EMPIRICAL RESEARCH

Help-Negation and Suicidal Ideation: The Role of Depression,Anxiety and Hopelessness

Coralie J. Wilson • Frank P. Deane

Received: 19 July 2009 / Accepted: 20 November 2009 / Published online: 2 December 2009

� Springer Science+Business Media, LLC 2009

Abstract Help-negation is expressed behaviorally by the

refusal or avoidance of available help and cognitively by

the inverse relationship between self-reported symptoms of

psychological distress and help-seeking intentions. The

current study examined the association between suicidal

ideation and intentions to seek help from friends, family

and professional mental health sources in a sample of 302

Australian university students. Participants were 77.5%

female and aged from 18–25 years old, with 85.4% aged

21 years or younger. Higher levels of suicidal ideation

were related to lower help-seeking intentions for family,

friends, and professional mental health care, and higher

intentions to seek help from no one. Moderation effects

indicated that higher levels of depressive symptoms

strengthen the help-negating effect of suicidal ideation for

seeking help from friends, family and no one. The results

indicate that, even at subclinical levels, suicidal ideation

impedes the cognitive help-seeking process at the decision

making stage. The results also highlight the importance of

improving our understanding of why young people become

reluctant to seek help as their levels of suicidal ideation and

depressive symptoms increase. Raising awareness that the

experience of suicidal ideation and depressive symptoms

can promote intentions to avoid help might reduce the help-

negation effect when symptoms are first recognized.

Keywords Help-seeking � Help-negation � Suicidal

ideation � Depression � Anxiety � Hopelessness

Introduction

Suicide is a concern for a number of cultures and countries.

Internationally, suicide is the third leading cause of death in

the 15–24-year age-group (Belfer 2008). In 2005, approx-

imately 10% of deaths amongst Americans aged 15–24-

years were by suicide, and in Australia between 2004 and

2006, 20% (n = 266) of all deaths in the 16–24 age-group

were by suicide (Australian Bureau of Statistics [ABS]

2008). Suicide is not an impulsive act, but lies on a con-

tinuum from suicidal ideation to attempt and completion

(Brown et al. 2006). Suicidal ideation refers to people’s

thoughts about death, suicide, and serious self-injurious

behaviors, and is an independent estimate of risk for suicide

completion (Beck et al. 1999; Brown et al. 2000; Reynolds

1988). For example, using a sample of 3,701 outpatients

seeking psychiatric treatment, Beck et al. (1999) found that

suicidal ideation at its worst point predicted suicide com-

pletion at a rate 14 times higher than ideation in a lower risk

category. Unfortunately, suicidal ideation is also relatively

common in young people. Epidemiological studies con-

verge to suggest that, at any point in time, almost one

quarter of young people worldwide are experiencing sui-

cidal thoughts (e.g., Goldney et al. 1989; Reinherz et al.

1995; Swanson et al. 1992). These sobering statistics indi-

cate that seeking appropriate help, before suicidal ideation

C. J. Wilson (&) � F. P. Deane

Illawarra Institute for Mental Health, Wollongong,

NSW, Australia

e-mail: Coralie_Wilson@uow.edu.au

F. P. Deane

e-mail: Frank_Deane@uow.edu.au

C. J. Wilson

Graduate School of Medicine, University of Wollongong,

Wollongong, NSW, Australia

F. P. Deane

School of Psychology, University of Wollongong,

Wollongong, NSW, Australia

123

J Youth Adolescence (2010) 39:291–305

DOI 10.1007/s10964-009-9487-8

is at its worst point, may be crucial for interrupting the

development of ideation to completion. The statistics also

underscore the need to identify and better understand vari-

ables that exacerbate suicide risk, together with those that

protect against the development of suicidal ideation and

consequent completion (Graham et al. 2000).

Appropriate Help-Seeking

Appropriate help-seeking refers to a match between prob-

lem type, severity and help source. For example, low levels

of distress following transitory stressful experiences may

only require support from a family member. More severe

and traumatic experiences might require professional

mental health treatment. A productive help-seeking expe-

rience might also facilitate problem-solving or access to a

more appropriate help provider. Accessing appropriate help

can successfully reduce the long-term impact of many

mental health problems and protect against the develop-

ment of psychological distress (Rickwood et al. 2007). In

turn, appropriate help can reduce the risk for suicide

completion when ideation is experienced or when suicidal

behaviors are exhibited (Greenberg et al. 2001; Kalafat

1997). However, epidemiological studies indicate that only

about a quarter of young people with a mental health

problem seek professional care (e.g., Zachrisson et al.

2006). This means that, globally, up to three quarters of the

young people who would likely benefit from mental health

care are not seeking or engaging in this type of help when

they are psychologically distressed or suicidal.

In Australia, even after a decade of universal and tar-

geted initiatives to improve mental health help-seeking,

preliminary results from 2007 National Survey of Mental

Health and Wellbeing suggest that only 23.3% of young

people, aged 16–24 years, who had common forms of

psychological distress during the last year, sought or

engaged in professional help for their condition (Burgess

et al. 2009). In the general population, 41% of those with

serious thoughts of suicide during the last year did not seek

or engage in professional help for their suicidality (John-

ston et al. 2009). Even more concerning are the preliminary

results from the 2007 Survey which suggest that 86% of

those who did not seek help for their common mental

disorders thought that they didn’t need any type of mental

health care (Meadows and Burgess 2009; age specific

results were not available). Although we still don’t know

why people with mental health problems do not want help

(Henderson et al. 2009), the 2007 Survey raises the pos-

sibility that a lack of perceived need for treatment

(Meadows and Burgess 2009) or incomplete mental health

literacy (Whiteford and Groves 2009) is implicated in low

service use. It is also possible that the gap between service

need and use is partially explained by the help-negation

process (Wilson and Deane 2009).

Help-Negation for Suicidal Thoughts in Clinical

Samples

Help-negation was first described in the literature as the

unique pattern shown by acutely suicidal clients who have

‘‘reached a state of utter hopelessness concerning treat-

ment, [to] soundlessly abandon, politely terminate, or

angrily reject treatment’’ (Clark and Fawcett 1992, p. 40).

As the research area has developed, help-negation has been

indicated behaviorally as the refusal or avoidance of

available help (e.g., Rudd et al. 1995), and cognitively, as

the inverse relationship between the cognitive response to

an episode of psychological distress (e.g., self-reported

suicidal ideation or depressive symptoms) and help-seeking

intention (i.e., the planning and action component of the

individual’s decision to seek help; e.g., Deane et al. 2001;

Wilson et al. 2005a, 2007, 2009). Help-negation differen-

tiates those who are at high risk for suicide completion

from those who are at low or moderate risk (Clark and

Fawcett 1992), and thus, provides an independent indica-

tion of risk for suicide completion (Stellrecht et al. 2006).

Help-negation suggests that people at the highest risk for

suicide completion are those who are most likely to avoid

seeking help for their potentially lethal thoughts and

behaviors (Wilson et al. 2009).

In one of the first empirical studies of help-negation,

Rudd et al. (1995) followed a group of 45 clients, aged

18–26 years old, who withdrew prematurely from treat-

ment. The researchers continued to assess the client’s

levels of suicidal ideation and behavior, and examined

whether suicidal clients who drop out of treatment feel

hopeless about the potential efficacy of treatment or whe-

ther help-negation might reflect personal characteristics

underpinning the suicidal state, that is, poor: judgment,

decision making, problem solving, and overall adaptive

coping. The study revealed that those clients who with-

drew from treatment prematurely shared similar sympto-

mology across diagnoses, personality characteristics, and

levels of psychological distress. Both groups exhibited

similar levels of hopelessness and negative expectancies

about the future, and neither group considered themselves

to be effective problem solvers. Yet, one group withdrew

from treatment and the other did not. Rudd et al. con-

cluded that, although help-negation seemed to be at least

in part a function of hopelessness in clinical samples, it is

‘‘most likely not unique to the therapeutic situation or

immediate crisis, but indicative of the individual’s general

adaptive coping and interpersonal style’’ (p. 503). The

researchers suggested that help-negation might be a

292 J Youth Adolescence (2010) 39:291–305

123

function of a general coping style that is avoidant, nega-

tivistic, and passive-aggressive, and which is exacerbated

by situational stress, associated symptomology, and resul-

tant Axis I diagnoses (i.e., clinical disorders, such as mood

and anxiety disorders, and other conditions that may be the

focus of clinical treatment).

Other studies have indicated that suicidal ideation itself

might be a factor associated with help-refusal. Studies also

suggest that the help-negation effect might exist for infor-

mal help-sources, such as friends and family, as it does for

formal professional mental health sources. For example, a

case-controlled study of one hundred and fifty-three 13–34-

year-old ‘‘nearly lethal’’ suicide attempters found that this

group was significantly less likely to seek help from any

source, either formal or informal, than the non-suicidal

controls (odds ratio = 0.50, p \ .05, 95% confidence

intervals = 0.3–0.8; Barnes et al. 2001). Importantly,

young people are more likely to seek help when they rec-

ognize that they have a mental health problem and have the

knowledge, skills and encouragement to seek help (Rick-

wood et al. 2006; Zwaanswijk et al. 2003a). This encour-

agement often comes from parents, friends, and family

doctors, who have a significant role in the pathway to pro-

fessional mental health care (Zwaanswijk et al. 2003b).

Parents are particularly important for younger adoles-

cents because they facilitate access to professional help

sources. While the capacity for self-referral develops over

adolescence into young adulthood, as independence and

autonomy from parents develops, parents continue to play a

significant role in the help-seeking process, particularly

until young people are financially independent (Rickwood

et al. 2006). As young people progress through adoles-

cence, the role of friends becomes prominent in help-

seeking pathways (Kramer and Garralda 2000; Rickwood

et al. 2005). For young adults, intimate relationships

become an important source of support, particularly for

males. Intimate partners have been shown to exert a strong

influence on men who seek specialist psychological ser-

vices (Cusack et al. 2004). Thus, indications that the help-

negation effect might extend to informal help sources are

particularly concerning. It means that suicidal young peo-

ple, who are most in need of professional help, may not

receive professional care because they simultaneously

reject help from the people they are often closest to.

Friends and family are often those who are most likely to

recognize a young person’s need for help (Wilson and

Deane 2001). Consequently, young people who are at risk

for suicide might not receive the support they need to

facilitate access to appropriate mental health services.

These possibilities underscore the importance of identify-

ing and addressing the variables that promote reluctance to

seek help from both formal and informal sources for sui-

cidal thinking.

Help-Negation for Suicidal Thoughts in Subclinical

Samples

Since help-negation may not be unique to the therapeutic

situation, or completely explained as a function of hope-

lessness, it is noteworthy that there is evidence of the help-

negation process in subclinical (i.e., non-acutely suicidal)

samples. A large American study, which examined suicidal

ideation as a predictor of formal help-seeking behavior in

17,193 adolescents, found that those with high levels of

suicidal ideation were less likely to obtain help than those

with less severe ideation (odds ratio = .90, p \ .05) or no

suicidal ideation (odds ratio = .81, p \ .001). It was con-

cluded that ‘‘substantial barriers to seeking help are

associated with suicidality’’ (Saunders et al. 1994, p. 727).

Two Australian studies have since confirmed that an

inverse relationship between suicidal ideation and help-

seeking intentions occurs in subclinical samples of ado-

lescents and young adults (Deane et al. 2001; Wilson et al.

2005a). Help-seeking intentions and levels of suicidal

ideation were measured because these variables proximate

help-seeking behavior and suicide completion (Martin

2002; Webb and Sheeran 2006; Wilson et al. 2005b). In

both studies, even with the developmental differences that

exist between adolescents and young adults (i.e., differ-

ences in brain development, developmental tasks and social

expectations), a help-negation effect was found for formal

and informal help-sources. As levels of suicidal ideation

increased, intentions to seek help from a range of formal

help-sources, such as a mental health professional and a

family doctor, decreased. Similarly, help-seeking inten-

tions for informal sources, such as friends and family, also

decreased as suicidal ideation increased. In addition, in

both studies as levels of suicidal ideation increased, stu-

dents became increasingly likely to report that they would

not seek help from anyone for managing their suicidal

thoughts (Deane et al. 2001; Wilson et al. 2005a). Toge-

ther, the behavioral and cognitive help-negation results

raise an important implication for suicide prevention ini-

tiatives that rely on young people to proactively seek and

access help. How successful can these initiatives be if a

consequence of experiencing suicidal ideation, even in its

very early stages of development, is a tendency to with-

draw both behaviorally and cognitively from specific

helping opportunities, or to avoid help altogether?

Help-Negation for Symptoms of General Psychological

Distress

Suicidal ideation without other psychological disturbance

is rare in young people (Marttunen et al. 1991). In an

Australian study of 590 adolescents, higher levels of

self-reported suicidal ideation and symptoms of general

J Youth Adolescence (2010) 39:291–305 293

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psychological distress were both related significantly to

lower intentions to seek help from a family doctor for

suicidal and physical health problems (Wilson et al. 2009).

These results extend our understanding of the help-nega-

tion effect by indicating that, at subclinical levels, increases

in general psychological distress symptoms, as well as

suicidal ideation, can lead to intentions to avoid help.

Depression and anxiety are two of the most frequent

mental health problems experienced by young people

(ABS 2008). Research has shown that people can experi-

ence acutely clinical levels of depressive symptoms,

hopelessness and suicidality as independent mental health

problems (Fairweather-Schmidt et al. 2009; Stellrecht et al.

2006), or together, in what appears to be a subtype of

depression, called suicidal depression, which is particularly

chronic and treatment resistant (Shahar et al. 2006). It is

also common for people to experience co-occurring

symptoms of depression and anxiety when these symptoms

are at both acutely clinical and subclinical levels (Sheffield

et al. 2004; Thompson et al. 2004). The extent to which

symptoms of depression, hopelessness, and/or anxiety

influence the help-negating effect of suicidal ideation is a

question that is yet to be answered. Another question is

whether help-negation is a phenomenon that occurs for

different symptom clusters in subclinical samples of young

adults rather than just in subclinical samples of adolescents.

Depressive Symptoms

Almost 50% of young people who complete suicide have a

diagnosable mood disorder, such as depression (Cheung

and Dewa 2007). Several large-scale studies also point to

symptoms of depression having a help-negation effect that

is independent of suicidal ideation. A 20-year prospective

study of 6,891 psychiatric outpatients found that current

suicidal ideation, together with major depression, were two

of four unique and modifiable risk factors for eventual

suicide (Brown et al. 2000). Two population-based epide-

miological studies also suggest that young people with

higher levels of depressive symptoms are often more

reluctant to seek help than those with low levels of

depression. In a study that examined the coping and help-

seeking strategies of 2,419 American adolescents, one

quarter of those who participated in the study, who also had

depressive symptoms, indicated that they would keep their

feelings to themselves (Gould et al. 2004). Similarly, when

the relationship between depressive symptoms and the

help-seeking behavior of 9,000 American adolescents was

examined, higher levels of depressive symptoms were

related to ‘‘not seeking help from anyone’’ (Sen 2004).

Aspects of depression, which have been linked theoreti-

cally to the help-negation process, include the loss of

motivation and apathy (Wilson et al. 2007). It is possible

that even when levels of suicidal ideation are not acute, as

levels of depressive symptoms increase, young people

might experience increased levels of apathy and indiffer-

ence towards help-seeking, which subsequently reduce

their motivation to seek help for suicidal thinking. It is also

possible that, even in samples with subclinical levels of

suicidal ideation, the help-negation effect might be a

function of co-occurring processes that are either explained

by, or associated with, depressive symptoms.

Hopelessness

Hopelessness is a cognitive-emotional process that is wor-

thy of further consideration in relation to help-seeking.

Although studies that have controlled for hopelessness have

found that it does not fully account for the help-negating

effect of suicidal ideation in subclinical samples (Deane

et al. 2001; Wilson et al. 2005a), there are indications that

hopelessness, together with depressive symptoms, might

have a role in help-negation. An epidemiological study of

364 currently symptomatic 40-year-olds with affective

disorders found that hopelessness and self-criticism were

the only affective symptoms that predicted future help-

seeking (Burns et al. 2003). The researchers observed that

these cognitions were essentially pessimistic appraisals

about the individual’s emotional state rather than somatic

manifestations of depression (e.g., insomnia, anhedonia).

This suggests that global pessimistic self-judgments (i.e.,

the individual’s cognitive response to their distressed state)

may be more overwhelming, and may consequently have a

greater influence on help-seeking, than the immediate

extent of distress (Burns et al. 2003). Thus, hopelessness,

when it co-occurs with depressive symptoms, might

decrease help-seeking intentions and promote the help-

negation relationship.

Anxiety Symptoms

Although suicidal ideation and depressive symptoms have

been associated with help negation, the relationship

between symptoms of anxiety and help-seeking is unclear.

A study of 233 clients at an Australian specialist anxiety

clinic found that increased illness severity was the primary

prompt for clients’ actual help-seeking (Thompson et al.

2004). The researchers concluded that higher levels of

anxiety symptoms act as an ‘‘approach’’ factor for help-

seeking in that, as they experience increased levels of

anxiety, individuals become more likely to recognize that

they have a problem needing help, then seek help for it

(Thompson et al. 2004). If anxiety symptoms are approach

factors for help-seeking, then those who are suicidal and

have accompanying symptoms of anxiety may be more

likely to seek help than those without anxiety symptoms.

294 J Youth Adolescence (2010) 39:291–305

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However, a large school-based survey of 15–16-year-old

Norwegian young people (n = 11,154) found that even at

the highest symptom levels for anxiety and depression,

only a third of adolescents had sought professional help for

their condition (Zachrisson et al. 2006). A clearer under-

standing of the relationship between levels of anxiety

symptoms and seeking help from different sources is

warranted.

A Theoretical Framework for Studying Help-Negation

Mental health help-seeking in emerging adults requires a

dynamic interaction between the individual, often their

family, and always their cultural values, beliefs about

mental health and help-seeking, and contextual or sys-

tematic factors, such as the availability of services and

social networks (e.g., Cauce et al. 2002; Issakidis and

Andrews 2002; Liang et al. 2005; Mechanic 1995; Pesc-

osolido and Boyer 1999). Unlike other social interactions,

the objective in mental health help-seeking is intensely

personal. The decision to seek help for symptoms of psy-

chological distress is at the nexus of the individual’s per-

sonal experience of their distress and their interpersonal

expression of this experience. Consequently, the individ-

ual’s cognitive, affective and behavioral responses to their

symptoms of psychological distress are implicated in

explaining the gap between mental health need and service

use (Rickwood et al. 2005).

Help-seeking models, which focus on the individual’s

cognitive processes, converge to provide a useful frame-

work for examining the cognitive aspects of help-negation

in subclinical samples (e.g., Ajzen 1991; Anderson 1995;

Leventhal et al. 1998; Prochaska et al. 1992). Most models

of the cognitive aspects of help-seeking include similar

constructs under different labels (e.g., Bandura 1998; Nigg

et al. 2002; Noar and Zimmerman 2004). Common ele-

ments across cognitive help-seeking models are: beliefs

about seeking help (attitudinal, self-efficacy, normative,

risk-related) and help-seeking intention (Schreiber et al.

2009). Across cognitive help-seeking models, it is gener-

ally agreed that beliefs and intention are embedded within

a non-linear help-seeking process, which comprises three

broad stages: problem recognition, deciding to seek help,

and selecting a help provider. It is also generally agreed

that these stages lie within a context that includes indi-

vidual, interpersonal and sociocultural variables, which

both promote and support help-seeking (e.g., Cauce et al.

2002; Fox et al. 2001; Greenlay and Mullen 1990; Liang

et al. 2005; Pescosolido 1992).

Although these models are helpful for guiding our

understanding of the cognitive help-seeking process, they

don’t contribute to our understanding of how suicidal ide-

ation and other symptoms of psychological distress might

influence the decision to seek help. A major weakness of

many well-established social-cognitive help-seeking mod-

els is the assumption that making a decision to seek help is

a solely rational process, which, in turn, determines

behavior (Wills and Gibbons 2009). Few models pay any

attention to the influence of the individual’s affective state

or their cognitive response to their affective state (Henshaw

and Freedman-Doan 2009). Yet, in order to seek help, an

individual needs to recognize their symptoms and need for

help (i.e., have good mental health literacy and perceive

their need for help), but at the same time, the individual’s

psychological state can cause a lack of awareness of their

state (anosognosia; Shad et al. 2007), which, in turn,

impairs the individual’s cognitive awareness of their need

for help (Saunders and Bowersox 2007). Adolescents have

explained that they usually don’t know that they are

experiencing elevated levels of psychological distress until

a friend or family member points out their symptoms or

behavioral changes (Wilson and Deane 2001).

Suicidal ideation is the individual’s cognitive response

to their experience of the suicidal state, which is charac-

terized by cognitive and affective restriction (Clark and

Fawcett 1992). Symptoms of depression and anxiety are

also associated with cognitive distortion and altered cog-

nitive and affective function (e.g., Weishaar 1996). While

people who recognize their psychological symptoms and

need for help will seek it, elevated levels of cognitive

impairment impede the process (Saunders and Bowersox

2007). This suggests that the help-negating effecting of

suicidal ideation might be a function of impaired capacity

to make a help-seeking decision. It also suggests that

psychological symptoms, which commonly co-occur with

suicidal ideation (e.g., depression, hopelessness, and anxi-

ety), will exacerbate the individual’s cognitive impairment

and consequently strengthen the help-negating effect of

suicidal ideation.

Study Aims and Hypotheses

The first aim of the current study was to examine the extent

to which levels of suicidal ideation are related to help-

seeking intentions for a range of formal and informal

sources, as well as no one. We hypothesized that a sig-

nificant inverse relationship would be found between levels

of suicidal ideation and intentions to seek help from

informal and formal sources for suicidal thoughts. We also

hypothesized that higher levels of suicidal ideation would

be associated significantly with higher intentions to seek

help from no one for suicidal thinking.

The second aim of the current study was to examine the

extent to which symptoms of depression, anxiety, and

hopelessness, both individually and together, account for,

J Youth Adolescence (2010) 39:291–305 295

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or strengthen, the help-negating effect of suicidal ideation

in the subclinical sample. We hypothesized that higher

levels of depressive symptoms, anxiety symptoms and

hopelessness would, individually and together, explain the

help-negating effect of suicidal ideation for suicidal

thoughts. We also predicted that the strength of the help-

negating effect of suicidal ideation would be increased by

higher levels of depressive symptoms and hopelessness,

and reduced by higher levels of anxiety symptoms.

We expected that the results from the current study would

clarify whether aspects of subclinical suicidal ideation itself

act as help-seeking barriers, or whether the help-negating

effect of subclinical suicidal ideation appears to be a func-

tion of co-occurring symptoms of depression, anxiety, and

hopelessness. We also expected the results to clarify whether

the help-negating effect of suicidal ideation appears to be a

global effect that exists across all help sources or for only

some sources when symptoms of depression, anxiety, and

hopelessness are controlled. Through this clarification, we

anticipate that the current study will provide timely direc-

tions for further developments in universal and targeted

youth suicide prevention and early intervention initiatives.

Method

Participants and Procedure

The research received approval from the University of

Wollongong Human Ethics Committee. The study was

described in an advertisement on a Department of Psychol-

ogy research project sign-up board. Participants voluntarily

signed up for inclusion in the study to gain additional course

credit. A total of 302 psychology undergraduates completed

the anonymous study questionnaire, individually and under

the supervision of a postgraduate research assistant. Sample

characteristics are presented in Table 1.

Measures

Help-Seeking Intentions

The General Help-seeking Questionnaire (GHSQ; Wilson

et al. 2005b) measures participants’ intentions by asking

them to rate the likelihood that they would seek help for

suicidal thoughts from a variety of specific help sources.

Help sources were: intimate partner, friend, parent, non-

parent family member, mental health professional (e.g.,

counselor, psychologist, and psychiatrist), doctor/GP, tele-

phone helpline (e.g., Lifeline), and ‘‘would not seek help

from anyone’’. The following problem prompt was used: ‘‘If

you were having suicidal thoughts, how likely is it that you

would seek help from the following people?’’ Participants

rated their intentions to seek help from each of the eight

help-source items on a 7-point scale (1 = ‘‘Extremely

unlikely’’, 7 = ‘‘Extremely likely’’). Higher scores indicate

higher help-seeking intentions and are related to prospec-

tive help-seeking behavior, as well as inverse associations

with negative beliefs about seeking professional psycho-

logical help (Wilson et al. 2005b). For ease of expression,

‘‘Non-parent relative’’ was relabeled ‘‘Family’’, ‘‘Telephone

helpline’’ was relabeled ‘‘Phone counseling’’ and ‘‘Would

not seek help from anyone’’ was relabeled ‘‘No-one’’.

‘‘Friend’’, ‘‘Mental health professional’’, and ‘‘Doctor’’ were

left unchanged (as listed in Table 2).

Suicidal Ideation

The Suicidal Ideation Questionnaire (SIQ; Reynolds 1988)

comprises 30 items reflecting suicidal thoughts that are

self-rated on a 7-point scale (0 = ‘‘I never had this thought

before’’, 6 = ‘‘Almost every day’’). Items are scored to

indicate the frequency with which each suicidal thought

has occurred in the preceding month. Scores range from 0

to 180. Scores of 41 or above are considered to indicate

potentially significant psychopathology and acute suicidal

risk (Reynolds 1988). The SIQ is supported by sound

reliability and construct validity data in high school sam-

ples, aged 12–18 years-old, and university samples, aged

18–21 years-old (Reynolds 1987, 1988). The measure has

been found to relate positively to adolescent depression,

adult depression, hopelessness, anxiety, and negative life

events, and correlates negatively with self-esteem (Reynolds

1987). In the present study, Cronbach’s alpha was .96, sug-

gesting good reliability for the measure.

Table 1 Sample characteristics

Total sample Level of suicidal ideation

Minimal-

moderate

Criticala

ntotal (% Total Sample) 302 (100%) 279 (92.4%) 23 (7.6%)

nfemale (% Total Sample) 234 (77.5%) 215 (91.9%) 19 (8.1%)

nmale (% Total Sample) 68 (22.5%) 64 (94.1%) 4 (5.9%)

M(SD)age in years 19.78 (1.59)b 19.81 (1.59) 19.48 (1.62)

Rangeage in years 18–25 18–25 18–24

M(SD)SIQ 19.61 (21.24) 14.82 (10.62) 77.70 (30.48)

RangeSIQ scores 0–145 0–40 41–145

a A sum score of 41 or above indicates a level of suicidal ideation in

need of further investigation (Suicidal Ideation Questionnaire [SIQ];

Reynolds 1988)b 85.4% of the sample was 21 years or younger (n = 258)

296 J Youth Adolescence (2010) 39:291–305

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Depressive Symptoms

The Depression, Anxiety and Stress Survey (DASS;

Lovibond and Lovibond 1995) consists of 42 statements

that measure symptoms of depression, anxiety and stress

experienced in the past week (14 statements per scale).

Items included in the depression scale are: ‘‘I couldn’t

seem to experience any positive feeling at all’’, ‘‘I was

unable to become enthusiastic about anything’’, and ‘‘I felt

I wasn’t worth much as a person’’. Each statement is rated

on a 4-point scale (0 = ‘‘Did not apply to me at all’’,

3 = ‘‘Applied to me very much, or most of the time’’).

Scores for each scale are summed to indicate participants’

levels of depressive, anxiety or stress symptoms, and can

range from 0 to 42 per scale. The DASS has shown good

discriminant and concurrent validity (e.g., Antony et al.

1998; Lovibond and Lovibond 1995). In previous studies

with clinical samples, the DASS has shown excellent factor

structure that supports the independent use of each scale

(e.g., Antony et al. 1998). In the current study, the DASS

depression scale had a Cronbach’s alpha of .94 and was

used to measure depressive symptoms.

Anxiety Symptoms

The DASS anxiety scale (Lovibond and Lovibond 1995)

was used to measure anxiety symptoms. Items included in

the anxiety scale are: ‘‘I experienced breathing difficulty

(e.g., excessively rapid breathing, breathlessness in the

absence of physical exertion)’’, ‘‘I was aware of the action

of my heart in the absence of physical exertion (e.g., sense

of heart rate increase, heart missing a beat)’’, and ‘‘I felt

scared without any good reason’’. In the current study, the

DASS anxiety scale also demonstrated acceptable reli-

ability with a Cronbach’s alpha .82.

Hopelessness

The Beck Hopelessness Scale (BHS; Beck et al. 1974)

comprises 20 true–false items that reflect hopelessness and

appear to assess the general hopelessness construct (e.g.,

‘‘My future seems dark to me’’). Items are scored to indi-

cate the existence of hopelessness and the extent to which

an individual holds negative attitudes about the future.

Possible scores range from 0 to 20. The BHS is supported

by sound reliability and construct validity data across

samples (e.g., Metalsky and Joiner 1992). The measure has

been found to associate positively with suicidal ideation

and attempt, single-episode major depression, recurrent-

episode major depression, dysthymia, drug and alcohol

misuse (Beck and Steer 1988), and other self-report mea-

sures of hopelessness (Beck et al. 1974). In the present

study, Cronbach’s alpha for the scale was .81, indicating

acceptable reliability for the measure.

Results

Preliminary Analyses

The mean score and standard deviation for the raw SIQ data

are reported in Table 1. Only 80% (n = 23) of the sample

reported a level of suicidal ideation similar to that of

suicidal attempters with chronic psychiatric problems

(Reynolds 1987). This result, together with the mean

scores and standard deviations for depression (M = 8.59,

SD = 8.80), anxiety (M = 4.46, SD = 4.29), and hope-

lessness (M = 3.27, SD = 3.21), indicate that in the current

study, the majority of participants were in the normal range

on all measures of psychological distress. The mean scores

and standard deviations for help-seeking intentions for each

help-source are reported in Table 2. Frequencies of help-

seeking intention scores, indicating whether students were

generally unlikely (scores of 1, 2, or 3) or likely to seek help

(scores of 5, 6 or 7), are also reported in Table 2 for each

help-source.

To correct for positive skew, loglinear transformation

was applied to SIQ scores prior to analysis. Log SIQ was

used in all reported analyses (unless otherwise specified as

raw SIQ data). For ease of expression, log SIQ is described

as suicidal ideation in the results.

Given the substantial difference in group size for males

versus females in the total sample, we examined the pos-

sibility of sex effects in the following main analyses.

Additional calculations found that the mean SIQ scores for

Table 2 Frequencies (listed with approximate % of the sample),

means, standard deviations, and factor loadings (as reported in the

pattern matrix with a Direct Oblimin rotation) for intentions to seek

help for suicidal thoughts by help-source

Help-source Frequency M SD Factors

Unlikelya Likelyb 1 2

Partner 68 (23%) 207 (69%) 5.14 2.08 .84 -.13

Friend 75 (25%) 198 (66%) 5.02 2.04 .81 -.03

Parent 118 (39%) 156 (52%) 4.34 2.34 .82 .07

Family 159 (53%) 108 (36%) 3.40 2.18 .66 .12

Mental health 117 (39%) 150 (50%) 4.07 2.17 .08 .81

Phone counseling 176 (58%) 90 (30%) 3.08 2.05 -.14 .86

Doctor 194 (64%) 74 (25%) 2.87 1.98 .15 .74

No-one 190 (63%) 69 (23%) 2.68 2.19 – –

n = 302a Includes intentions scores of 1 = ‘‘extremely unlikely’’, 2 =

‘‘unlikely’’, and 3 = ‘‘somewhat unlikely’’b Includes intentions scores of 5 = ‘‘somewhat likely’’, 6 =

‘‘likely’’, and 7 = ‘‘extremely likely’’

J Youth Adolescence (2010) 39:291–305 297

123

females and males were not significantly different

(p = .572), the correlation between sex and suicidal idea-

tion was non-significant (p = .722), and there were no sex

differences on measures for intentions to seek help from

any sources for suicidal thoughts, or for depressive symp-

toms and hopelessness (all ps [ .05). Being female had

only a small correlation with higher levels of anxiety

symptoms (r = .13, p \ .05). Consequently, sex is not

included in further analyses.

Next, we examined whether categories of help-source

could be identified that would allow us to combine help-

source items to form subscales for use in the main analyses.

We submitted the seven sources of actual help to an

exploratory principle component analysis (PCA). Seeking

help from no one was not included in the PCA since ‘‘no

one’’ is not an actual source. We uncovered two factors with

eigenvalues greater than 1, which explained 65.61% of the

variance (Keiser–Meyer–Olkin measure of sampling ade-

quacy = .746; Bartlett’s test of sphericity: Approx

v2 = 677.470, df = 21, p \ .001). Factor loadings are

presented in Table 2. Based on this factor analysis, new

variables for different help-source categories were formed

by averaging group items with factor loadings that were

greater than .65. The new help-source variables were labeled

‘‘Family and friends’’ (4 items: M = 4.48, SD = 1.72,

a = .81) and ‘‘Professional care’’ (3 items: M = 3.34,

SD = 1.69, a = .75). The mean difference between the new

subscales revealed that intentions to seek help from family/

friends were significantly higher (p \ .001) than from

sources of professional care. The new help-seeking variables

were used in the main analysis, together with the single item

measuring intentions to seek help from no one.

Main Analyses

Intercorrelations between measures are reported in Table 3.

Evidence for help negation is indicated by significant

inverse correlations between suicidal ideation and help

seeking intentions. Higher levels of suicidal ideation were

significantly associated with lower intentions to seek help

from family/friends and health care professionals, and

higher intentions to seek help from no one, for suicidal

thoughts (Table 3). It is noteworthy that the magnitude of

the help-negation effect was strongest for seeking help

from no one. It is also noteworthy that depressive symp-

toms and hopelessness had significant inverse correlations

with intentions to seek help, and significant positive cor-

relations with intentions to seek no help, for suicidal

thoughts.

To test the hypotheses that university students with

higher levels of suicidal ideation might negate help because

they feel generally hopeless, depressed, or anxious, we

conducted three hierarchical regression analyses, one for

each intentions variable, with suicidal ideation and hope-

lessness entered in Step 1, depressive symptoms in Step 2

and anxiety symptoms in Step 3. As reported in Table 4,

with hopelessness, depressive symptoms and anxiety

symptoms controlled, suicidal ideation remained associated

significantly with lower intentions to seek help from fam-

ily/friends and health care professionals, and higher

intentions to seek help from no one for suicidal thoughts

(Step 3: Friends and family, F(4, 298) = 8.65, p \ .001;

Professional sources, F(4, 298) = 5.26, p \ .001; No one,

F(4, 298) = 9.77, p \ .001). Contrary to expectations, hope-

lessness, depressive symptoms and anxiety symptoms,

neither individually nor together, were able to fully account

for the help-negation effect for family and friends or

seeking help from no one for suicidal thoughts. For

intentions to seek help from a mental health professional,

the inclusion of depressive symptoms at Step 2 meant that

the inverse relationship between suicidal ideation and

intentions became non-significant. However, the extent to

which depressive symptoms explain the help-negating

effect of suicidal ideation for mental health professionals is

Table 3 Intercorrelations between measures

Measure 2 3 4 5 6 7

1 Suicidal ideation(SIQ) .62*** .50*** .55*** -.32*** -.20*** .37***

2 Depression(DASS) .68*** .52*** -.20*** -.18** .31***

3 Anxiety(DASS) .38*** -.10 -.06 .19**

4 Hopelessness(BHS) -.23*** -.22*** .29***

Help-seeking intentions for suicidal thoughts(GHSQ)

5 Friends and family .37*** -.46***

6 Professional carea -.29***

7 No one

n = 302; SIQ = Suicidal Ideation Questionnaire; DASS = Depression, Anxiety, Stress Scales; GHSQ = General Help-Seeking Questionnairea Professional care includes mental health specialists as well as general medical practitioners (family doctors)

*** p \ .001, ** p \ .01

298 J Youth Adolescence (2010) 39:291–305

123

unclear. Entering depressive symptoms into the model for

professional mental health care reduced the standardized

Beta coefficient by only .1 from -.14 to -.13 and did not

increase the amount of variance explained by the model.

This suggests that if depressive symptoms have a unique

influence on the help-negation effect for mental health

professionals, it is only minimal.

To examine this result further, the possibility that

depressive symptoms might influence the overall strength

of university students’ help-negation was explored. On the

basis of recommendations made by Cohen et al. (2003),

regression analyses were used to evaluate whether

depressive symptoms moderated the help-negation rela-

tionship (Cohen et al. 2003). A series of regression anal-

yses were conducted using suicidal ideation then

depressive symptoms and the product terms between sui-

cidal ideation and depressive symptoms to predict each

help-seeking intentions variable. Following the procedure

outlined in Aiken and West (1991) for testing moderation

effects involving continuous variables, all continuous

variables were converted to z scores before analysis. Alpha

was set to .01 to minimize the problem of Type 1 error.

The suicide x depressive symptom interaction was sig-

nificant for seeking help from friends/family (b = .66,

p = .002) and not seeking help at all (b = -.56,

p = .006). In contrast, the interaction was not significant

for seeking professional mental health care. These results

provide evidence of a moderation effect between depres-

sive symptoms and the help-negation relationship for

informal help sources and seeking help from no one, but

not for formal help sources. Exploring these interactions

further, we followed the procedure suggested by Aiken and

West (1991) and generated values from the regression

equation based on assigning z score values of 1 and -1 to

depressive symptoms and suicidal ideation (generating four

values). The results confirmed that for seeking help from

friends/family and no one, the help-negating effect of

suicidal ideation was greater amongst those with high

levels of depressive symptoms compared to those experi-

encing low levels of depressive symptoms.

Finally, we conducted the same analyses as above but

with the high scorers in the top 8% (n = 23; equivalent to a

suicidal attempter, Reynolds 1987) removed from the

sample. With the sample reduced, the analyses replicated

the results described above and suggest that the current

results apply to university students, aged 18–25 years old,

with subclinical levels of suicidal ideation only.

Discussion

The current study provides evidence that, even at sub-

clinical levels, suicidal ideation impedes the cognitive

help-seeking process at the decision to seek help stage. The

study found that, as levels of suicidal ideation increase

within a subclinical range, young peoples’ intentions to

seek help for suicidal thoughts decrease. This was for

informal help-sources, including intimate partners, friends,

parents and other family, as well as formal professional

mental health sources. Conversely, intentions to seek help

from no one for suicidal thoughts increase as levels of

suicidal ideation increase.

Higher levels of depressive symptoms and hopelessness

were associated significantly with lower intentions to seek

help from friends, family and mental health care profes-

sionals. In contrast, anxiety symptoms were not associated

significantly with intentions to seek help from either type

of help source. A young person’s primary means of

recognizing that a problem exists usually includes attitu-

dinal, affective, behavioral and/or physiological cues

(Frauenknecht and Black 2003). We hypothesized that,

even at subclinical levels, anxiety would act as an approach

factor for help-seeking because anxiety symptoms, partic-

ularly those such as agitation and shaking that are

Table 4 Summary of

regression analyses for suicidal

ideation predicting help-seeking

intentions for suicidal thoughts

*** p \ .001, ** p \ .01,

* p \ .05

B SE b Adj R2

Step 1: Hopelessness controlled

Friends and family -.44*** .10 -.30 .11

Professional care -.25* .13 -.14 .07

No-one .63*** .17 .26 .12

Step 2: Hopelessness and depressive symptoms controlled

Friends and family -.47*** .11 -.32 .11

Professional care -.23 .14 -.13 .06

No-one .47* .20 .19 .12

Step 3: Hopelessness, depressive symptoms and anxiety symptoms controlled

Friends and family -.47*** .12 -.32 .10

Professional care -.24 .15 -.14 .06

No-one .50** .20 .20 .13

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123

physiological and often visible, would improve problem

recognition and, in turn, enable the cognitive help-seeking

process. However, we found no evidence to support this

hypothesis. Since anxiety symptoms are associated with

help-seeking in acutely anxious patients (Thompson et al.

2004), it is possible that anxiety acts as an approach factor

only when symptoms are acute. There may be a critical

level that anxiety symptoms need to reach before a young

person will respond to them by seeking help. Further

research needs to examine this possibility.

With symptoms of depression, anxiety and hopelessness

controlled, higher levels of suicidal ideation predicted lower

help-seeking intentions for friends and family, and higher

intentions to seek no help from anyone. The covariates were

unable to fully account for the help-negating effect of sui-

cidal ideation for seeking help from friends, family and no

one. In contrast, for mental health professionals, the sig-

nificant inverse relationship between suicidal ideation and

intentions became non-significant once depressive symp-

toms were controlled. Entering depressive symptoms into

the regression equation reduced the standardized Beta

coefficient by .1 and did not increase the amount of variance

explained by the model. This suggests that the role of

depressive symptoms in explaining the help-negation rela-

tionship for mental health professionals is, at best, minimal.

Instead, these results suggest that before suicidal ideation

reaches levels that would be considered acute and clinically

significant, there are variables over and above the symptom

clusters examined in the current study, which might explain

the help-negation process. The results also confirm that

suicidal ideation itself is both a significant barrier to seeking

help and a general help-avoidance factor, which impedes

the cognitive help-seeking process by reducing help-seek-

ing intentions that are located in the decision making stage.

Saunders and Bowersox (2007) have outlined a 7-step

cognitive process model for seeking professional mental

health care. After problem recognition (Step 1) and before

selecting a help source (Step 7), the model suggests that

five steps are involved in deciding to seek treatment:

deciding the problem is mental health related (Step 2),

deciding change is needed (Step 3), deciding to make

efforts to effect change (Step 4), deciding professional help

is needed to effect change (Step 5), and deciding to seek

professional mental health care (Step 6). Since Steps 4–6

are planning and action steps, and thus, the intention steps

involved in making a mental health help-seeking decision,

the model suggests that suicidal ideation has the greatest

impact on Steps 4–6.

Saunders and Bowersox’ (2007) model also suggests

that each intention step (Steps 4–6) relates to specific

barriers, which are prominent at these steps and which

impede the mental health help-seeking process. At Step 4,

the prominent barrier that promotes treatment delay or

help-avoidance is the preference for solving one’s own

problems. At Step 5, doubting the need for treatment,

having negative attitudes about treatment, distrusting

mental health professionals, and fearing stigma, others’

reactions to seeking treatment and vulnerability through

self-disclosure in treatment are the prominent barriers. At

Step 6, the prominent barrier is the real or perceived

inadequate availability of services. It is notable that most

barriers, which are related to Steps 4–6, are beliefs that

might influence help-negation for mental health sources.

Even at low levels, suicidal ideation might exacerbate these

beliefs and consequently reduce the individual’s intention

and decision to seek treatment for their suicidal thinking.

Further research needs to examine this possibility. Whether

these specific beliefs have a role in the help-negation

process for informal sources or generally avoiding help

also needs to be clarified.

Although depressive symptoms couldn’t fully explain

the help-negation relationship for informal sources and no

one, the current study found evidence that depressive

symptoms moderate help-negation for seeking help from

family, friends, and seeking no help at all. This suggests

that at least some depressive symptoms have a role in

strengthening the help-negating effect of suicidal ideation

for friends and family, as well as in promoting general

reluctance to seek help from everyone. These results are

also consistent with a study of over 1,700 adolescents and

young adults which found that higher levels of depressive

symptoms were related significantly to lower help-seeking

intentions for informal sources for personal-emotional

problems (Wilson et al. 2007). Wilson et al. found that the

help-negating effect of depressive symptoms was strongest

for parents when compared to other help sources, but that

young people with the highest levels of depression were

also those who were most likely to avoid help altogether.

This trend is particularly concerning given the major role

that friends and parents often have in providing support and

access to professional help sources (e.g., Burns et al. 2003;

Cusack et al. 2004).

Other aspects of depression that might be of interest

include the loss of motivation or apathy that is part of the

depressive symptom spectrum. As levels of depressive

symptoms increase, young people might experience

increased levels of apathy and indifference towards help-

seeking, which subsequently reduce their motivation to

seek help (Wilson et al. 2007). Limited cognitive aware-

ness of one’s psychological state, which is associated with

the experience of different types of psychological symp-

toms, is also implicated in help-negation (Saunders and

Bowersox 2007). Further research needs to identify the

specific aspects of depression that contribute to the help-

negation process, together with the ways that these aspects

function to reduce help-seeking intentions when depressive

300 J Youth Adolescence (2010) 39:291–305

123

symptoms are at subclinical levels. Answers to these

questions might explain why almost 90% of Australians

who didn’t seek help for their common mental disorders in

the last year did not think that they needed any type of

mental health care (Meadows and Burgess 2009).

There are several variables that might influence the help-

negation process specifically for family and friends, some of

which are consistent with the barriers that are related to

treatment seeking by Saunders and Bowersox (2007).

Firstly, it is possible that individuals who are experiencing

suicidal ideation or increased levels of depressive symptoms

become reluctant to seek support or advice from informal

sources because they do not think these sources can help.

Help-negation in acutely suicidal and depressed individuals

‘‘involves the belief that one’s problems are so severe or so

complicated that others are unlikely to understand them or

even be capable of providing assistance’’ (Stellrecht et al.

2006, p. 1131). The belief that ‘‘nothing could help’’ was the

second most endorsed barrier (18%) to seeking help for

symptoms of psychological distress in the 1997 Australian

National Survey of Mental Health and Well-being (Sawyer

et al. 2000). Past experiences where seeking help is not

perceived as helpful by the young person may also contribute

to help avoidance (Wilson et al. 2007). This can include

experiences where the young person felt that they were not

listened to or that their problems were not taken seriously

(Rickwood et al. 2005; Stellrecht et al. 2006). It also seems

likely that help-avoidance would be exacerbated in families

and friendships that are experiencing dysfunction or inter-

personal distance.

Secondly, it is possible that suicidal or depressed young

people strive to maintain an appearance of strength,

believing that to tell family or friends about their distress

might ‘‘let their friends or family down’’. Prior research has

identified several belief-based barriers to help-seeking that

support this possibility. The beliefs: ‘‘I think it is important

to remain strong and silent in the face of hardship, even if

you are hurting inside’’ and ‘‘I work hard to prevent people

from seeing my vulnerable side’’ have both been found to

impede help-seeking (Burns et al. 2003; Kuhl et al. 1997).

Alternatively, young people have described their concern

about unduly worrying their friends and family if they talk

about a distressing problem, and particularly if that prob-

lem relates to suicide (Wilson and Deane 2001). For friends

and family, this suggests that the help-negating effect of

suicidal ideation might be underpinned by a fear that tell-

ing one’s friends and family about suicidal thoughts would

place too great a burden on these loved ones.

Another possibility is that the meaning that a young

person associates with their psychological distress symp-

toms might contribute to help-seeking reluctance (Wilson

et al. 2009). Young people are particularly concerned about

being seen as ‘‘mental’’ by their friends and others

(Wisdom et al. 2006). Stigma is associated with different

types of mental health problems and is a major barrier to

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

Bowersox 2007; Vogel et al. 2007). Young people who are

experiencing suicidal ideation, even at subclinical levels,

might avoid help because they predict negative conse-

quences if they tell their friends or family about their

problem (e.g., Barney et al. 2005). The extent to which

each of these hypotheses can explain the help-negation

effect is unknown and requires further research.

In the meantime, the current results suggest that help-

seeking promotion programs would do well to place further

attention on the role of parents and friends, as well as other

gatekeepers such as coaches and teachers, in the pathway

to professional mental health care. Australia provides

several examples of how this might be done. Beyondblue—

the Australian national depression initiative—runs a tele-

vision and radio advertising campaign that teaches friends

how to support friends who are depressed. The Motor

Trade Association of Australia promotes the slogan ‘‘mates

help mates’’ through its readthesigns website. The website

also teaches strategies for colleagues, friends and family

members to recognize and facilitate access to professional

mental health care for signs of depression, anxiety and

suicidality; in employees, peers and loved ones. The Aus-

tralian national headspace PASS!—Promoting Access and

Support Seeking—program uses classroom presentations to

promote the value of help-seeking from a range of avail-

able sources. It also implements a range of rehearsal

activities to teach young people how to seek help and what

they can do when they find the response of others, to their

initial help-seeking advances, to be unhelpful. Similar

initiatives are also implemented internationally (Gould

et al. 2003). Help-seeking programs such as these would

also benefit from preparation of helpers or ‘‘gatekeepers’’

(i.e., the support people in a young person’s community

who are not trained mental health professionals). For

example, gatekeepers might benefit from assistance in

recognizing the signs of mental disorders, reducing stigma,

and recognizing their own personal barriers to help-seek-

ing. This would serve the dual purpose of modeling healthy

behavior for young people, as well as maintaining gate-

keepers’ own mental health and their ability to function

effectively as help-providers (Cartmill et al. 2009). Such

initiatives should also emphasize teaching skills to young

people and their gatekeepers, which involve practicing the

specific steps involved in seeking help. By rehearsing the

steps involved in help-seeking when people are not dis-

tressed, it might be possible to improve their use of these

steps when they are distressed and needing appropriate

support and good advice.

At a policy level, the current study reinforces the need

for Governments to fund suicide prevention strategies that

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123

focus on reducing barriers to help-seeking, paying particu-

lar attention to the help-negation process and the ways in

which this trend might differ for different indicators of

mental health problems, different help sources, and for each

of the five systems of interaction within an individual’s

bioecological system (i.e., their Microsystem, Mesosystem,

Exasystem, Macrosystem, and Chronosystem; Bronfen-

brenner 2005). There is also a need for Governments to fund

longitudinal epidemiological research that maps help-

seeking pathways for different types of psychiatric symp-

toms, together with the impact of co-morbidity between

these symptoms, across cultures and countries. For exam-

ple, there is evidence that different forms of mood disorder

are equally severe in young people but that they may have

different patterns of associated factors that might influence

help-seeking (Flament et al. 2001). Such research might

make it possible to address help-avoidance early, and con-

sequently, reduce the high prevalence of mental illness that

currently exists among young people the world over (Belfer

2008).

Limitations

There are several limitations to the current study that should

be considered when reviewing these results. It is encour-

aging that the help-negation effect, as found in the current

results, appears consistent with the pattern of results found

in previous behavioral help-negation studies using acutely

suicidal samples, as well as in large-scale help-seeking

studies using subclinical community samples. Nonetheless,

the use of university students as the only source of data in

the current study means that the extent to which these

results generalize to young adults at the community- or

population-level is not known. Similarly, the use of cross-

sectional data, collected at one time-point, does not allow

for unequivocal causal conclusions. The extent to which the

results were influenced by shared sources of method vari-

ance in self-report data is also not known.

In addition to the limitations above, the current study

used a measure of help-seeking intentions (GHSQ) that

asked participants about problems that might be experi-

enced hypothetically. It is unclear to what extent partici-

pants were actually able to identify with the problem when

making their ratings. Subsequent studies might address this

issue by supplementing the GHSQ with aspects of Hinson

and Swanson’s (1993) methodology for assessing willing-

ness to seek help. Their method used two personal-emo-

tional problem vignettes (one with high severity and one

with low severity) to examine participants’ help-seeking

intentions. Future studies might be improved by obtaining

behavioral data (e.g., via observer rating or diary) to sup-

port self-report ratings, from participants who are recruited

from a wide range of contexts.

Ultimately, there is a need for prospective epidemio-

logical studies to more clearly define the causal relation-

ships between different forms of psychological distress,

particularly suicidal ideation and depressive symptoms,

and subsequent help-seeking cognitions and behaviors. In

the meantime, less expensive cross-sectional studies, which

have stronger correlational designs than used in the current

study, are needed to identify modifiable variables that show

promise for explaining the help-negation process. In future

studies, the directions of relationships between variables

might be examined by using a prospective-longitudinal,

cross-lagged, multi-wave design (Shahar et al. 2006).

Future studies would also benefit by the guidance of a

person-centered model, which is framed by a person-in-

context model, and which accounts for both the actual and

perceived availability of support that exists across the

developmental course of an individual’s life.

Conclusion

The current study provides evidence that, even at sub-

clinical levels, suicidal ideation impedes the cognitive

help-seeking process at the decision to seek help stage in

18–25-year-old university students. Higher levels of sui-

cidal ideation predicted lower intentions to seek help from

formal and informal help sources, and higher intentions to

seek no help, for suicidal thoughts. Depressive symptoms

moderated the help-negation relationship for seeking help

from friends, family and no one. Thus, it appears that

higher levels of depressive symptoms have a role in

strengthening the help-negating effect of suicidal ideation

for informal sources and seeking help from no one.

Although the identification of the specific variables that

account for these results remains for further research, the

current results highlight the importance of improving our

understanding of why young people become reluctant to

seek help as their levels of suicidal ideation and depressive

symptoms increase. Future research would do well to

examine the impact of suicidal ideation on the other stages

of the cognitive help-seeking process (i.e., problem rec-

ognition and selecting a help provider). Future research

also needs to identify the determinants of help-negation for

suicidal ideation and depressive symptoms, whether the

effect occurs for symptom clusters other than those

examined in the current study, and whether the effect

occurs for different symptom clusters across groups with a

range of demographic and developmental characteristics.

In the meantime, mental health promotion strategies should

continue to focus on promoting appropriate help-seeking,

as well as to alert young people, and their families, friends

and mental health care clinicians, about the help-negation

effect for suicidal ideation and depressive symptoms. By

302 J Youth Adolescence (2010) 39:291–305

123

raising awareness, it might be possible to reverse this effect

when symptoms of depression and suicidal thoughts are

first recognized.

Acknowledgments The study was funded by the National Health

and Medical Council of Australia (Grant YS060). The authors wish to

thank Greg Scott and Associate Professor Joseph Ciarrochi for their

contribution to data collection and entry.

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Author Biographies

Dr. Coralie Wilson is the Academic Leader for the Professional and

Personal Development Curriculum Theme and a Senior Lecturer in

Behavioral Health Sciences in the Graduate School of Medicine at the

University of Wollongong. She is also Co-Chair of the Graduate

School of Medicine Research Themes. Coralie received her PhD in

clinical psychology research from the University of Wollongong, has

professional training in both teaching and psychology, and has major

research interests in help-seeking and behavioral psychological

medicine.

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

and Director of the Illawarra Institute for Mental Health at the

University of Wollongong. He received his PhD from Massey

University and has major research interests in the areas of mental

health and drug & alcohol service use, medication alliance, the use of

homework in clinical practice and help-seeking.

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