Understanding ambivalence in help-seeking for suicidal people with comorbid depression and alcohol misuse.

Help-seeking prior to a suicide attempt is poorly understood. Participants were recruited from a previous research trial who reported a history of suicidal behaviours upon follow-up. Qualitative interviews were conducted with six adults to understand their lived experience of a suicide attempt and the issues affecting help-seeking prior to that attempt. Participants described being aware of personal and professional supports available; however, were ambivalent about accessing them for multiple reasons. This paper employs an ecological systems framework to better understand the complex and multi-layered interpersonal, societal and cultural challenges to help-seeking that people with suicidal ideation can experience.

Introduction

Suicide is a prominent public health concern, which accounts for almost one million deaths per year worldwide and has devastating impacts on individuals, families and communities [1]. Suicide attempts constitute a major risk factor for completed suicide [2], however, research shows that help-seeking for suicidal ideation is low [3] and suicide prevention services are underutilised [4]. Although limited, prior research shows that negative attitudes and stigma relating to suicide and help-seeking behaviour result in lower intentions to seek help [3].

Suicide refers to the act of deliberately killing oneself [1]. A suicide attempt refers to the non-fatal attempt to inflict self-harm with the intent to die [5]. Suicidal ideation is a term used to refer to experiencing thoughts about suicide, which can be fleeting, can involve detailed planning, self-harm, and suicide attempts. Suicidal ideation can be assessed by determining frequency, intensity and duration of these suicidal thoughts [5]. Suicidal ideation is generally associated with depression; however, associations have been reported with many other psychiatric disorders, life events, and family events, all of which may increase the risk of suicidal ideation [5].

Comorbid conditions, such as mental health and substance disorders, may present additional complexities and challenges to help-seeking by people experiencing suicidal ideation [6]. In particular, comorbid mood and substance disorders have been found to decrease help-seeking behaviours [6], suggesting that people with these comorbidities may require additional support when experiencing suicidal ideation. The urgency of this issue becomes even more apparent in light of the finding that depression and alcohol use disorders are the most common diagnoses in people with suicidal ideation, and that the risk of suicide increases exponentially when these disorders co-occur [7]; [8].

Suicide is often conceived of as a “funnel process” [9]. Individuals tend to first experience suicidal ideation and may then engage in planning ways to act on their ideation, leading to an attempt and in some cases suicide. However, contrary to the idea of suicidal thoughts and behaviours being on a continuum, research has shown that suicidal behaviours can be sporadic, and do not always occur in a progressive sequence. De Leo, Cerin, Spathonis and [10] used telephone interviews followed by a postal survey of 1,311 participants to determine the lifetime prevalence of suicidal ideation and attempts, and the possible development of suicidal behaviours on a continuum. They found that 57.1% (n = 190) of participants identified that their suicidal thoughts fluctuated irregularly before they attempted suicide and that this was affected by co-morbid depression and alcohol use. These results indicate that, at least for this population, suicidal thoughts did not occur on a continuum of exacerbation, but that there are individuals who will continue to use suicide behaviour as a method for managing stressful life events. Further research examining the suicidal process, reckless behaviour, and help-seeking attitudes are therefore valuable to assist in the development of long-term prevention strategies and programs, as preventive interventions are possible at a number of points prior to suicide completion [9].

The interplay of broader social and environmental factors that impact on people’s beliefs, attitudes and behaviours regarding help-seeking for suicidal ideation is complex. While the importance of multilevel, multifactorial systemic approaches to reducing suicide risk is beginning to be recognised in Australia [11]; [12], systems approaches to understanding and addressing suicide are in their infancy [13]. Accordingly, most studies have explored specific components of the help-seeking process, but very few have acknowledged or applied ecological approaches to a comprehensive exploration of the environmental influences (e.g., family, friends, and broader social networks) that appear critical in helping or hindering an individual’s decision to seek help [14].

Bronfenbrenner’s (1979)[15] ecological systems theory suggests that individuals are best understood within the context of their environment [16]. This theory provides a useful lens for understanding the multiple socio-cultural and political systems that surround and influence an individual. It also recognises the potential for individuals to influence their environment [17]. According to Bronfenbrenner (1979) [15], interaction between an individual and their environment occurs at multiple, interconnected levels, including in the microsystem, mesosystem, exosystem, macrosystem, and chronosystem (see Table 1). He argued that people are embedded within these multilayered systems, and that their development, behaviours and experiences ultimately result from their complex interactions with and between these systems.

Table 1

Bronfenbrenner’s (1974) ecological systems.

System	Explanation
Microsystem	The immediate environmental context in which an individual participates, and the people within this context, with whom the individual has direct contact; e.g. the family unit, school, work or other immediate social groups.
Mesosystem	The connections or influences between different elements of the microsystem; e.g. the intersection between work and family relationships.
Exosystem	The indirect or external influences on an individual from systems not directly related to, or connected with, the microsystem; e.g. the media, educational systems, community structures and legislation.
Macrosystem	Broader social, cultural and political influences/ideologies such as social and economic status, cultural values, beliefs, customs and laws. These underpin individual philosophies and behaviours, and filter throughout other systems of an individual’s environment.
Chronosystem	Changes in an individual, their multi-layered systems, and all members of their environment across time.

While the ecological approach positions human development as intimately connected with, and dependent on, the multilayered contexts that surround them, it is important to acknowledge individuals’ own agency within these systems. Early literature on this theoretical approach tended to overemphasise systemic factors, and somewhat neglected the role of individual difference [16]. Consequently, the theory was revised by Bronfenbrenner, introducing the term ‘bio-ecological’[18], which acknowledges the influence of individual–alongside systemic–factors on a person’s development and experiences.

The current paper reports on the findings of a qualitative study, which explored the experiences of people with comorbid depression and alcohol use disorders who had previously attempted suicide, and in particular, the help they sought and received prior to and following the attempt. The central aim of the study was to identify opportunities to encourage help-seeking by this population prior to potential suicide attempts. Applying an ecological systems theory lens to the discussion of findings, this paper also aims to present a deeper, more interconnected understanding of the multiple and broader systemic factors that may influence help-seeking behaviours for suicidality in situations where people are already experiencing complex life challenges.

Methods

Participants for the current study were recruited by recontacting original participants from the Self–Help for Alcohol and other drug and Depression study (SHADE—[19]) to establish their history of suicide behaviour and help-seeking behaviour. As part of their participation in the original SHADE study, participants (N = 274) gave extended consent to be contacted for further research projects (the SHADE project, Hunter Area Health Service HREC: 03/12/10/3.17, University of Newcastle HREC H-750-0204, Mid-Western Area Health Service HREC 2004/04, Central Coast Area Health Service HREC 04/30). Those who provided this extended consent formed the eligible pool for the current study, which received ethical approval from University of Newcastle (HREC reference H-2011-0335).

Participants

Participants for the current study were recruited by recontacting original participants (N = 274) from the SHADE study (SHADE–[19], which tested a computerised treatment program for depression and alcohol/other drug use. Eligible participants in the original SHADE study were adults over 18 years of age who reported elevated depression symptoms (a score greater than 17 on the Beck Depression Inventory II [20] and concurrent use of alcohol in excess of national guidelines for low-risk consumption in place at the time of the study (four standard [10g ethanol] drinks per day for men or two for women) and/or at least weekly use of cannabis for the month prior to baseline. Exclusion criteria were active psychosis, inability to comprehend English sufficiently to understand the study interventions, and history of traumatic brain injury severe enough to impair capacity to consent and participate in the study interventions. As part of the original SHADE study, all 274 participants were recontacted via mail after 5 years and asked to participate in a follow-up assessment (five-years following the original SHADE baseline). Participants received an information sheet, consent form, and an invitation to participate in the follow-up assessment. They were also advised that the follow-up assessment would include specific questions about previous suicidal thoughts and behaviours they may have experienced and that, if disclosed, they would receive an invitation to participate in an additional sub-study (the present study) about previous suicide attempts and help-seeking around those attempts. For the current study, eligible participants were those who provided consent to participate in the 5-year follow-up assessment for SHADE study participants, and who, during this assessment, indicated at least one previous suicide attempt. Participation in this sub-study was offered until it was determined that no new themes were emerging from the interviews.

Procedure

Following provision of informed consent to participate in the qualitative sub-study a 30-minute semi-structured telephone interview occurred via the telephone, either at the time consent was provided, or at a subsequent time that was suitable for the participant. Participants were reimbursed $20AUD for their time and contribution to the study. The interview commenced with an open question about the participant’s specific experience of their suicide attempt, and then probed for specific details around help sought and received at the time of the suicide attempt, allowing participants to initiate and discuss those aspects of their suicide attempt and associated help-seeking that were most salient to them (as per Braun and Clarke, 2006[21]). All interviews were audio recorded and transcribed verbatim by the interviewer (VH) immediately following the interview.

Interviews were conducted until it was determined that no new information or themes were observed in the data [22]. In order to reach this point in the study, each interview was reviewed for emerging themes by VH and TEH independently following each interview and before the next interview was scheduled. Once this was completed, VH and TEH met to discuss identified themes. This assisted in identifying new themes and determining when no new themes emerged. As an added measure of reliability in interview analysis, FKL was involved in review and interview discussions following three interviews (1st, 3rd and 6th). As a result of this process, a sample size of six was the point at which no new themes were emerging from the interviews.

Measures

Of relevance to the current study are the following assessment measures that were collected for the 5-year follow-up assessment:

Beck Depression Inventory Fast Screen [23]: The BDI-FS is a 7-item self-report questionnaire used to screen for the presence of depressive symptoms. It is an affective measure of depression, while excluding symptoms potentially related to medical complications. Authors reported that scores 0–3 indicate minimal depression; 4–6 indicate mild depression; 7–9 indicate moderate depression; and 10–21 indicate severe depression.

Opiate Treatment Index [24]: The OTI was used in this study to measure the quantity and frequency of Alcohol, Cannabis and Tobacco use. Each subtype is assessed in terms of both quantity and frequency of use in the prior month to assessment. An average use quotient is calculated for the prior month, such that a sore of 1 equates to once daily use per day for the month prior to assessment.

General Help-Seeking Questionnaire [25]: The GHSQ was developed to assess intentions to seek help from different sources and for different problems. It uses a matrix format that can be modified according to purpose and need, therefore help sources and problem-types can be modified to meet sample characteristics and study requirements.

Suicide Behaviours Questionnaire-Revised [26]: The SBQR is a four-item assessment tool which assesses four domains of suicidality: lifetime attempts and ideation, suicide ideation in the last 12 months, the disclosure of suicidal behaviour and the self-reported likely hood of suicide behaviour.

Analysis

Braun and Clarke’s (2006)[21] six-phase model of thematic analysis was used in this study due to its accessible, theoretically flexible approach and potential to yield a ‘rich and detailed, yet complex account of data’ (p. 5). Thematic analysis was considered particularly useful for application in this study due to its ‘theoretical freedom’ [21]; [27], which made it suitable for use within the ecological systems theory framework that formed the basis of this study.

Qualitative data arising from the interviews were analysed using a combination of manual methods and NVivo 12. Using the best features of manual and electronic methods of analysis has been found to yield the best results in qualitative research [28]. Audio files were retained so the researcher could return to the recordings for a nuanced verification or clarification of content or meaning.

Initially, a manual thematic analysis was conducted independently by the student researcher (VH) and her two supervisors (TEH, FKL), through a brief reading of the six transcripts to identify recurrent patterns or themes within the data. This method was consistent with Braun and Clarke’s (2006)[21] recommendation that “it is ideal to read through the entire data set at least once before you begin your coding, as ideas and identification of possible patterns will be shaped during the read through” (p. 87). In this study, the significance of a theme was determined not by quantifiable measures but rather by whether it captured something important in relation to the overall research question.

Following initial coding, each transcript was re-read and coded according to the preliminary codes established. Annotations were also made about possible connections between themes and additional themes. This stage involved the cross checking of coding strategies and interpretation of data by the student researcher and her two supervisors independently. The final stage of the analysis was to identify the ‘story’ that each theme tells and how this linked with the overall ‘story’ about the data [21]. This final stage was carried out by MH and DS.

Results

There were six participants in this study (3 females and 3 males), and their background characteristics, based on their assessment from Part One of the study, are presented in Table 2.

Table 2

Participant characteristics.

ID	Gender	Age	BDI FS*	Alcohol**	Cannabis**	Tobacco**
P1	Female	36	10.00	0.60	0.00	0.00
P2	Male	44	8.00	14.75	0.00	12.00
P3	Male	62	0.00	8.20	0.00	0.00
P4	Female	29	5.00	0.36	8.00	1.00
P5	Male	60	0.00	0.42	0.00	0.00
P6	Female	39	9.00	10.40	0.00	25.00

*BDI FS = Beck Depression Inventory–Fast Screen score

**As measured by the Opiate Treatment Index. Scores indicate average use of each drug type in previous month to assessment. A score of 0.14 equates to once weekly use for the prior month; 1 is one use occasion per day for the previous month, 2 is two use occasions per day for the previous month, and so on.

As indicated in Table 2, participants ranged in age from 30–62 years, and reported depression scores between 0.00 (no current depressive symptoms) through to 8–9 (moderate depressive symptoms) through to 10 (severe current depressive symptoms). Only one participant (P4) indicated use of cannabis in the past month prior to the 5-year assessment (8 use occasions per day for the prior month), and three participants (P2, P3 and P6) indicated daily alcohol consumption in the previous month of between 8–14 standard drinks per day. Tobacco use ranged from minimal (P1, P3, P4 and P5) through to daily use in the prior month, of between 5–25 cigarettes per day.

All participants reported at least one previous suicide attempt as part of their eligibility for the current study. Details relating to these attempts are displayed in Table 3.

Table 3

Suicide history of participants in the qualitative study.

ID	How many previous attempts?	Years of previous attempts	Thoughts of suicide in past year?	Ever told someone you were going to suicide?
P1	2	1999, 2000	3–4 times	No
P2	1	1980	Never	No
P3	1	2000	Never	No
P4	1	2008	Never	No
P5	3	2000, 2003, 2014	Once	No
P6	2	1979, 2006	Never	No

As indicated in Table 3, participants reported between 1 and 3 (P5) previous attempts, and none had previously told another person (friend, family member or health professional) of the impending attempt. Two participants reported suicidal thoughts in the past 12 months, ranging from once only (P5) to 3–4 times (P1).

Table 4 displays the self-reported help-seeking intentions of the participants from a range of professional and non-professional sources in relation to thoughts about suicide.

Table 4

Likelihood of help-seeking for suicidal thoughts from a range of sources.*

ID	Family/Friend**	Mental Health Professional	Phone Helpline	GP	Religious Leader	Would not seek help
P1	2.50	7.00	3.00	7.00	1.00	3.00
P2	5.50	4.00	7.00	4.00	7.00	1.00
P3	1.00	1.00	1.00	1.00	1.00	7.00
P4	3.25	7.00	1.00	7.00	1.00	4.00
P5	4.00	7.00	7.00	7.00	1.00	1.00
P6	2.50	4.00	7.00	1.00	1.00	3.00

*Participants rated each source of help on the same scale from 1 (extremely unlikely), 3 (unlikely), 5 (likely) to 7 (extremely likely).

**Scores averaged for each participant across: intimate partner, friend, parent, other relative.

As Table 4 indicates, likelihood of help-seeking for suicidal thoughts was generally higher from professional than non-professional sources, with only one participant (P3) indicating he would be extremely unlikely to seek help at all for suicidal thoughts. Support from family/friends for suicidal thoughts ranged between extremely unlikely (P3) through to likely (P2), with no participant indicating this would be extremely likely for them. One participant (P2) indicated he would be extremely likely to seek support from a Minister or Religious Leader. Three participants reported they were extremely likely to seek support from a helpline for their suicidal thoughts (P2, P5, P6), however two also indicated they would be extremely unlikely to seek support from said helpline (P3, P4).

Thematic analysis: Overview of themes

The participants willingly and openly described their suicidal experiences and their ability to seek help at the time of their attempt. Overall it was evident that participants were largely aware of the help available to them both through informal social networks and formal services. What was also very clear was a reluctance to access these supports in times of need for varying reasons including; affordability, access to, and awareness of services; compounding life events; coping mechanisms; and challenges of service engagement. Within these, sub-themes were identified, which were significant in describing the meaning associated with each key theme.

Reluctance to seek help

A key theme identified in this study was participants’ reluctance to seek help for suicidal thoughts and behaviours from both family and friends and from community-based services. There was an overarching sense that participants gained little benefit from seeking help within their immediate social network of family, friends, or close relatives. Two key reasons were identified for this. Firstly, participants indicated that their social supports were judgmental, unsupportive, and unresponsive to cries for help:

“I was just attention seeking as far as they were concerned… something happened and I ended up at the front of my place in a crumbled heap on the ground out of frustration, my two sisters and brother, were there and they just looked at me and laughed and drove off.” (P1, female, age 36 years).

For some, this lack of support was connected to the stigma of mental health:

“Well it’s the way people treated you… what would have helped? Not having [suicidal thoughts] and … not having the stigma that people put on having mental problem.” (P1, female, age 36 years)

Participants also expressed concern that a request for help may place an undue burden on family and friends, who may not be emotionally equipped or prepared for such a role:

“The burden of ‘I’m going to finish it’ is a bit too much of a burden to lay on a friend or intimate partner. Especially an intimate partner, I mean I can share things of life with my partner but the deep seeded emotions… no. You can’t be openly transparent even with the closest…person you are with” (P2, male, age 44 years).

Several participants who did seek help from a friend felt that the high level of distress this caused placed pressure on the relationship, which in turn, decreased the likelihood that they would share these thoughts with friends or family in the future.

“Most probably not [seek help from a friend again] because it freaked her totally out, and it’s not a nice thing to put on someone, I don’t think.” (P4, female, age 29 years).

One participant (P5) spoke highly of the support he received from his friend after his suicide attempt. This participant expressed gratitude that his friend persisted with her attempts to engage him with professional assistance at the peak of his distress:

“He [Psychiatrist] had the order from the Court to say that I had to be released [from inpatient unit] into her [friend] care … she was there to sort of manage me, if you like … and she sort of…she’s put me on the right track” (P5, male, age 60 years)

Participants’ responses reflected the complexity of their decision making in relation to who they would seek help from. While some recognised the value of talking with a trained professional who is less involved, they also indicated that they would find it easier to confide in someone they feel close to:

“Maybe a trained professional is better… someone that’s not so close…but I find it easier talking to a close friend.” (P6, female, age 39 years)

In relation to engagement with community support services, no participants had engaged with a service as their first point of contact for help for suicidal thoughts, although some participants were linked into mental health services at the time. Of these participants, none discussed their suicidal thoughts directly with their treating professionals, with one participant choosing to communicate via his friend instead:

“I spoke to my friend about it, and not with any of the professionals or anything, and my friend went around and spoke to the psychiatrist.” (P5, male, age 60 years).

One reason cited for the lack of communication with service providers was an impression that available providers did not offer adequate, proactive support, particularly once people had been discharged into the community:

“We looked after my dad, he had a stroke, and when he died apparently I had a nervous breakdown. Then they put me in a mental home and then I came up here [moved house]. The mental health [service] came and assessed me, said they’d be back and I never ever saw then again or heard from them or nothing.” (P4, female, age 29 years).

One participant noted that she had intended to disclose her suicidal thoughts to her doctor but did not feel safe to do this in the presence of his medical students:

“I had to go for my appointment with [service provider] and he had students in the room and I didn’t want to see him with students …didn’t want to talk about it in front of them…I left and went home” (P1, female, age 36 years).

Importantly, there were cases where participants were linked into public community-based services post-attempt, and these participants were more likely to engage in help-seeking for future suicidal crises:

“Yeah… I really hooked into mental health…they have saved my life” (P3, male, age 62 years).

An interesting finding was that help-seeking was associated with a lack of intent to commit suicide, with one participant noting that if he really wanted to commit suicide, he would not tell anybody:

“If I was going to attempt suicide right now, I wouldn’t tell anybody because that to me means that I don’t really want to commit suicide.” (P3, male, age 62 years).

Affordability, access and awareness of services

Affordability, access to, and awareness of, services were identified as barriers to help-seeking. For example, one participant described living alone in an unfamiliar location where help was difficult to access:

“I was living on my own in a strange town…[help was] an hour away” (P4, female, age 29 years).

Another participant highlighted the perceived cost of therapy as an inhibiting factor to help-seeking, combined with a sense that support was not available anyway:

“Couldn’t afford it. And there wasn’t any really here. You know like there was no help… and it’s still the same.” (P4, female, age 29 years).

Lack of awareness of available support was also related to age, with one participant noting that he was young and did not know about existing support options:

“Well maybe they were in place… but I was pretty young, and I was unaware of other help” (P2, male, age 44 years).

Availability of services did not always enhance help-seeking, with one participant reporting that living in a small rural town prevented the anonymity she needed to access available help:

“I mean… just if there was a psychiatrist in [town] … but then everybody would have known about…it’s one of those little towns that everyone knows everyone” (P6, female, age 39 years).

Compounding life events and coping mechanisms

Participants all reported experiencing adverse and compounding life events immediately prior to their suicide attempt, which placed a high level of stress on them, leading them to contemplate suicide as an escape route:

“Yeah I had three young children and was bringing them up on my own. The situation had arose, I had no family to turn to, my youngest sister accused my ex-husband to have interfered with her as a child … I had only just really recovered from a bad marriage, and severe chronic back pain and surgery on my back. I was trying to cope with all of that and still work and look after my children… so it was like I don’t want to be here right now without thinking of the consequence.” (P1, female, age 36 years).

Participants’ decision to attempt suicide was often influenced by a sense that there was no solution to, or way of escaping, their current situation. For example, one participant described his suicide as a response to his fear of the future as a young man:

“You fear leaving your job but you also fear going forward…the story goes…overdose of pills and I drove my car into the bush until I crashed and went to sleep in the back seat and two hours later the sun was blaring in my face and I went oh that didn’t work. … I went home and told my parents this is what I did… I tried to commit suicide and they went yeah right you stupid young man… This is what I went through with my counsellor as well, in an odd way I still probably had pent up feelings about that until probably my 40’s.” (P2, male, aged 44 years).

Some participants reported using alcohol as a coping mechanism at times of significant stress, noting that this hindered them from addressing the difficulties they were experiencing:

“I didn’t know what was going on with me. And I was using alcohol as an excuse to, you know, just drown everything out, which was bad.” (P4, female, age 29 years).

Need for proactive, flexible support

While a number of participants demonstrated good knowledge of available services, many expressed ambivalence about engaging with services due to prior negative experiences with service providers, or fears about how a service provider might respond to a disclosure of suicidal ideation. However, participants often reported that, while they would not have sought help themselves, they would have accepted it had it been offered. They emphasised the importance of proactive, sensitive service engagement during a suicidal crisis. However, they also expressed a need to be self-reliant once the immediate crisis had passed.

Initial support followed by self-reliance. Participants who received initial support during a suicidal crisis often reported withdrawing from this support once the crisis had passed. These participants continued to make use of the materials and skills provided to them, suggesting that brief interventions and information provision might be important modes of support for people experiencing suicidal crisis:

“I ended up, I did, you know the Cognitive [Behaviour] Therapy. Well you have the paperwork, you can always read back over it, or you know stuff like that. … And that was, that was good. Well I was seeing like a counsellor, you know, where she sits and talks to you and gives you other opinions and ideas. You know how to go about things different ways. …. And then I was supposed to go back and see her because I was a bit all over the place, and I just couldn’t have been bothered. My doctor said like why haven’t you gone back? I said “Oh I couldn’t have been bothered, was over it.” He said, “Oh okay.”… But she’s there you know if I needed to go and see and talk to her. I try and just use what she taught me, work it out, sometimes it doesn’t” (P4, female, age 29 years).

The importance of the initial response was highlighted by participants who described a single comment or insight that had helped them to move forward after a suicide attempt. For example, one participant reflected on a conversation with her son in which she was reminded of the impact a suicide would have on her family and grandchild:

“I was happy they [Emergency Department] didn’t put me in the psych unit. … No [I didn’t seek help]. I just woke up to myself when my son said I had the photo of my granddaughter with me when I tried it [suicide] and I thought well, you know this is just bloody selfish, I can’t do it.” (P6, female, age 39 years).

Some participants did report receiving a more extended response from mental health professionals. However, this support was generally associated with higher levels of crisis, while initial help-seeking tended to be directed towards friends and regular service providers like the GP:

“Well I thought it was a bit funny at first because I’d walk in and sit down with the guy [psychologist] and he’d be, ‘how’d you go, what have you been doing, catching any fish’ or whatever. I didn’t realise at the time he was just getting me relaxed and then he’d say ‘you haven’t felt like this have you’ …. I never realised that I’d given him the answer and then he’d say, ‘well last time when I asked you about that you said so and so, this time you’ve said, so and so, that’s an improvement on this’ you know. Yeah, that’s right he set me up really well. …Oh yeah, yeah, if I ever got down I’d go and see him but, you know, my first port of call, other than my two friends is my doctor…’ cause he’s really taken me under wing” (P5, male, age 60 years).

Need for proactive service engagement. Several participants highlighted that their most critical need for service engagement and support was during the initial crisis stage, and that they felt services did “not try hard enough” (P4) to engage or intervene with them at this time. Where support was not offered during a crisis, participants reported experiencing adverse consequences:

“The first time I was seeking help I had an appointment to see a counsellor, I think it was, I was very distraught, I had held myself together until I got to that appointment. I turned up and I was a day early. And I was so stressed and I said ‘but I need to see someone now’… but they said no not until tomorrow. I went home and said how am I going to get through ‘til tomorrow? I took a couple of valium to help me get to sleep and before I knew it I had taken the whole packet in that state.” (P1, female, age 36 years).

Some participants perceived a lack of service response during a crisis as a clear indication that the service did not care, and this discouraged any further attempt to seek help:

“Because when I rang up like and said to them you know “you came out and assessed me. You said you’d be back. You haven’t come back. You have given me nothing. You’ve just got me hanging, and I don’t know what’s wrong with me”. And they [service providers] said, “Oh that’s not our problem, we’re booked out.” …they didn’t give a sXXX really …I won’t do that again” (P4, female, age 29 years)

Several participants emphasised the importance of receiving an offer of help at times when they were not able to ask for support:

“… there is no one I would have asked…it was easier to end it then tell people because you felt stigmatised …and they [services] didn’t offer either…really other people should have seen the writing on the wall but didn’t.” (P3, male, age 62 years).

Participants often reported that while they would not have sought help themselves, they would have accepted it had it been offered:

“I just didn’t think of it, I didn’t want to go to the doctors. And really others should have seen the writing on the wall, but I didn’t …If someone had offered a hand to me, I would have taken it.” (P3, male, age 62 years)

Discussion

This study aimed to explore the help-seeking experiences and attitudes of individuals with comorbid depression and alcohol use who had a suicide attempt in their lifetime. Findings show that the relationship between help-seeking behaviours and suicidal thoughts and attempts is a complex one, involving internal conflict between an individual’s perception that they “should” manage these thoughts and behaviours on their own without “burdening” family and close friends, while at the same time wanting family and friends to understand them, and to “offer” support. This complexity was also apparent in relation to service engagement, with many participants expressing a belief that professionals and services have a significant role to play in preventing a suicide attempt, while also emphasising a need for self-sufficiency and independence once the immediate crisis had passed. These findings suggest that individuals at risk of suicide require support that is both flexible and occurs at multiple systemic levels.

In particular, findings reveal the importance of communication between, and amongst, the people and services who inhabit the various systems surrounding an individual at risk of suicide–their mesosystem. For example, one participant reported a preference for communicating with treating professionals via his friend. Others noted that they would seek help from friends and family in the first instance, suggesting the microsystem has a crucial role to play in linking individuals experiencing suicidal ideation with support services. Participants who were encouraged to access services in this way, were more likely to engage in help-seeking for future suicidal crises. These findings reflect the need for a ‘circle of support’, in which family, friends and professionals work together to offset a suicide attempt. The notion of a circle of support confirms previous research findings, which identified the importance of social connectedness and support networks for reducing suicide risk [29].

The finding that individuals experiencing a suicidal crisis are more likely to seek support from family and friends in the first instance, is consistent with ecosystems theory, which emphasises the primacy of a person’s microsystemic interactions [30]. According to Rogoff (2003)[31] the microsystem exerts a more powerful influence on individuals than any other contextual factors. Interactions that occur at this level have the power to be either extremely beneficial, or detrimental, to a person’s development and wellbeing. This perspective usefully illuminates participants’ ambivalence about seeking support from family, friends and support services, in an effort to avoid the damaging personal consequences of a judgemental, unsupportive response, at a time when they are arguably at their most vulnerable. Conversely, participants who encountered positive responses within their circle of support indicated that this had a crucial impact on their decision not to attempt suicide in the future.

Participants in this study expressed a need for proactive service engagement during a suicidal crisis. However, many individuals did not disclose their suicidal thoughts to health professionals they were in contact with prior to their suicide attempt. A central reason for this was a belief that services either did not recognise the seriousness of the situation or did not care enough to offer support. This suggests that it might be important for professionals to consider routinely asking suicide risk assessment questions of all clients who are engaged with health services (acute, community), irrespective of perceived risk, as this may have important preventative implications. Privacy was revealed as an important consideration in this context, with one participant noting she had planned to disclose to her doctor but decided not to do so in front of medical students. This highlights a need for service providers to ensure that their provision of professional development opportunities does not impact on service-user wellbeing, and to employ a high level of sensitivity when including trainees in routine service provision.

A further finding was that adverse and compounding life events significantly impacted participants’ level of stress. For some, this led to an increase in unhealthy coping mechanisms, such as alcohol use, which presented a further barrier to addressing challenges or accessing support. This supports findings from previous research that comorbid conditions such as substance disorders present additional complexities and barriers to help-seeking for people experiencing suicidal ideation [6]. From an ecological systems perspective, the influence of an individual’s microsystem extends beyond their interactions with other people, to their engagement with objects and symbols [32]. It is therefore possible to infer that, in the absence of support from significant others, an individual may seek comfort in non-human objects such as drugs and alcohol.

This study revealed the ambivalence that people who are acutely suicidal can experience when engaging with different systems of support, with several participants expressing fears of negative, stigmatising reactions by family members or formal providers to a disclosure of suicidal ideation. This supports Calear et al.’s (2014)[3] finding that perceived negative attitudes and stigma relating to suicide and mental illness can lead to a reduction in help seeking intentions and behaviours. An ecological systems perspective usefully illuminates the critical role of broader social and cultural—macrosystemic—factors in shaping people’s attitudes and behaviours to suicidality. The macro-system constitutes the shared belief systems and values of a cultural group [32]. This system has a cascading influence on interactions at all other systemic levels [33]. Employing this perspective, it is possible to observe the continuing legacy of the historical stigmatisation of suicide as a ‘taboo’ subject [34] and a ‘sinful’ act [35] at the individual level. In this way, an ecological systems frame may enhance our critical awareness of the wider socio-political context that shapes people’s experiences of, and responses to, suicidal ideation [17]; [16].

Limitations

The present study has several limitations that should be considered when evaluating the presented conclusions and implications. The authors acknowledge the difficulties in determining true data saturation [36] particularly when working with such small sample sizes [37] as in the current study. It is uncertain if other participants might have provided differing themes and experiences. It is a limitation that the exclusion criteria extended to people who could not speak or understand English sufficiently to engage in the study, highlighting further the potential issues with generalising these results to diverse groups in the community. Even though a randomised approach to the interview schedule was applied it is uncertain if there could be a bias in the sample pool. In addition, although rigorous standards for interpreting and analysing the qualitative data were applied, these are still subject to the researchers’ experience and subjectivity may have affected the results.

Conclusion

This study revealed the complex challenges people who are acutely suicidal experience when they engage with different systems of support. Findings highlight important considerations for friends and family members, who are often the first point of call for a person seeking support. They also emphasise the need for sensitive and proactive service engagement with individuals experiencing a suicidal crisis, to avoid the damaging impacts of inaction, stigma and judgement. The qualitative data revealed themes that illustrated many challenges of engaging with different support systems which lends itself well to an ecological systems theory perspective when considering interventions and approaches for this complex population.

14 Jun 2019

Submitted filename: 130619 - response to reviewers.pdf

Click here for additional data file.

5 Aug 2019

PONE-D-19-16846

The paradox of engagement: The support needs of people with comorbid depression and alcohol misuse who had previously attempted suicide

PLOS ONE

Dear Professor Kay-Lambkin,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we have decided that your manuscript does not meet our criteria for publication and must therefore be rejected.

I am sorry that we cannot be more positive on this occasion, but hope that you appreciate the reasons for this decision.

Yours sincerely,

Vincenzo De Luca

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This manuscript provides an in-depth report of interviews conducted for six individuals who have previously attempted suicide to explore the relationship between depression, previous alcohol use and barriers to obtain help. The first author appears to be a student who has a great interest in suicide research and a compassion for those she has interviewed.

Although the enthusiasm for the topic is clearly present, the scientific rigor needed to contribute useful information for future work on prevention and treatment is totally absent. First, a sample that is 10-100 times larger would be needed in order to include a sufficient number of participants of varying gender, ethnicity, socioeconomic status, and access to health care providers, to name just a few of the variables that would appear to be important, to evaluate the hypotheses the authors wish to test. It is critical that any new research provide clear and convincing evidence that the sample studied is representative of the geographic and demographic areas of interest. This manuscript does not do this.

The instruments used are not adequate for the hypotheses to be tested. There are no standard measures of alcohol use, for example, such as the AUDIT. Without this standardization, the results obtained in this study cannot be put into the context of other studies. Use of the Beck Depression Inventory is standard for assessing depression as a current state. However, the study suffers from lack of information about what lifetime psychiatric diagnoses the participants have. One would expect the access to empathetic treatment providers would differ greatly among those with psychotic depression and those without as just one example.

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Reviewer #1: No

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For journal use only: PONEDEC3

9 Sep 2019

Thank you for the opportunity to formally appeal the rejection of our manuscript (PONE-D-

19-16846). Please see below our point-by-point response to the reviewer:

Reviewer #1: Although the enthusiasm for the topic is clearly present, the scientific rigor

needed to contribute useful information for future work on prevention and treatment is totally

absent. First, a sample that is 10-100 times larger would be needed in order to include a

sufficient number of participants of varying gender, ethnicity, socioeconomic status, and

access to health care providers, to name just a few of the variables that would appear to be

important, to evaluate the hypotheses the authors wish to test. It is critical that any new

research provide clear and convincing evidence that the sample studied is representative of the

geographic and demographic areas of interest. This manuscript does not do this.

Response: Firstly, the reviewer’s comment regarding sample size (“a sample that is 10-100

times larger would be needed”) does not align with standards of rigour in qualitative research,

where sample size recommendations for studies using qualitative interviews range from five-

25 on average for HDR studies (Mason, 2010). Further, the reviewer’s assumption that we

were seeking to test a hypothesis, or to generalise our findings to the larger population, is

inconsistent with the stated aims of our paper (“to present a deeper, more interconnected

understanding of the multiple and broader systemic factors that may influence help-seeking

behaviours for suicidality”) or the exploratory nature of qualitative methodologies, which do

not intend to provide conclusive answers, but to gain a more in-depth understanding of the

complex nature of the issue under investigation. Including a more detailed statement about the

limitations of the sample size, and the subsequent lack of generalisability, in manuscript

would address this issue.

Reviewer #1: The instruments used are not adequate for the hypotheses to be tested. There are

no standard measures of alcohol use, for example, such as the AUDIT. Without this

standardization, the results obtained in this study cannot be put into the context of other

studies. Use of the Beck Depression Inventory is standard for assessing depression as a

current state. However, the study suffers from lack of information about what lifetime

psychiatric diagnoses the participants have. One would expect the access to empathetic

treatment providers would differ greatly among those with psychotic depression and those

without as just one example.

Response: In response to the reviewer’s comment that the instruments used do not test thestudy hypotheses, we would like to clarify that there are no study hypotheses for this paper.

We fear the reviewer is confusing the purpose of this submission with the parent randomised

controlled trial which has already been reported on, and from which participants in the current

study were recruited. The quantitative data is presented as context for the participants who

provided the individual interviews, but has indeed been collected using standardised,

validated measures as outlined in the methods.

Additionally, we note that this manuscript was submitted previous to the current submission

and was reviewed by two expert reviewers. At that point in time the decision was a ‘major

revision and resubmit’. We took some time to revise the submission, and thus submitted the

current manuscript as a new submission. However, we addressed all reviewer comments from

the prior submission, and uploaded a document indicating how this occurred with our

submission. This is also now provided below.

The paradox of engagement: The support needs of people with comorbid depression and

alcohol misuse who had previously attempted suicide

REVIEWER 1 – please see Reviewer Comments in bold and our response in normal text.

The authors present a well-written qualitative study of suicidal behavior among people

experiencing depression and alcohol/substance use. The analytic insights contain a few

quite promising leads, such as the “paradox of engagement,” wherein participants

wanted to be self-reliant yet expected others/health systems to reach out and help them.

The authors’ identification of complexities with regard to social support systems and

suggested use of alternative forms of support for individuals avoiding formal ones are

well-received. I do think, however, that the paper needs a bit more revision before being

suitable for publication.

We thank the Reviewer for this thoughtful reflection on the manuscript and for the comments

that follow. We trust we have addressed them adequately.

First, there is an issue with the nature and organization of findings. With qualitative

research of this kind that, as you mentioned, attempts to describe participants’

experienced meanings, the overarching themes should reflect such experienced

meanings as directly as possible. As it stands now, however, some of the themes do not

reflect their experienced meanings, but more seem to reflect the researcher’s frame and

understandable intention to enhance help-seeking behaviors. For instance, “mode of

help-seeking”, “barriers to help-seeking”, and “comorbidities” are themes that do not

appear to reflect participants’ directly experienced meanings. From my reading, it

appears that almost no one in this sample reached out for support, which would suggest

that there was little to no help-seeking involved (at least based on the data presented).

The realm of others were experienced more along the lines of shaming and dismissive,

with the participant feeling like a burden to them. These experiential parts were placed

under your heading of “barriers to help-seeking”, but it does not seem that, for many,

they tried to reach out and then experienced barriers (some did experience it this way,

but not all). For most, it seemed that there was a basic deprivation of support,

exacerbated by logistical, financial, and geographical structures, all of which presented a

context in which participants rarely considered help. Even the notion of “help” needs to

be explored more, perhaps with reference to the circumstances that led them to consider

suicide in the first place. I imagine that participants wanted “help” for many things,

including with aspects of their life circumstances (e.g., more help with childcare).

This is an important insight, and we thank the Reviewer for these reflections. We have gone

back to the data provided by participants and sought to more accurately apply thematic

meaning to their experiences as per their utterances, rather than from the higher order labels

that we (as healthcare providers and researchers) might use to categorise these experiences.

For example, we have reframed “mode of help-seeking” to “affordability, access, and

awareness of services”, “barriers to help-seeking” to “reluctance to seek help”, and

“comorbidities” to “compounding life events and coping mechanisms”. We have retained the

theme of “paradox of engagement in help seeking” and attempted to expand on this paradox.

We have attempted to represent, from the participants’ experience, what these themes

represent, rather than interpret (using our own frameworks) what we thought they were

referring to.

One main purpose of making these qualitative distinctions and of remaining close to the

original experience is to go beyond what is already conceptually known about the topic,

in order to uncover insights that may be currently obscured by our own frames of

theorizing. After all, it is clear that the mental health system was not a suitable option

for these participants, so research that remains closer to their actual experience is better

positioned to close the gap between everyday community life and mental health systems.

The section on paradox of engagement gets much, much closer to the way they

experience it and was a quite good section overall (the summary at the lead of the

Discussion was also quite good and near-to-experience in this respect). In all, though,

there needs to be much more attempt at reflecting the structure of the experience as

lived, replete with descriptions of essential meanings.

Again, we thank the reviewer for these valuable insights, and have tried to reframe the data

using the participants’ own utterances rather than our interpretation of what this relates to in

the broader healthcare literature and context. We have applied Bronfenbrenner’s ecological

systems theory to the interpretation of the main findings of the study, and have attempted to

ensure that this interpretative discussion is separated out from the results of the study.

Second, the concrete rationale for this specific study needs to be better developed. As of

now, it appears as a more global connection between previous literature and this

study—which is a bit too general for a journal of this type. One way to correct this is, I

believe, if the authors conduct a more concrete critique of the previous literature, which

would then set up the specific need for this current study. There are some gaps

otherwise: For instance, why focus on suicide attempts? Why focus on help received and

desired? It may seem obvious but filling in these gaps would greatly aid both the

organization and readability of your paper. On a related note, I find the following

statement hard to believe: “Despite this, little research exists on the relationship between

alcohol use and suicidal behaviours.” Most practicing clinicians are well-aware of this

link, as it is also reflected in most suicide prevention guidelines. Presumably these

guidelines come not only from years of clinical experience but also from research

(including case studies). I imagine many readers will also wonder about this, so I would

suggest that the authors at least mention some of the available research or guidelines,

and then suggest a reason as to why more research is needed.

We have added literature and a consideration of the nature of suicidality into the introduction,

and removed the statement about alcohol use and suicidal behaviours. To clarify, however,

whilst clear data have demonstrated the links between suicidal behaviours and alcohol misuse,

much less has examined help-seeking for suicidal ideation/attempts in people with alcohol

misuse problems. We have also presented a discussion of why more research is needed in this

area.

Once the above two issues are addressed, I believe that the authors will be in a place to

offer even more specified and novel suggestions for policy, practice, and action. Some of

the ones mentioned are of course good and thoughtful, such as the focus on alternative

means of support and ways to address the “burden” issue. But I believe more can be

said about ways to combat stigma, isolation, and hopelessness, such as access to stories

of recovery or the involvement of peers who have been through it. And again, we need to

know more about the life circumstances that are leading them to consider suicide in the

first place, which may ultimately also implicate the depriving social world around them.

Our interviews did not explore the life circumstances leading participants to consider suicide

in the first place, which is a limitation of the current study (reflected in the Discussion). We

have applied Ecosystems theory to the study results, which attempts to understand (and place)

the role of peers, family, and other support systems in the life of our participants leading up to

their suicide attempt. We believe that applying this lens deepens the insights gained from this

piece of work.

I would explain more about your view of what “data saturation” entails. I generally

remain a bit uncomfortable with this idea of saturation, given that more can always be

said or explored about a given topic, even within one participant. Further, your sample

appears to be quite acculturated to mainstream culture. So, I would personally avoid

suggesting that saturation means that your findings are all that can be said about the

topic.

We have removed the term ‘data saturation’ from the manuscript, as we agree with the

Reviewer’s comments in relation to the current sample. We have addressed the sample size as

a limitation in the revised manuscript.

On a related note, there’s a need to speak on limitations with regard to excluding people

with an ‘inability to comprehend English’. I’d imagine these folks are doubly suffering

from social isolation and are in great need of support.

This has indeed been added to the limitations section in the discussion.

Kindly clarify if the 4 standard drinks is the recommended limit or exceeds the limit—

the writing is a bit unclear.

Four standard drinks is the recommended limit and drining in excess of this limit was the

basis for inclusion in the study. This has been clarified.

There are a handful of typos which can be found upon another read-through.

We hope we have addressed these.

I was unsure what the restrictions on data access were, or if these need to be stated.

Thank you for this point. Given the limits of our ethics approval for the study, and the

identifiable nature of the interview transcripts, we are unable to provide open access to the

data for the current study. Instead, we can provide access to the transcripts by application via

our Human Research Ethics committee and have provided details about this accordingly.

Overall, this paper holds promise and is in a much-needed area of study. My suggestion

is for the authors to return to their participants’ experience again, to reflect its internal

structures more closely, all in the attempt to close the gap between those in need and the

supports that could perhaps help them.

Thank you for this comment. We hope that in doing this, we have been able to address (and

adequately reflect) the Reviewer’s comments on the manuscript.

Submitted filename: 130619 - response to reviewers.docx

Click here for additional data file.

23 Jan 2020

PONE-D-19-16846R1

The paradox of engagement: The support needs of people with comorbid depression and alcohol misuse who had previously attempted suicide

PLOS ONE

Dear Professor Kay-Lambkin,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Catherine Haighton, PhD

Academic Editors

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Comments to the Author

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Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: I Don't Know

**********

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

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6. Review Comments to the Author

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Reviewer #2: Challenges and ambivalence in help-seeking for suicidal individuals with comorbid depression and alcohol use disorder is a clinically relevant and complex topic. I applaud the authors of this paper for trying to delve deeper into this topic using qualitative based research methodology. In my opinion, the main flaw of this paper is the attempt of the authors to make general inferences from very limited qualitative data to support their theory in the Discussion and Conclusion sections. This paper would be stronger if the authors stuck more closely to their qualitative data without trying to make larger inferences. Below area a few examples that illustrate my points:

1. I think it is appropriate to use a theoretical lens as you do (Ie. ecological systems theory) to interpret your findings, but some caution is warranted when you try to use your qualitative data to justify your theoretical lens in both the Discussion and Conclusion. For example, at the end of the Conclusion you state that “Application of an ecological systems perspective confirmed the significance of support at the microsystemic level. It also illuminated the critical link between attitudes and behaviours at the micro level, and constructions of suicide at the broader macro level. Recognising and addressing the cascading influence of broader socio-cultural perspectives on suicide, mental health and comorbidity, is crucial to ensuring the effectiveness of future intervention and prevention measures. ” I do not think your qualitative data “confirms” these conclusions and I did not see any evidence from the data to support a “critical link” between the micro and macro level. Perhaps you could say something like: “the qualitative data revealed themes that illustrated many challenges of engaging with different support systems which lends itself well to an ecological systems theory perspective when considering interventions and approaches for this complex population.”

2. Similarly, in the last paragraph of the Discussion Section, you make statements that are too broad and do not justify the data, e.g.: “The key finding of this study, that individuals experiencing acute phases of suicidality do not typically access traditional treatment services and are reluctant to seek support from family and friends, is consistent with findings from a number of previous studies (Fogarty et al. 2018). While this finding highlights the importance of support and engagement at the micro and meso-systemic levels, it also illuminates the critical role of broader social and cultural macrosystemic – factors in shaping people’s attitudes and behaviours” I do not think that is the “key finding” of this study based on the qualitative data you presented. In my opinion, your study illustrates the ambivalence and different types of challenges people experience seeking help when they are suicidal when they engage with different systems of support. In addition, you state in an earlier paragraph in the Discussion Section that people are more likely to seek help from family and friends rather than professionals which contradicts this last paragraph where you introduce the “key finding” that e people are reluctant to seek help from family and friends.

3. I don’t find the concept “paradox of service engagement” very helpful and I don’t think it does justice to your data. My impression from your data is that many of these individuals had significant ambivalence asking for help due several factors such as negative experiences with family or formal providers or fears about how these different groups would respond if they reached out for help and disclosed being suicidal. I would prefer more descriptive words in your title and abstract that are closer to the data such as the words “ambivalence” or “challenges” rather than the impression that you have discovered a whole new concept called “paradox of service engagement” – again similar to the Discussion and Conclusion sections it seems like you are trying to reify concepts from qualitative data which does not lend itself to such generalizations.

**********

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Reviewer #2: No

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26 Feb 2020

Response to Reviewers:

Thank you for taking the time to review our manuscript and provide such thoughtful feedback on our work, which has helped to strengthen our paper. Please see our response to each point raised by the reviewer below. We welcome any further feedback on our revisions.

Reviewer #2: In my opinion, the main flaw of this paper is the attempt of the authors to make general inferences from very limited qualitative data to support their theory in the Discussion and Conclusion sections. For example,

At the end of the Conclusion you state that “Application of an ecological systems perspective confirmed the significance of support at the microsystemic level. It also illuminated the critical link between attitudes and behaviours at the micro level, and constructions of suicide at the broader macro level. Recognising and addressing the cascading influence of broader socio-cultural perspectives on suicide, mental health and comorbidity, is crucial to ensuring the effectiveness of future intervention and prevention measures.” I do not think your qualitative data “confirms” these conclusions and I did not see any evidence from the data to support a “critical link” between the micro and macro level. Perhaps you could say something like: “the qualitative data revealed themes that illustrated many challenges of engaging with different support systems which lends itself well to an ecological systems theory perspective when considering interventions and approaches for this complex population.”

Author response: Thank you. We agree with your feedback and have amended our wording in line with your suggestion.

Reviewer #2: Similarly, in the last paragraph of the Discussion Section, you make statements that are too broad and do not justify the data, e.g.: “The key finding of this study, that individuals experiencing acute phases of suicidality do not typically access traditional treatment services and are reluctant to seek support from family and friends, is consistent with findings from a number of previous studies (Fogarty et al. 2018). While this finding highlights the importance of support and engagement at the micro and meso-systemic levels, it also illuminates the critical role of broader social and cultural macrosystemic – factors in shaping people’s attitudes and behaviours” I do not think that is the “key finding” of this study based on the qualitative data you presented. In my opinion, your study illustrates the ambivalence and different types of challenges people experience seeking help when they are suicidal when they engage with different systems of support. In addition, you state in an earlier paragraph in the Discussion Section that people are more likely to seek help from family and friends rather than professionals which contradicts this last paragraph where you introduce the “key finding” that e people are reluctant to seek help from family and friends.

Author response: Thank you for making us aware of these issues. We have revised this paragraph to address the inaccuracies and the contradicting statements you refer to (see p. 25).

Reviewer #2: I don’t find the concept “paradox of service engagement” very helpful and I don’t think it does justice to your data. My impression from your data is that many of these individuals had significant ambivalence asking for help due several factors such as negative experiences with family or formal providers or fears about how these different groups would respond if they reached out for help and disclosed being suicidal. I would prefer more descriptive words in your title and abstract that are closer to the data such as the words “ambivalence” or “challenges” rather than the impression that you have discovered a whole new concept called “paradox of service engagement” – again similar to the Discussion and Conclusion sections it seems like you are trying to reify concepts from qualitative data which does not lend itself to such generalizations.

Author response: Upon reflection, we agree that the “paradox of engagement” does not do justice to our data. We have removed this expression from the manuscript (including from the title and abstract) and have instead used descriptive words that are closer to the data (see p. 1, 2, 19, 23, 26).

Submitted filename: Response to Reviewers.docx

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30 Mar 2020

Understanding ambivalence in help-seeking for suicidal people with comorbid depression and alcohol misuse

PONE-D-19-16846R2

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Reviewer #2: Yes: Jan Malat

2 Apr 2020

PONE-D-19-16846R2

Understanding ambivalence in help-seeking for suicidal people with comorbid depression and alcohol misuse

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