Easing the path for improving help-seeking behaviour in youth.

Everything is at stake when we talk about preventing mental illness in children and adolescents. It is estimated that one in five teenagers experience mental health (MH) difficulties every year worldwide, which is the highest incidence and prevalence of mental illness across the lifespan [1]. Globally, Child and Adolescent MH services are scarce or insufficient, and there are disparities for the implementation of policies directed to prevent mental illness.

There is evidence that school based interventions (SBI) are effective means to address health problems as well as improving child MH, with the advantage of being potentially scalable, generalizable and possibly cost-effective. Not surprisingly, SBI are a direct recommendation by the World Health Organization to tackle health problems in youth [2,3].

Among SBI for MH problems are improving literacy in MH, reducing stigma with psychoeducational interventions, social and emotional wellbeing learning, and developing coping skills [4]. Nevertheless, there is a gap in evidence regarding SBI designed to prevent but also promote MH. Among the existing initiatives, a few are validated through well designed randomized controlled trials [4], thus little evidence is available for stakeholders when designing programs to prevent MH in youth. Explanations for the lack of evidence in this area are that are very complex to implement, by requiring coordination of stakeholders from different gubernamental sectors (education, health, justice). Secondly, these interventions require much staffing to effectively implement the intervention, therefore costly and time consuming [4].

In this context, the work done by Lubman et al. is interesting for the MH community, by providing information on how it can be possible to improve help-seeking when drug abuse or MH issues are a problem in youth. Lubman and his team developed MAKINGtheLINK, intervention based on models of behaviour change: the Motivation-Behavioural Skills Model and the Theory of Planned Behaviour, implemented through five interactive classroom activities plus a booster session one month later to reiterate key messages and help students gain practical experience in applying the skills they had been taught. The classroom activities focused on addressing MH issues by educating about risky behaviours, enriching help-seeking strategies such as how, when and whom to contact when needed, and empowering to detect a friend in need of help [5].

In terms of outcomes MAKINGtheLINK was not associated with overall help-seeking at the 12-month follow up (odds ratio [OR]=1.00, 95% CI=0.70–1.42), or help-seeking for depression (OR=1.21, 95%CI=0.86–1.69), neither for stress and anxiety (OR=1.04, 95%CI=0.74–1.47), or for alcohol and other drugs (OR=1.12, CI=0.37–3.37). This could be a surprising and disappointing result, nonetheless it is informative. As the chosen definition of help-seeking was too broad, after a categorization of the type of help-seeking there was a substantial difference between the intervention arm and control arm. There was a significant increased help-seeking from formal sources (health and MH professionals) compared to informal sources (family, teachers, etc.), both overall (OR=1.81, 95%CI=1.19–2.75), as well as for depression (OR=2.09, 95%CI=1.19–3.67), and stress and anxiety (OR=1.72, 95%CI=1.17–2.54). Apparently, educating on how to ask for help does not impact on the number of effective times participants asked for help to someone, but it significantly impacts on increasing formal sources of care, by doubling the chances of asking for help at health care centres and health care professionals. And this is why MAKINGtheLING should be known, adapted and replicated in other settings and cultures: it is very difficult to approach and effectively engage teenagers to open up and let themselves be helped by unknown adults such as MH professionals.

Adolescence is a critical period of time for self-regulation, individualization and autonomy, thus learning how to self-care is crucial. Previously a systematic review by Gulliver et al., identifies stigma, embarrassment, poor MH literacy, and a preference for self-reliance as the most important barriers for adolescents reaching formal MH centers [6]. Apparently peers come into a new level of importance in life, which could be a double-edged sword in terms of an obstacle or an entry point for reaching formal MH services. We thank MAKINGtheLINK for providing a useful tool to improve formal help-seeking behaviour in youth. We are looking forward for more information about its cost-efectiveness, impact on duration and severity of illness, health-care services use and externalization to other MH problems, such as psychosis.