Beliefs About Help Seeking for Mental Disorders: Findings From a Mental Health Literacy Study in Singapore

Mental health literacy has been defined as “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” (1). Mental health literacy consists of several components, including the ability to recognize specific disorders or different types of psychological distress; knowledge and beliefs about risk factors, causes, self-help interventions, and professional help available; attitudes that facilitate recognition and appropriate help seeking; and knowledge of how to seek mental health information (2). Studies of mental health literacy suggest that poor recognition of symptoms, lack of knowledge and understanding about treatment options, and stigma related to mental disorders create barriers to help seeking and thus adversely affect treatment outcomes (1,3,4).

Despite the availability of various effective treatments, mental disorders are often underrecognized and undertreated (5). This may be largely due to the fact that help-seeking behavior is complex and encompasses a combination of interacting and influencing factors. Research has shown that failure to recognize signs and symptoms of mental disorders leads to delayed help seeking (6) or seeking help from inappropriate sources. It is therefore crucial to understand the factors that may impede help seeking for health problems (7), including mental disorders.

Help seeking for mental disorders is related not only to recognition of the problem but also to beliefs about the effectiveness and helpfulness of treatment and interventions. Recognition is most commonly viewed as the necessary first step to seeking appropriate help. However, it is also important to promote appropriate help seeking for mental health problems, especially from evidence-based sources. Improving mental health literacy in the community is pivotal to increasing appropriate help seeking and ameliorating the high level of unmet need for treatment of mental disorders (8,9).

Most mental health literacy research has been conducted in Western countries. Research in Asian settings has revealed some obvious cultural differences in help-seeking beliefs. For example, in a mental health literacy study about schizophrenia, Chinese from Shanghai were more likely than Chinese living in Hong Kong or Australia to prefer medical treatments to psychosocial treatments (10). In Malaysia, witchcraft and possession by spirits are believed to be important causes of mental illness, which led people to seek help from traditional and religious healers rather than from mental health professionals (11).

Research on mental health literacy in Singapore is limited. Parker and colleagues (12) surveyed psychiatrists, nurses, and allied health staff at a psychiatric hospital in Singapore, and Yeo and colleagues (13) undertook a similar survey at the same hospital of psychiatric and general nurses. However, given that neither study involved the general population, lay beliefs, attitudes, and perceptions about help seeking and outcomes for people with mental disorders are not well studied in Singapore. Furthermore, previous research in Singapore has shown a significant treatment gap for several mental disorders; 96% of persons with alcohol abuse and 90% of those with obsessive-compulsive disorder (OCD) reported not receiving any treatment (5), which may be a result of poor mental health literacy. This finding emphasizes the need for a national mental health literacy study.

Singapore is an island city-state in Southeast Asia, with a multiethnic population of approximately 5.5 million people in 2014, of which 3.9 million are Singapore citizens or permanent residents. The ethnic breakdown of the resident population is as follows: Chinese (74.3%), Malays (13.3%), Indians (9.1%), and other ethnic groups (3.3%) (14). Mind Matters was the first national, population-based study that aimed to assess recognition of and beliefs pertaining to causes, treatment options, and outcomes for alcohol abuse, dementia, depression, OCD, and schizophrenia in Singapore and to determine the sociodemographic correlates of mental health literacy. The study reported here specifically aimed to investigate beliefs about help seeking, treatment options, and expected outcomes in a multiethnic Asian population, by using a vignette-based approach describing a person with each of these five disorders.

Methods

Participants and Procedure

The Mind Matters study was a comprehensive, population-based, cross-sectional survey conducted among Singapore citizens and permanent residents ages 18 to 65 who were living in Singapore between March 2014 and April 2015. Respondents were randomly selected via a national registry that maintains names and sociodemographic details, such as age, gender, ethnicity, and household addresses of all Singapore residents. Residents living outside Singapore, those who were unable to be contacted because of incomplete or incorrect addresses, and those who were unable to complete the interview in one of the specified languages were excluded from the survey. Respondents were interviewed in their homes or another preferred location and completed the interviewer-administered questionnaire in English, Mandarin, Malay, or Tamil, according to their preference.

The study was approved by the National Healthcare Group Domain Specific Review Board. All respondents provided written informed consent; for those under age 21, written informed consent was also obtained from their legally acceptable representative, parent, or guardian. More information about methods and procedures of the Mind Matters study is available elsewhere (15).

Survey Interview

The interview was based on a vignette describing a person with one of five mental disorders—alcohol abuse, dementia, depression, OCD, or schizophrenia—and followed a protocol similar to those used in previous research (1). The five disorders were chosen for various reasons, including their prevalence in the local population, the associated treatment gap, age at onset, and their significant effect on quality of life. Respondents were randomly allocated one of the five vignettes, which described a person of the same gender and ethnicity as themselves. All vignettes reflected DSM-IV and ICD-10 diagnostic criteria for the five disorders and were written in conjunction with local experts in each of the disorders. The vignettes and related questions, along with the other measures included in the questionnaire, were pretested to ensure an adequate level of understanding in the local population, and adaptations were made where needed before the survey began. The five vignettes are available on request.

After being read the vignette, respondents were asked a series of questions, including the open-ended question, “Whom do you think the person in the vignette should seek help from?” This was followed by a series of questions about the likely helpfulness of 28 different interventions, which the respondent rated as likely to be helpful, harmful, or neither for the person described in the vignette. The interview also included questions about the likelihood of recovery for the person in the vignette with and without “seeking professional help”; the following response options were used: “full recovery with no further problems,” “full recovery but problems may come back,” “partial recovery but problems may come back,” “no improvement,” and “get worse.” Sociodemographic information about the respondents was collected with a structured questionnaire, and items such as age and ethnicity were verified against the respondent’s National Registration Identity Card. Respondents were also asked whether they or someone close to them had experienced problems similar to those described in the vignette.

Field Supervision and Quality Control

Professionally trained interviewers from an external survey firm conducted the interviews after being trained by research staff at the Institute of Mental Health (IMH) in Singapore. After passing a detailed evaluation, interviewers were initially closely supervised by IMH staff and field executives from the survey firm. Throughout the data collection phase, quality assurance processes were also implemented to ensure high-quality data. A minimum of 20% of each interviewer’s cases were subjected to detailed verification by the survey firm, which used a structured script to identify any falsification of data, and all quality control efforts were reported fortnightly to the research team. Repeated attempts were made to contact each respondent; interviewers were required to make at least ten attempts (on different days and at different times) to reach the respondent, before the respondent could be classified as a nonresponder.

Coding and Content Analysis of Open-Ended Questions

Responses to the question “Whom do you think the person in the vignette should seek help from?” were coded as follows: “talk to family or friends,” “seek help from the IMH” (the only tertiary psychiatric hospital dedicated to providing mental health services in Singapore), “see a psychologist,” “see a psychiatrist,” “see a doctor or general practitioner (GP),” “see a counselor or have counseling,” “the person does not need help,” and “don’t know.” Most respondents recommended one source of help; however, when respondents suggested multiple sources, only the first response was coded. Responses endorsed by less than 3% of respondents were categorized as “other.” This category included the following sources: talk to someone, online help, traditional Chinese medicine/Jamu/Ayurvedic–based treatment, government agency, voluntary welfare organization, support group, religious advisor or organization, telephone helpline, disorder-specific organization or clinic, community development council, community center, social worker, specialist, manage on his or her own, and get out more or be more social. Some respondents suggested that the person in the vignette must first recognize that he or she has a problem.

Statistical Analysis

All estimates were weighted to adjust for oversampling and poststratified for age and ethnicity distributions between the survey sample and the Singapore resident population in the year 2012. Weighted means and standard errors were calculated for continuous variables, and frequencies and percentages were calculated for categorical variables. Demographic characteristics were compared between groups and tested for significant differences with chi-square tests. Multinomial logistic regression models were used to generate odd ratios and 95% confidence intervals for the relationship between nominal outcome variables and predictor variables. Standard errors and significance tests for survey data analysis procedures were estimated by using the Taylor series linearization method to adjust for the weighting. Multivariate significance was evaluated by using Wald chi-square tests based on design-corrected coefficient variance-covariance matrices. Statistical significance was evaluated at the .05 level with two-sided tests. Data analysis was conducted with SAS, version 9.3.

Results

Of 4,231 persons contacted, 3,006 completed the survey, yielding a response rate of 71%. Females represented 49.1% and males 50.9% of the sample. The mean±SD age of the respondents was 40.9±13.4 years. Most of the sample was of Chinese ethnicity (74.7%) and married (64.0%). [A table summarizing other sociodemographic characteristics is available in an online supplement to this article.]

Table 1 shows the frequency of responses to the open-ended question about help seeking. “Talk to family or friends” was the most common source of help recommended for alcohol abuse (30.1%), depression (54.2%), and schizophrenia (21.5%), and “see a doctor or GP” was the most common source for dementia (53.8%) and OCD (26.8%).

Significant sociodemographic differences were associated with recommending the various sources of help and in whether respondents reported having or knowing someone with a mental disorder (Table 2 ). For example, when “talk to family or friends” was used as a reference group, we found older respondents (age 35–49 and 50–65) were less likely than younger respondents (18–34) to recommend seeing a psychologist, females were more likely than males to recommend seeing a counselor, and those of Indian ethnicity were less likely than those of Chinese ethnicity to suggest seeing a doctor or GP.

Tables 3 and 4 summarize responses about whether specific help-seeking interventions were rated as helpful or harmful. Across vignettes, “see a psychiatrist” (88.4%) and “read about how people have dealt with similar problems” (86.4%) were viewed as most helpful. “Dealing with problems on his or her own” (64.6%) and “having an occasional drink to relax” (55.4%) were viewed as the most harmful interventions.

Table 5 summarizes respondents’ views about the most likely outcome if the person in the vignette sought appropriate help or if he or she did not. Excluding the dementia vignette, the most frequently reported outcome if appropriate help was sought was “full recovery but problems may come back.” For all five vignettes, “get worse” was considered the most likely outcome if appropriate help was not sought.

Discussion

This is the first national study on beliefs and attitudes related to help seeking, treatment options, and outcomes for people with mental disorders in Singapore. We found that the most commonly recommended source of help for persons described in the alcohol abuse, depression, and schizophrenia vignettes was talking to family or friends. Research has consistently shown that Asians prefer to seek help from less formal sources, such as family, for mental health problems (16–19). Alternatively, respondents may have believed that the family should decide where further help should be sought (20,21).

These findings have important implications because informal sources of help should have adequate skills, knowledge, and mental health literacy to recognize mental health issues and to recommend professional sources of help when needed. Seeking appropriate help from professional sources is crucial for prevention, early detection, and treatment of and recovery from mental disorders (22,23), and timely referral to these sources is essential. For the dementia and OCD vignettes, the largest proportion of respondents recommended seeing a doctor or GP, which may indicate that these disorders are viewed as more serious or require more professional help.

Seeking help from a psychiatrist was less commonly recommended, which may reflect poor awareness of psychiatric services or a lack of understanding of the types of effective treatments offered by such professionals. Help-seeking behavior may also be influenced by cultural and religious influences, which play an important role in mental health literacy (24). As a result of cultural factors, people may be uncomfortable explicitly acknowledging their mental health problems to a health professional and may thus choose to confide in family or friends. Stigma, which is manifested in bias, distrust, stereotyping, fear, embarrassment, anger, and avoidance (25), may be another deterrent and has been identified as a barrier to service use in Asian societies.

Sociodemographic correlates were associated with help-seeking preferences. For example, older persons were less likely than younger persons to recommend seeing a psychologist compared with talking to family or friends, which may reflect their poorer mental health literacy compared with younger persons (26–28). Alternatively, this finding may reflect young adults’ widespread use of social media, in which mental health messages are conveyed.

Ethnic differences were also observed. Indians were less likely than Chinese to recommend seeing a doctor or GP (versus talking to family or friends). These findings are consistent with previous research conducted in India related to depression and psychosis (29), as well as a study among Indians in Malaysia that focused on depression (24). Both these studies, which also used vignettes, found that very few people suggested seeing a doctor or going to a hospital for depression. Given that the vast amount of mental health literacy research has been conducted in Western countries, further research exploring ethnic and cultural differences and preferences for mental health help seeking in Asian societies is needed.

Respondents who reported having experienced problems similar to those described in the vignette were significantly less likely to recommend seeking help from a doctor or GP versus talking to family or friends. A previous study that examined service use by persons with mental illnesses in Singapore (30) found that only a small number sought help from a doctor or GP. Respondents who reported that they knew someone with problems similar to those in the vignette were less likely to recommend seeking help from a psychiatric hospital compared with talking to family or friends. These findings may be explained by possible stigma associated with seeking treatment at a psychiatric institution; however, further research is required to examine this possibility.

Most respondents indicated that seeking help from a psychiatrist (88.4%) or psychologist (82.8%) was the most helpful intervention for someone with a mental illness. It is important to recognize that even though these sources were perceived as helpful, they were not necessarily the source of help that people recommended; help from a psychiatrist or psychologist may be a last option, after talking to family and friends or seeing a doctor or GP.

Discrepancies were observed between what health professionals (13) and the general population in Singapore believe about the helpfulness of certain medications. In a previous study, health professionals viewed sleeping pills as helpful (13), whereas 39.1% of the respondents in our study viewed sleeping pills prescribed by a doctor as harmful. These results may help health professionals understand patients’ and family members’ possible views of specific medications and how their views may diverge from those of professionals. Among the most harmful interventions identified by respondents in our study were “dealing with the problems on his or her own” (64.6%) and “having an occasional drink to relax” (55.4%). These results are consistent with findings among health professionals in Singapore (13,14).

When asked about possible outcomes of appropriate help seeking, the most frequently reported response was “full recovery but problems may come back,” with the exception of dementia, for which the most common response was “partial recovery but problems may come back.” These findings indicate that most people had a fairly optimistic outlook for people with a mental illness, although they recognized that relapse or problems can return. For all five vignettes, “getting worse” (79.3%) was considered the most likely outcome if appropriate help was not sought, which highlights the perceived importance of seeking professional help for people with a mental illness.

Our findings should be viewed in light of several limitations. Some participants may have provided socially desirable responses. Although a representative sample was used, nonresponders may have had different views and beliefs about mental health help seeking. Finally, respondents were asked to indicate the helpfulness or harmfulness of specific interventions; responses were not hierarchically organized and therefore do not represent the extent to which interventions were prioritized. Despite these limitations, this first national study of mental health literacy in Singapore yielded a good response rate and included a representative sample of the general population. Additional strengths were the use of widely accepted assessments in the form of vignettes that were cognitively tested, the option of completing the survey in various languages, and the superior quality control measures and processes that were implemented throughout the study.

Conclusions

This population-based study is the first step toward monitoring mental health literacy in Singapore and provides a crucial platform from which improvements can be made in the future. These results can inform efforts to encourage people with mental disorders to take timely and appropriate action to seek help and to receive and adhere to evidence-based treatments while being supported by their social networks.