , 72 ]. Some authors have advocated for the use of extended models of the TPB to better explain help-seeking intentions and behavior [ 89 , 90 ]. In the present scoping review, most non-intervention studies (67%) used extended models or both traditional and extended models to conceptualize help-seeking intentions; however, the variances explained by these models were comparable to traditional TPB models. Thus, factors that influence help-seeking intentions beyond the theoretical factors in the TPB require further investigation.

Fewer studies applied the TPB to predict mental health help-seeking behavior ( n = 8). Intentions and perceived behavioral control were significant predictors of behavior in most of these studies, supporting the TPB framework. Of the studies that did predict help-seeking behavior, past and/or present behaviors were commonly used as the outcome. We only located three studies, which explored the ability of the TPB to predict future behavior [ 29 , 55 , 75 ]. This is a key gap in the evidence related to predicting whether people would seek help for mental health problems if a future need arose. Whilst studies have found past behavior to have been a good indicator of future behavior, this is not always the case [ 24 ]. Additionally, there is a widely recognized intention–behavior gap, where positive intentions are not always antecedent for actual behavior [ 91 ]. Thus, there exists an important opportunity to develop TPB models for predicting future behavior, to identify groups who are in need and yet are less likely than other populations to seek help, and to enable targeted interventions to address their needs as well as increase help-seeking behaviors among them.

The current state of knowledge on TPB-based interventions for mental health help-seeking is in its infancy, with few studies published, all within the last decade. It is both difficult and premature to draw conclusions as to the role of the TPB as a framework for developing behavior change interventions for mental health help-seeking, due to the variation in predictor variables examined, lack of diversity in populations, and limited ways in which the interventions were delivered. Of the seven studies we located on TPB-based interventions to improve mental health help-seeking, six used digital technology, mostly to target young adults. This is of concern, given recommendations from researchers to use the TPB to promote behavioral change across populations, and the various approaches which can be trialed to facilitate the greatest change in behavior, e.g., persuasive communications, face-to-face discussions, and observational modeling [ 42 , 92 , 93 ]. There is a need and room for the development and evaluation of TPB-based interventions using different modes of delivery and targeting both community samples and at-risk populations, which may be effective in promoting help-seeking and facilitating service utilization.

There is also space for the TPB to be applied across subgroups who experience disparities in service provision, to explain intentions and behavior towards mental health service utilization; however, this has been largely overlooked in studies to date. Background factors such as age, race, ethnicity, and social class are associated with different behavioral beliefs, behavioral intentions, and prevalence rates of behaviors [ 94 ]. Such factors can be incorporated into the TPB model to identify inequities in health and health-related behaviors and guide the allocation of resources to better meet the needs of diverse communities who have differential access to care [ 94 ]. For example, people from culturally and linguistically diverse groups are less likely to engage mental health services than members of the wider population, due to a lack of knowledge of services and how to access them, communication barriers, financial barriers, racism, and culturally insensitive practices [ 95 , 96 , 97 ]. Moreover, attitudes towards and beliefs about mental health problems and treatments among diverse groups may differ from dominant Western approaches, and access to culturally appropriate care is often limited [ 98 ]. The TPB can be applied to identify background factors that influence help-seeking, and attitudes, norms, and control beliefs associated with help-seeking among racial and ethnic minority groups, providing insight into service access and use. Such research is important to accurately address the needs of marginalized populations and promote inclusive practices.

Implications for future research and practice

The current scoping review provides a resource for researchers and practitioners to understand mental health help-seeking through the lens of TPB. Prominent research gaps are highlighted in Fig. 3 .

Research gaps

There is scope for a number of systematic reviews to determine the most significant predictors of mental health help-seeking intentions and behavior, which can be used as target areas for intervention. Systematic reviewers may wish to focus their investigations on determining the key TPB-based predictors of mental health help-seeking among student samples, given the predominance of studies on this population. There is also scope to conduct a systematic review on methods for measuring TPB variables due to the diversity in quantitative tools used to assess these constructs. This will enable more accurate measurement of these variables and greater ability to compare findings. An investigation of the most reliable evidence for the effects of TPB-based interventions on mental health help-seeking intentions and behaviors is also warranted. Such reviews could provide stakeholders a sound basis for their decisions on how to assess and improve mental health help-seeking.

Strengths and limitations

By employing a scoping review methodology and a systematic approach to the selection of studies, we conducted a comprehensive and structured review of the literature in line with current recommendations for good practice [ 99 ]. This clear structure makes the current results more accessible to stakeholders interested in applying the findings to inform policy and practice [ 40 ]. It is still possible that we did not locate all relevant studies or misclassified relevant papers.

Whilst we aimed to include only those studies relevant to adults, defined as people aged 18 years and over, there were three studies which did not define the age of participants [ 65 , 66 , 68 ]. As the sample in Miller [ 65 ] comprised lawyers, it is safe to assume that the age of participants was >18 years. In Rathbone (2014) and Mills (2010), however, the target samples were college students, and it is, therefore, possible that the mean age of participants in these studies was <18 years [ 66 , 68 ]. As we cannot be certain, these three studies were included in this review to ensure we did not falsely exclude relevant papers.

A further limitation is the paucity of TPB-based standardized questionnaires on mental health help-seeking, which restricts our confidence in the accurate measurement of TPB variables. Many authors have created their own measures or adapted previous measures to fit their study contexts [ 21 , 53 , 78 ]. Additionally, validated tools such as the Attitude Toward Seeking Professional Psychological Help Scale (ATSPPHS) and IASMHS have been constructed and applied to mental health help-seeking, but do not necessarily reflect the true nature of the TPB. For example, the ATSPPHS has been widely used as a measure of help-seeking attitudes; however, this tool precedes the TPB and its development was not guided by any explicit theoretical framework [ 49 , 76 ]. The IASMHS was designed to improve upon this measure by including items, which directly target the TPB predictor variables; however, the three subscales of the IASMHS only loosely reflect the TPB and contain other constructs such as mental health literacy, self-disclosure, avoidance coping, or self-concept clarity [ 49 , 76 ]. We, therefore, cannot detect whether intentions to seek help were influenced by the components of the TPB or the overlapping or related constructs inherent in this measure. Furthermore, studies that used the IASMHS but did not reference the TPB would not have been identified by our searches but may add to our understanding of mental health help-seeking within a TPB framework. More consistency is needed in the assessment of TPB variables to strengthen the conclusions drawn about the explanatory role of the TPB in the present context.

Additionally, we applied a strict inclusion and exclusion criteria, which may have resulted in the exclusion of closely related studies. We chose this approach to strengthen our understanding of the original TPB framework, without modifications.

As the TPB is one of the most prominent theories in the social and behavioral sciences, the current scoping review was prudent to improve our understanding of the role of the TPB in explaining mental health help-seeking among adults. With the increase in effective psychological treatments, there is a pressing need for researchers and clinicians to promote engagement with mental health services to alleviate some of the personal and societal costs associated with ill mental health.

As a result of mapping the evidence base, we have identified a considerable body of research on the TPB for predicting mental health help-seeking intentions. Attitudes and perceived behavioral control, in particular, appear to be well-cited factors influencing people’s intentions to seek or not seek help. Less attention was paid to help-seeking behavior; however, among the eight studies that explored help-seeking behavior, intentions and perceived behavioral control were found to be significant predictors of help-seeking behavior, which further supports the TPB in this context. The evidence base for TPB-based interventions to improve mental health help-seeking is in its early stages, and there appears to be a number of gaps in the literature that limit our understanding of the applicability of the TPB in this context and warrant further research.

An important line of future enquiry could be to utilize the theoretical framework of the TPB to find ways to increase help-seeking behavior to improve mental health outcomes. A particular focus should be paid to groups at-risk of mental health problems, such as veterans, people with chronic illnesses, and immigrants, to reduce the personal and societal burden of unmet mental health needs. The current scoping review provides a broad map of the evidence related to mental health help-seeking, which can inform future research, policy, and practice.

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Abbreviations

Attitude Toward Seeking Professional Psychological Help Scale

Inventory of Attitudes towards Seeking Mental Health Services

Mental Help-Seeking Attitudes Scale

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews

Theory of Planned Behavior

Theory of Reasoned Action

World Health Organization

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Acknowledgements

The authors would like to thank Dr. Beron Wei Zhong Tan for his assistance during the initial stages of the project.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Claire Adams

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Eyal Gringart

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CA under the supervison of EG and NS designed the study and drafted the study protocol. CA conducted the systematic searches of databases and gray literature. CA and NS screened and extracted the articles. CA prepared the draft manuscript. EG and NS technically edited the manuscript. The author(s) have read and approved the final manuscript.

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Additional file 1..

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.

Additional file 2: Table S1

. Characteristics of studies – non-interventions. Table S2 . Characteristics of studies – interventions.

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Adams, C., Gringart, E. & Strobel, N. Explaining adults’ mental health help-seeking through the lens of the theory of planned behavior: a scoping review. Syst Rev 11 , 160 (2022). https://doi.org/10.1186/s13643-022-02034-y

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Help-Seeking: A review of the literature

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This study was supported by grants from the Administration on Aging, #90-A-644, and from the National Institute on Aging, NIA 5-PO1-AG 00123.

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Gourash, N. Help-Seeking: A review of the literature. Am J Commun Psychol 6 , 413–423 (1978). https://doi.org/10.1007/BF00941418

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Issue Date : September 1978

DOI : https://doi.org/10.1007/BF00941418

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