Adolescent public stigma and help seeking intention are associated with later service use: A five-year follow-up study using annual self-report surveys and medical records

Adolescent public stigma and help seeking intention are associated with later service use: A five-year follow-up study using annual self-report surveys and medical records | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Adolescent public stigma and help seeking intention are associated with later service use: A five-year follow-up study using annual self-report surveys and medical records Shinsuke Koike, Sakine Shinohara, Kei-Ichiro Watanabe, Shintaro Yanagimoto, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6425632/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Purpose Various barriers including public stigma and lack of mental health literacy have been identified to adolescent help-seeking intention for their mental health problems. However, few prospective studies have investigated whether adolescent public stigma and help-seeking intentions are associated with actual service use in a long-term prospective design including medical records. Methods This prospective study over a five-year period used questionnaire responses from 1919 students on admission (608 females [19.7%], mean age: 18.92 [SD 0.68] years), and follow-up information from annual health checkups and medical records from 1437 participants (74.9%). The baseline stigma questionnaire included practically useful knowledge of mental health problems, past experiences and behavioral intentions with people with mental health problems, and help-seeking intentions and disclosing comfortability questions about their own mental health problems. Logistic regression analyses were performed, including any psychiatric and psychological service use during the follow-up period as the dependent variable, baseline stigma measures as independent variables, and demographic and psychosocial factors as covariates. Results After mutually adjusted for independent and confounding variables, behavioral intention ( OR = 1.060 [ 95%CI 1.003―1.120], p = 0.037) and help-seeking intention (1.234 [1.029―1.479], p = 0.023) were significantly associated with any psychiatric and psychological service use. Conclusion Our five-year prospective study showed that behavioral intention with people with mental health problems and help-seeking intention about their own mental health problems were associated with later service use in adolescents. The results suggest the importance of anti-stigma campaigns and mental health literacy programs for earlier service use in adolescents. Mental illness Adolescence Service use Help-seeking behaviors Public stigma Prospective study Long-term follow-up Figures Figure 1 Figure 2 1. Introduction Early support and care for people with mental health problems are one of the most important factors for better symptomatic remission and functional recovery in later life [1]. Since approximately three-fourths of the cases of psychiatric disorders are encountered by age at 24 years [2, 3], educational curriculum and psychiatric and psychosocial support in schools are important for better mental health. However, around one-third of the adolescents who needed to care for their mental health problems received psychiatric care and psychosocial support [4, 5]. Systematic reviews of help-seeking behaviors in adolescents showed that gender, age, ethnic minority, stigma, mental health literacy, autonomy, service cost, the gap in service needs and locations, family beliefs, and negative beliefs about mental health services and professionals were barriers to seeking help towards their mental health problems [6–9]. Of these wide range of the factors, public stigma towards people with mental health problems and mental health literacy are modifiable factors and have been targeted in the educational and intervention programs [6, 10]. For example, randomized controlled trials (RCTs) have shown that the interventions of social contacts with people with mental health problems decrease social distance and increase behavioral intention towards them [11–13]. Educational interventions using controlled biomedical messages about psychiatric disorders increase practically useful knowledge of mental health problems without increasing public stigma [14]. Mental health literacy programs improve the intention to seek help for participants’ own mental health problems [8, 15]. Many studies have focused on help-seeking behaviors, especially among adolescents, however, most of the studies used cross-sectional surveys [7, 8, 15, 16]. Most of the RCTs above introduced also used self-report questionnaires to change the behavioral intention and assess retrospective help-seeking behaviors. A 4-year prospective study in a university showed that more psychological risk factors on admission were associated with the use of psychological counseling after admission, based on service use records [17]. A prospective study showed that functional impairment and previous help-seeking behaviors were associated with later service use, but not directly with help seeking intention and personal and perceived stigma [18]. It is also suggested that public stigma indirectly promotes help-seeking behaviors by helping individuals recognize mental health problems [18–20]. However, few long-term prospective studies using large adolescent samples have investigated the relationship between stigma measures and later psychiatric and psychological service use, considering a variety of demographic and psychosocial assessments. In this study, we used 1437 questionnaire responses on admission and five-year follow-up surveys by annual health checkups and medical records from a health service center at the university. The questionnaire included a variety of stigma measures including practically useful knowledge, past experience, behavioral intention, help-seeking intention, and disclosing comfortability as well as various demographic and psychosocial assessments. Using these abundant survey responses and prospective five-year follow-up investigations, this study aimed to examine whether behavioral intention with people with mental health problems and help-seeking intentions about their own mental health problems would be associated with later psychiatric and psychological service use after admission. The hypothesis is that after mutually adjusted for the factors, high behavioral intention (low public stigma) and high help-seeking intentions would be associated with later service use. 2. Methods and materials 2.1. Participants Eligible participants were 3088 students who were enrolled in a university located in Tokyo, received health checkup on admission in April of one year in the 2010s to understand the health status of the students, under School Health and Safety Act, and were aged 25 years or younger at baseline ( Figure 1 ). Of these, 1919 participants responded to the stigma questionnaire (62.1%, 608 females [19.7%], mean age: 18.92 [SD 0.68] years; Table 1 ). There were significant differences in sex, age, NEO Five-Factor Inventory (NEO-FFI) subscale scores, Kessler 6 scale (K6), presence of psychotic experiences (PEs), 10-item short version of the Autism Spectrum Quotient scale (AQ-10) scores, follow-up status, and service use after admission between those who were followed up or not. Ethical approval for this study was obtained from the Research Ethics Committee of The University of Tokyo (approval no. 19-324 and 22-452) according to the provisions of the Declaration of Helsinki. All participants provided check-box informed consent after receiving an explanation of the research use before responding to the questionnaires. During the five-year follow-up period after admission, all students were requested to undergo annual health checkups under the Act, and 4331 valid questionnaire responses from 2131 participants were used ( Figure 1 ). We also used 2873 medical records from 253 participants in the department of psychiatry, health service center in the university. Finally, 1437 participants were analyzed using the health checkup and stigma questionnaire on admission and follow-up service use ( Table 1 ). 2.2. Psychiatric and psychological service use On admission, we asked about past use of psychiatric and psychological services using a grid item of service (i.e., school nurse’s office, school counselor, and psychiatry) and period (i.e., primary school, junior high school, high school, and later) in the questionnaire. We defined any positive response as past service use. After admission, we assessed service use from annual health checkups and medical records in the department of psychiatry, the health service center. In annual health checkups, we asked about the use of psychiatric and psychological services within one year using six options: ‘None,’ ‘student counseling,’ ‘general consultation,’ ‘communication support,’ ‘department of psychiatry in the health service center,’ and ‘psychiatry or psychosomatic medicine outside of the university.’ We confirmed a sensitivity of 0.925 and specificity of 0.983 for the use of the health service center from the questionnaire responses by refereeing to the medical records. We defined any positive response to the use of the health service center and/or psychiatry or psychosomatic medicine outside the university, and/or the use of the health service center according to the medical records, as psychiatric service use. We also defined any positive response of the use of student counseling and/or communication support as psychological service use. 2.3. Questionnaires on admission 2.3.1. Stigma measures In a voluntary anonymous stigma survey, we assessed the stigma levels of participants using the Mental Illness and Disorder Understanding Scale (MIDUS) for practically useful knowledge of mental health problems, the Japanese version of the Reported and Intended Behavior Scale (RIBS-J) for past experiences and behavioral intentions with people with mental health problems, and help-seeking intentions and disclosing comfortability questions about their own mental health problems. The MIDUS consists of 15 items rated on a five-point Likert scale (range 0―60, with a lower score representing more practically useful) [21]. The MIDUS was originally developed in Japan and its factorial validity and moderate internal consistency have been confirmed. The factor analysis revealed the three subscales including treatability of illness (e.g., ‘Mental illness is treatable’), efficacy of medication (e.g., ‘Medication is effective in improving symptoms’) and social recognition of illness (e.g., ‘Mental illnesses are very common’). The RIBS is widely used to assess public stigma toward people with mental health problems, and consists of reported and intended behavior parts [22, 23]. The reported behavior subscale comprises four items asking whether a respondent has ever experienced social contact with close people (i.e., living-in, co-workers, neighbors, and close friends) with mental health problems in the past (e.g., ‘Are you currently living with, or have you ever lived with, someone with a mental health problem?’). The options were ‘yes,’ ‘no,’ and ‘do not know.’ For each item, a score of 1 was allocated for past and present experiences, whereas the other options were scored as 0 (range: 0―4). For the 4-item intended behavior subscale (e.g., ‘In the future, I would be willing to live with someone with a mental health problem.’) The options were ‘agree strongly,’ ‘agree slightly,’ ‘neither agree nor disagree,’ ‘disagree slightly,’ ‘disagree strongly,’ and ‘do not know.’ For each item, a score of 5 was allocated for strong agreement, while a score of 1 was assigned to strong disagreement (range: 4―20). The response option ‘don’t know,’ was coded as neutral (i.e., 3). Higher scores indicate more favorable behavioral intentions, suggesting a smaller public stigma toward people with mental illness. Help-seeking intention was assessed using one item, ‘If you felt that you had a mental health problem, how likely would you be to go to your general practitioner for help?’ [24] Responses are rated on a 5-point scale scores indicating a greater likelihood of seeking help. Disclosing comfortability was also assessed using one item, ‘In general, how comfortable would you feel talking to a friend or family member about your mental health?’ [24] Responses are rated on a 7-point Likert scale, with higher scores reflecting greater comfort to disclose. 2.3.2. Demographic and psychological assessment The demographic assessment on admission included admission from abroad, resident status, usual sleep time on weekdays and holidays, and exercise frequency. Admissions from abroad were assessed using a simple dichotomous question. Resident status after admission was asked using a single question with six options: ‘Alone,’ ‘dormitory,’ ‘with family,’ ‘with relatives,’ ‘share house,’ and ‘others.’ We used the response ‘Live with family and/or relatives’ as the reference category to see the effect of category ‘Living alone or in dormitory.’ Usual sleep time on weekdays and holidays was asked using a single question with seven options: ‘less than 5 h,’ ‘5―6 h,’ ‘6―7 h,’ ‘7―8 h,’ ‘8―9 h,’ ‘9―10 h,’ and ‘10 or longer.’ We categorized the responses into ‘Less than 6 hours,’ ‘Between 6 and 8 hours’ as the reference, and ‘8 or more hours.’ Exercise frequency was asked using a single question with four options: ‘No exercise,’ ‘Once a month,’ ‘Once a week (reference),’ and ‘Everyday.’ The health checkup on admission also assessed students’ personality traits using the NEO-FFI [25], depressive symptoms using the K6 [26, 27], PEs [28, 29], autistic spectrum using the AQ-10 [30, 31], and social support using the Social Support Questionnaire Short Form (SSQ6) [32, 33]. In this study, PE was used as a dichotomized variable with any positive response to PE items or never, and the other scale scores were used as continuous variables. The details of the questionnaires are described in Supplementary Materials . 2.4. Statistical analysis Statistical analyses were performed using the RStudio Server version 4.3.0. and statistical significance was set at p < 0.05. First, we tested whether stigma factors would be associated with the past experience of psychiatric and psychological service use in the admission survey using a logistic regression model. The models included each factor as an independent variable (Model 1), and were mutually adjusted for independent and confounding demographic and psychosocial variables (Model 2). We applied a bi-directional stepwise method to model 2 using ‘MASS’ package version 7.3-60 [34]. Second, we tested whether stigma factors would be associated with psychiatric and psychological service use after admission using logistic regression models. The models included each factor as an independent variable (Model 1) and mutually adjusted for demographic, psychosocial, and stigma factors (Model 2). Finally, to see what variables from the significant factors would be a possible good predictor or whether the combined classification would be a best one for later service use, we obtained a cut-off point for each independent variable using a receiver operating characteristic (ROC) curve analysis and top-left criteria implemented in ‘pROC’ package version 1.18.5 [35]. After determining the cut-off points, we explored an ROC curve for combined predictors to see whether the surveys on admission would provide reliable information for service use after admission and what scales would be good predictors compared to the overall accuracy. The criteria of the area under the curve (AUC) were set at 0.5 < AUC < 0.7 as poor, 0.7 ≤ AUC < 0.8 as acceptable, 0.8 ≤ AUC < 0.9 as excellent, and AUC ≥ 0.9 as outstanding discrimination. 3. Results 3.1. Stigma factors associated with the experience of psychiatric and psychological service use in admission The correlation matrix is shown in Figure 2 . In a cross-sectional survey, a logistic regression model showed that low MIDUS, high RIBS reported and intended behaviors, and high help-seeking intention scores were associated with the experience of any psychiatric and psychological service use ( Table 2 ). After mutually adjusting for these factors and demographic and psychosocial variables, high RIBS reported behavior and help-seeking intention scores were associated with service use ( OR 1.560 [ 95% CI 1.133―2.149], p = 0.006; 1.634 [1.247―2.142], p < 0.001; respectively). A model for the experience of psychiatric service use also showed significant stigma factors (RIBS reported behavior: 1.691 [1.124―2.545], p = 0.012; help-seeking intention: 1.950 [1.322―2.876], p = 0.001; Supplementary Table S1 ). 3.2. Stigma factors associated with the experience of psychiatric and psychological service use after admission A logistic regression model for psychiatric and psychological service use after admission showed significant factors for the MIDUS and RIBS reported and intended behavior scores ( Table 3 ). After mutual adjustment, RIBS intended behavior (1.060 [1.003―1.120], p = 0.037) and help-seeking intention (1.234 [1.029―1.479], p = 0.023) were still significant factors. When the dependent variable limited to psychiatric service use after admission, a stepwise mutually adjusted logistic regression model showed non-significant stigma factors ( p > 0.001; Supplementary Table S2 ), although the MIDUS and RIBS reported and intended behavior scores were significant in a crude model. 3.3. ROC curve analysis The ROC model showed poor discrimination for each variable in any type of service use after admission. Of these, the K6 scale is one of the highest AUCs across the types of service use. Using a model combining all significant scales, The ROC models showed acceptable discrimination for psychiatric and psychological service use after admission (AUC = 0.713, Supplementary Figure S1 and Table S3 ) and psychiatric service use (AUC = 0.715; Supplementary Figure S2 and Table S4 ). 4. Discussion In this study, we tested which stigma-related factors were associated with later psychiatric and psychological service use after admission in a five-year prospective follow-up. Service use was assessed using prospective follow-up questionnaire responses and medical records in department of psychiatry, and the reliability of the questionnaire responses was confirmed by the medical records. The mutually adjusted logistic regression models including various demographic and psychosocial variables as covariates showed that favorable behavioral intention with people with mental health problems and help-seeking intention about their own mental health problems were associated with psychiatric and psychological service use after admission. To the best of our knowledge, this is the first study to show a relationship of low stigma and high help-seeking intention with later psychiatric and psychological service use in a long-term prospective follow-up. This study showed that favorable behavioral intention in stigma scales was associated with later service use. Since the limitation of most RCTs targeting the decrease of public stigma is self-report outcome measures that may not accurately reflect actual service use in the follow-up assessment [11–14], the results may be helpful in promoting anti-stigma campaigns and educational curriculum targeting on decreasing public stigma. Help-seeking intentions regarding their own mental health problems were also associated with later service use. Since systematic reviews of help-seeking behaviors have also raised the limitation of previous studies that assessed no actual behaviors but asked only self-reports retrospectively [7, 8, 15, 16], prospective and confirmed service use records may support the evidence of the relationship between self-reported help-seeking intention and later behaviors. Notably, literacy program interventions for mental health intend to increase awareness and help-seeking intention about the mental health problems of the participants. Therefore, the present findings may also help to improve early support for young people who have recently experienced psychological problems in the educational curriculum and specialized interventions on admission. In the mutually adjusted models, we found no significant effect of other stigma measures such as practically useful knowledge and past experience with people with mental health problems. Both of the stigma factors are related to the recognition of mental health problems and are thought to be associated with mental health literacy. Prospective studies have suggested that public stigma also indirectly affects help-seeking behavior by helping with the recognition of mental health problems [18–20]. Therefore, investigating the pathways of various stigma factors and service use in a longitudinal investigation is the next step. This study had several limitations. First, the participants were new students admitted in April of one year in the 2010s at a university in Tokyo, Japan. We need to conduct replicative studies using other datasets. In particular, the ROC curve analysis needs to be confirmed using an independent dataset from different admission periods at the university and the others, that is why we did not conduct a machine learning approach. Better and more reliable prediction for service use after admission can help better support systems and educational curricula in universities and better health outcomes for students. Second, only 44% of the students received two or more health checkups, and around 30% did not receive any health checkups for five years. The lack of information and unfollowed participants may miss their potential service uses and bias the present findings. In conclusion, our five-year prospective study showed that favorable behavioral intention with people with mental health problems and help-seeking intention about their own mental health problems were associated with later psychiatric and psychological service use. To the best of our knowledge, this is the first prospective study using a large adolescent sample, a variety of demographic and psychosocial assessments, and later service use. The results suggest the importance of anti-stigma campaigns for reducing public stigma and mental health literacy programs regarding earlier service use for their own mental health problems. Future studies are needed to explore the changes of public stigma and help-seeking intention in a longitudinal investigation would effect on service use. Declarations Acknowledgement This study was supported by grants from JSPS KAKENHI (No. JP22H05212 and JP24H00899 to SK). Availability of Data and Materials The annual health check-up and medical record in the Health Service Center will not be provided to anyone outside of the affiliation due to the decision of the department. The stigma survey data may be provided after the revision of the ethical review committee in response to a request to the corresponding author. All analysis codes can be provided as requested. References Colizzi M, Lasalvia A, Ruggeri M (2020) Prevention and early intervention in youth mental health: is it time for a multidisciplinary and trans-diagnostic model for care? Int J Ment Health Syst 14:23. https://doi.org/10.1186/s13033-020-00356-9 Solmi M, Radua J, Olivola M, et al (2022) Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry 27:281–295. https://doi.org/10.1038/s41380-021-01161-7 McGrath JJ, Al-Hamzawi A, Alonso J, et al (2023) Age of onset and cumulative risk of mental disorders: a cross-national analysis of population surveys from 29 countries. Lancet Psychiatry 10:668–681. https://doi.org/10.1016/S2215-0366(23)00193-1 Sayal K, Yates N, Spears M, Stallard P (2014) Service use in adolescents at risk of depression and self-harm: prospective longitudinal study. Soc Psychiatry Psychiatr Epidemiol 49:1231–1240. https://doi.org/10.1007/s00127-014-0843-y Jörg F, Visser E, Ormel J, et al (2016) Mental health care use in adolescents with and without mental disorders. Eur Child Adolesc Psychiatry 25:501–508. https://doi.org/10.1007/s00787-015-0754-9 Clement S, Schauman O, Graham T, et al (2015) What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychol Med 45:11–27. https://doi.org/10.1017/S0033291714000129 Reardon T, Harvey K, Baranowska M, et al (2017) What do parents perceive are the barriers and facilitators to accessing psychological treatment for mental health problems in children and adolescents? A systematic review of qualitative and quantitative studies. Eur Child Adolesc Psychiatry 26:623–647. https://doi.org/10.1007/s00787-016-0930-6 Aguirre Velasco A, Cruz ISS, Billings J, et al (2020) What are the barriers, facilitators and interventions targeting help-seeking behaviours for common mental health problems in adolescents? A systematic review. BMC Psychiatry 20:293. https://doi.org/10.1186/s12888-020-02659-0 Radez J, Reardon T, Creswell C, et al (2021) Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies. Eur Child Adolesc Psychiatry 30:183–211. https://doi.org/10.1007/s00787-019-01469-4 Schnyder N, Panczak R, Groth N, Schultze-Lutter F (2017) Association between mental health-related stigma and active help-seeking: Systematic review and meta-analysis. Br J Psychiatry 210:261–268. https://doi.org/10.1192/bjp.bp.116.189464 Thornicroft G, Mehta N, Clement S, et al (2016) Evidence for effective interventions to reduce mental-health-related stigma and discrimination. Lancet Lond Engl 387:1123–1132. https://doi.org/10.1016/S0140-6736(15)00298-6 Koike S, Yamaguchi S, Ojio Y, et al (2018) A randomised controlled trial of repeated filmed social contact on reducing mental illness-related stigma in young adults. Epidemiol Psychiatr Sci 27:199–208. https://doi.org/10.1017/S2045796016001050 Yamaguchi S, Ojio Y, Ando S, et al (2019) Long-term effects of filmed social contact or internet-based self-study on mental health-related stigma: a 2-year follow-up of a randomised controlled trial. Soc Psychiatry Psychiatr Epidemiol 54:33–42. https://doi.org/10.1007/s00127-018-1609-8 Ojio Y, Yamaguchi S, Ohta K, et al (2020) Effects of biomedical messages and expert-recommended messages on reducing mental health-related stigma: a randomised controlled trial. Epidemiol Psychiatr Sci 29:e74. https://doi.org/10.1017/S2045796019000714 Özparlak A, Karakaya D, Özer Z (2023) The association of mental health literacy with mental well-being and help-seeking in young people: A systematic review and meta-analysis. J Pediatr Nurs Nurs Care Child Fam 73:e243–e250. https://doi.org/10.1016/j.pedn.2023.09.017 Osborn TG, Li S, Saunders R, Fonagy P (2022) University students’ use of mental health services: a systematic review and meta-analysis. Int J Ment Health Syst 16:57. https://doi.org/10.1186/s13033-022-00569-0 Liu F, Zhou N, Cao H, et al (2017) Chinese college freshmen’s mental health problems and their subsequent help-seeking behaviors: A cohort design (2005-2011). PloS One 12:e0185531. https://doi.org/10.1371/journal.pone.0185531 Doll CM, Michel C, Rosen M, et al (2021) Predictors of help-seeking behaviour in people with mental health problems: a 3-year prospective community study. BMC Psychiatry 21:432. https://doi.org/10.1186/s12888-021-03435-4 Schomerus G, Stolzenburg S, Freitag S, et al (2019) Stigma as a barrier to recognizing personal mental illness and seeking help: a prospective study among untreated persons with mental illness. Eur Arch Psychiatry Clin Neurosci 269:469–479. https://doi.org/10.1007/s00406-018-0896-0 Yu BCL, Chio FHN, Chan KKY, et al (2023) Associations between public and self-stigma of help-seeking with help-seeking attitudes and intention: A meta-analytic structural equation modeling approach. J Couns Psychol 70:90–102. https://doi.org/10.1037/cou0000637 Tanaka G (2003) Development of the Mental Illness and Disorder Understanding Scale. Int J Jpn Sociol 12:95–107. https://doi.org/10.1111/j.1475-6781.2003.00045.x Evans-Lacko S, Rose D, Little K, et al (2011) Development and psychometric properties of the Reported and Intended Behaviour Scale (RIBS): a stigma-related behaviour measure. Epidemiol Psychiatr Sci 20:263–271. https://doi.org/10.1017/s2045796011000308 Yamaguchi S, Koike S, Watanabe K, Ando S (2014) Development of a Japanese version of the Reported and Intended Behaviour Scale: Reliability and validity. Psychiatry Clin Neurosci 68:448–455. https://doi.org/10.1111/pcn.12151 Rüsch N, Evans-Lacko SE, Henderson C, et al (2011) Knowledge and attitudes as predictors of intentions to seek help for and disclose a mental illness. Psychiatr Serv Wash DC 62:675–678. https://doi.org/10.1176/ps.62.6.pss6206_0675 Costa PT, McCrae RR (1992) Revised NEO Personality Inventory (NEO-PI-R) and NEO Five-Factor Inventory (NEO-FFI) professional manual. Psychological Assessment Resources, Odessa, FL Kessler RC, Barker PR, Colpe LJ, et al (2003) Screening for serious mental illness in the general population. Arch Gen Psychiatry 60:184–189. https://doi.org/10.1001/archpsyc.60.2.184 Furukawa TA, Kawakami N, Saitoh M, et al (2008) The performance of the Japanese version of the K6 and K10 in the World Mental Health Survey Japan. Int J Methods Psychiatr Res 17:152–158. https://doi.org/10.1002/mpr.257 Poulton R, Caspi A, Moffitt TE, et al (2000) Children’s self-reported psychotic symptoms and adult schizophreniform disorder: a 15-year longitudinal study. Arch Gen Psychiatry 57:1053–1058. https://doi.org/10.1001/archpsyc.57.11.1053 Nishida A, Tanii H, Nishimura Y, et al (2008) Associations between psychotic-like experiences and mental health status and other psychopathologies among Japanese early teens. Schizophr Res 99:125–133. https://doi.org/10.1016/j.schres.2007.11.038 Wakabayashi A, Tojo Y, Baron-Cohen S, Wheelwright S (2004) [The Autism-Spectrum Quotient (AQ) Japanese version: evidence from high-functioning clinical group and normal adults]. Shinrigaku Kenkyu 75:78–84. https://doi.org/10.4992/jjpsy.75.78 Allison C, Auyeung B, Baron-Cohen S (2012) Toward brief “Red Flags” for autism screening: The Short Autism Spectrum Quotient and the Short Quantitative Checklist for Autism in toddlers in 1,000 cases and 3,000 controls. J Am Acad Child Adolesc Psychiatry 51:202-212.e7. https://doi.org/10.1016/j.jaac.2011.11.003 Sarason IG, Levine HM, Basham RB, Sarason BR (1983) Assessing social support: The Social Support Questionnaire. J Pers Soc Psychol 44:127–139. https://doi.org/10.1037/0022-3514.44.1.127 Furukawa TA, Harai H, Hirai T, et al (1999) Social Support Questionnaire among psychiatric patients with various diagnoses and normal controls. Soc Psychiatry Psychiatr Epidemiol 34:216–222. https://doi.org/10.1007/s001270050136 Venables WN, Ripley BD (2002) Modern applied statistics with S, 4th Ed. Springer, New York Robin X, Turck N, Hainard A, et al (2011) pROC: an open-source package for R and S+ to analyze and compare ROC curves. BMC Bioinformatics 12:77. https://doi.org/10.1186/1471-2105-12-77 Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterialsSPPE.docx Tablesf.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 18 Dec, 2025 Reviewers agreed at journal 20 Nov, 2025 Reviewers invited by journal 19 Nov, 2025 Editor assigned by journal 01 May, 2025 Submission checks completed at journal 11 Apr, 2025 First submitted to journal 11 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6425632","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":548227933,"identity":"c76fa843-f8d8-45c1-8e8d-e63308db74e4","order_by":0,"name":"Shinsuke Koike","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIie3Ru2rDMACF4RMCngTuKDdgv4KKxryMglcVDFk6lOLJXQRZnbdIlswWAmdx9kCymID3LJ1KW18g3RSPhepfJIQ+0AVwuf5iBNBpO1JMC4ANi2wMoRSeGE8mAyH2jbciZbTOX/AW5PLj8Zic4b8XWCYWwg6Z0JsKdEafdzPJGtBKgOc24hOm6+ybhgMxwBHgxHawVUe+0BLZ9CS6R3BQTG/T7mDS6wm7R1hVCp2XCNaq4fOWkKdqkVrvEqnYXNUrfLqP65P8NGG4NyW3vdhvD6Ifun/K+CgBv7hNp5dxxOVyuf5JP7C5SoGOWPK1AAAAAElFTkSuQmCC","orcid":"","institution":"University of Tokyo Institute for Diversity and Adaptation of Human Mind, The University of Tokyo","correspondingAuthor":true,"prefix":"","firstName":"Shinsuke","middleName":"","lastName":"Koike","suffix":""},{"id":548227935,"identity":"25064cbd-3808-4d43-b1e6-9ff1023ca53a","order_by":1,"name":"Sakine Shinohara","email":"","orcid":"","institution":"The University of Tokyo","correspondingAuthor":false,"prefix":"","firstName":"Sakine","middleName":"","lastName":"Shinohara","suffix":""},{"id":548227937,"identity":"431bc914-9c67-4d6e-af0b-bb9ff4019f32","order_by":2,"name":"Kei-Ichiro Watanabe","email":"","orcid":"","institution":"The University of Tokyo Health Service Center","correspondingAuthor":false,"prefix":"","firstName":"Kei-Ichiro","middleName":"","lastName":"Watanabe","suffix":""},{"id":548227938,"identity":"cfc8643d-fb31-4ab7-b22c-8f81c9c8c04d","order_by":3,"name":"Shintaro Yanagimoto","email":"","orcid":"","institution":"The University of Tokyo Health Service Center","correspondingAuthor":false,"prefix":"","firstName":"Shintaro","middleName":"","lastName":"Yanagimoto","suffix":""},{"id":548227939,"identity":"f658d250-b704-4f17-b42c-4bd3aa1b887d","order_by":4,"name":"Shuntaro Ando","email":"","orcid":"","institution":"The University of Tokyo","correspondingAuthor":false,"prefix":"","firstName":"Shuntaro","middleName":"","lastName":"Ando","suffix":""},{"id":548227940,"identity":"53093a5b-bfdf-4d18-9787-882f5e4d1490","order_by":5,"name":"Sosei Yamaguchi","email":"","orcid":"","institution":"National Institute of Mental Health","correspondingAuthor":false,"prefix":"","firstName":"Sosei","middleName":"","lastName":"Yamaguchi","suffix":""},{"id":548227941,"identity":"aac97a57-23ab-47ad-962d-56391e1fdbe5","order_by":6,"name":"Norihito Oshima","email":"","orcid":"","institution":"The University of Tokyo Health Service Center","correspondingAuthor":false,"prefix":"","firstName":"Norihito","middleName":"","lastName":"Oshima","suffix":""}],"badges":[],"createdAt":"2025-04-11 07:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6425632/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6425632/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96977782,"identity":"9131e2cd-d7c9-4e54-9687-e98ad93e1dbc","added_by":"auto","created_at":"2025-11-28 08:49:02","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":58502,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParticipant flow chart of this study.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAbbreviations: HC, health checkup; HSC, health service center.\u003c/p\u003e","description":"","filename":"fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6425632/v1/6064b2f0cc67cf0c5c7b27d1.jpg"},{"id":96977784,"identity":"c5566c0b-aa86-48d0-855b-e984842b21a6","added_by":"auto","created_at":"2025-11-28 08:49:02","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":164996,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCorrelation matrix of questionnaire responses on admission and service use after admission.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAbbreviations: K6, Kessler 6 scale; PEs, psychotic experiences; AQ-10, 10-item short version of the Autism Spectrum Quotient scale; SSQ6, Social Support Questionnaire Short Form; MIDUS, Mental Illness and Disorder Understanding Scale; RIBS, Japanese version of the Reported and Intended Behavior Scale.\u003c/p\u003e","description":"","filename":"fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6425632/v1/0f844626a8bddfc6967772a4.jpg"},{"id":97138411,"identity":"f71e219f-b0a8-400d-bed0-5ffded6e9f61","added_by":"auto","created_at":"2025-12-01 09:58:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":777612,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6425632/v1/c064ed5a-78f4-45bf-a1aa-7731a5988235.pdf"},{"id":96977785,"identity":"1f203d25-cded-4c82-b557-56a6fee5e499","added_by":"auto","created_at":"2025-11-28 08:49:02","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":383365,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterialsSPPE.docx","url":"https://assets-eu.researchsquare.com/files/rs-6425632/v1/1549bf3e15c425c102e3191e.docx"},{"id":96977783,"identity":"41dea63b-d346-40a4-a611-9b9a1f9af81c","added_by":"auto","created_at":"2025-11-28 08:49:02","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":54941,"visible":true,"origin":"","legend":"","description":"","filename":"Tablesf.docx","url":"https://assets-eu.researchsquare.com/files/rs-6425632/v1/db0c990c67e391c58d019ce2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Adolescent public stigma and help seeking intention are associated with later service use: A five-year follow-up study using annual self-report surveys and medical records","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eEarly support and care for people with mental health problems are one of the most important factors for better symptomatic remission and functional recovery in later life [1]. Since approximately three-fourths of the cases of psychiatric disorders are encountered by age at 24 years [2, 3], educational curriculum and psychiatric and psychosocial support in schools are important for better mental health. However, around one-third of the adolescents who needed to care for their mental health problems received psychiatric care and psychosocial support [4, 5]. Systematic reviews of help-seeking behaviors in adolescents showed that gender, age, ethnic minority, stigma, mental health literacy, autonomy, service cost, the gap in service needs and locations, family beliefs, and negative beliefs about mental health services and professionals were barriers to seeking help towards their mental health problems [6–9].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOf these wide range of the factors, public stigma towards people with mental health problems and mental health literacy are modifiable factors and have been targeted in the educational and intervention programs [6, 10]. For example, randomized controlled trials (RCTs) have shown that the interventions of social contacts with people with mental health problems decrease social distance and increase behavioral intention towards them [11–13]. Educational interventions using controlled biomedical messages about psychiatric disorders increase practically useful knowledge of mental health problems without increasing public stigma [14]. Mental health literacy programs improve the intention to seek help for participants’ own mental health problems [8, 15].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany studies have focused on help-seeking behaviors, especially among adolescents, however, most of the studies used cross-sectional surveys [7, 8, 15, 16]. Most of the RCTs above introduced also used self-report questionnaires to change the behavioral intention and assess retrospective help-seeking behaviors. A 4-year prospective study in a university showed that more psychological risk factors on admission were associated with the use of psychological counseling after admission, based on service use records [17]. A prospective study showed that functional impairment and previous help-seeking behaviors were associated with later service use, but not directly with help seeking intention and personal and perceived stigma\u0026nbsp;[18]. It is also suggested that public stigma indirectly promotes help-seeking behaviors by helping individuals recognize mental health problems [18–20]. However, few long-term prospective studies using large adolescent samples have investigated the relationship between stigma measures and later psychiatric and psychological service use, considering a variety of demographic and psychosocial assessments.\u003c/p\u003e\n\u003cp\u003eIn this study, we used 1437 questionnaire responses on admission and five-year follow-up surveys by annual health checkups and medical records from a health service center at the university. The questionnaire included a variety of stigma measures including practically useful knowledge, past experience, behavioral intention, help-seeking intention, and disclosing comfortability as well as various demographic and psychosocial assessments. Using these abundant survey responses and prospective five-year follow-up investigations, this study aimed to examine whether behavioral intention with people with mental health problems and help-seeking intentions about their own mental health problems would be associated with later psychiatric and psychological service use after admission. The hypothesis is that after mutually adjusted for the factors, high behavioral intention (low public stigma) and high help-seeking intentions would be associated with later service use.\u0026nbsp;\u003c/p\u003e"},{"header":"2. Methods and materials","content":"\u003cp\u003e2.1. Participants\u003c/p\u003e\n\u003cp\u003eEligible participants were 3088 students who were enrolled in a university located in Tokyo, received health checkup on admission in April of one year in the 2010s to understand the health status of the students, under School Health and Safety Act, and were aged 25 years or younger at baseline (\u003cstrong\u003eFigure 1\u003c/strong\u003e). Of these, 1919 participants responded to the stigma questionnaire (62.1%, 608 females [19.7%], mean age: 18.92 [SD 0.68] years; \u003cstrong\u003eTable 1\u003c/strong\u003e). There were significant differences in sex, age, NEO Five-Factor Inventory (NEO-FFI) subscale scores, Kessler 6 scale (K6), presence of psychotic experiences (PEs), 10-item short version of the Autism Spectrum Quotient scale (AQ-10) scores, follow-up status, and service use after admission between those who were followed up or not. Ethical approval for this study was obtained from the Research Ethics Committee of The University of Tokyo (approval no. 19-324 and 22-452) according to the provisions of the Declaration of Helsinki. All participants provided check-box informed consent after receiving an explanation of the research use before responding to the questionnaires.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring the five-year follow-up period after admission, all students were requested to undergo annual health checkups under the Act, and 4331 valid questionnaire responses from 2131 participants were used (\u003cstrong\u003eFigure 1\u003c/strong\u003e). We also used 2873 medical records from 253 participants in the department of psychiatry, health service center in the university. Finally, 1437 participants were analyzed using the health checkup and stigma questionnaire on admission and follow-up service use (\u003cstrong\u003eTable 1\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.2. Psychiatric and psychological service use\u003c/p\u003e\n\u003cp\u003eOn admission, we asked about past use of psychiatric and psychological services using a grid item of service (i.e., school nurse’s office, school counselor, and psychiatry) and period (i.e., primary school, junior high school, high school, and later) in the questionnaire. We defined any positive response as past service use.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;After admission, we assessed service use from annual health checkups and medical records in the department of psychiatry, the health service center. In annual health checkups, we asked about the use of psychiatric and psychological services within one year using six options: ‘None,’ ‘student counseling,’ ‘general consultation,’ ‘communication support,’ ‘department of psychiatry in the health service center,’ and ‘psychiatry or psychosomatic medicine outside of the university.’ We confirmed a sensitivity of 0.925 and specificity of 0.983 for the use of the health service center from the questionnaire responses by refereeing to the medical records.\u003c/p\u003e\n\u003cp\u003eWe defined any positive response to the use of the health service center and/or psychiatry or psychosomatic medicine outside the university, and/or the use of the health service center according to the medical records, as psychiatric service use. We also defined any positive response of the use of student counseling and/or communication support as psychological service use.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.3. Questionnaires on admission\u003c/p\u003e\n\u003cp\u003e2.3.1. Stigma measures\u003c/p\u003e\n\u003cp\u003eIn a voluntary anonymous stigma survey, we assessed the stigma levels of participants using the Mental Illness and Disorder Understanding Scale (MIDUS) for practically useful knowledge of mental health problems, the Japanese version of the Reported and Intended Behavior Scale (RIBS-J) for past experiences and behavioral intentions with people with mental health problems, and help-seeking intentions and disclosing comfortability questions about their own mental health problems.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe MIDUS consists of 15 items rated on a five-point Likert scale (range 0―60, with a lower score representing more practically useful) [21]. The MIDUS was originally developed in Japan and its factorial validity and moderate internal consistency have been confirmed. The factor analysis revealed the three subscales including treatability of illness (e.g., ‘Mental illness is treatable’), efficacy of medication (e.g., ‘Medication is effective in improving symptoms’) and social recognition of illness (e.g., ‘Mental illnesses are very common’).\u003c/p\u003e\n\u003cp\u003eThe RIBS is widely used to assess public stigma toward people with mental health problems, and consists of reported and intended behavior parts [22, 23]. The reported behavior subscale comprises four items asking whether a respondent has ever experienced social contact with close people (i.e., living-in, co-workers, neighbors, and close friends) with mental health problems in the past (e.g., ‘Are you currently living with, or have you ever lived with, someone with a mental health problem?’). The options were ‘yes,’ ‘no,’ and ‘do not know.’ For each item, a score of 1 was allocated for past and present experiences, whereas the other options were scored as 0 (range: 0―4). For the 4-item intended behavior subscale (e.g., ‘In the future, I would be willing to live with someone with a mental health problem.’) The options were ‘agree strongly,’ ‘agree slightly,’ ‘neither agree nor disagree,’ ‘disagree slightly,’ ‘disagree strongly,’ and ‘do not know.’ For each item, a score of 5 was allocated for strong agreement, while a score of 1 was assigned to strong disagreement (range: 4―20). The response option ‘don’t know,’ was coded as neutral (i.e., 3). Higher scores indicate more favorable behavioral intentions, suggesting a smaller public stigma toward people with mental illness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHelp-seeking intention was assessed using one item, ‘If you felt that you had a mental health problem, how likely would you be to go to your general practitioner for help?’ [24] Responses are rated on a 5-point scale scores indicating a greater likelihood of seeking help. Disclosing comfortability was also assessed using one item, ‘In general, how comfortable would you feel talking to a friend or family member about your mental health?’ [24] Responses are rated on a 7-point Likert scale, with higher scores reflecting greater comfort to disclose.\u003c/p\u003e\n\u003cp\u003e2.3.2. Demographic and psychological assessment\u003c/p\u003e\n\u003cp\u003eThe demographic assessment on admission included admission from abroad, resident status, usual sleep time on weekdays and holidays, and exercise frequency. Admissions from abroad were assessed using a simple dichotomous question. Resident status after admission was asked using a single question with six options: ‘Alone,’ ‘dormitory,’ ‘with family,’ ‘with relatives,’ ‘share house,’ and ‘others.’ We used the response ‘Live with family and/or relatives’ as the reference category to see the effect of category ‘Living alone or in dormitory.’ Usual sleep time on weekdays and holidays was asked using a single question with seven options: ‘less than 5 h,’ ‘5―6 h,’ ‘6―7 h,’ ‘7―8 h,’ ‘8―9 h,’ ‘9―10 h,’ and ‘10 or longer.’ We categorized the responses into ‘Less than 6 hours,’ ‘Between 6 and 8 hours’ as the reference, and ‘8 or more hours.’ Exercise frequency was asked using a single question with four options: ‘No exercise,’ ‘Once a month,’ ‘Once a week (reference),’ and ‘Everyday.’\u003c/p\u003e\n\u003cp\u003eThe health checkup on admission also assessed students’ personality traits using the NEO-FFI [25], depressive symptoms using the K6 [26, 27], PEs [28, 29], autistic spectrum using the AQ-10 [30, 31], and social support using the Social Support Questionnaire Short Form (SSQ6) [32, 33]. In this study, PE was used as a dichotomized variable with any positive response to PE items or never, and the other scale scores were used as continuous variables. The details of the questionnaires are described in \u003cstrong\u003eSupplementary Materials\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e2.4. Statistical analysis\u003c/p\u003e\n\u003cp\u003eStatistical analyses were performed using the RStudio Server version 4.3.0. and statistical significance was set at\u003cem\u003e\u0026nbsp;p\u003c/em\u003e \u0026lt; 0.05. First, we tested whether stigma factors would be associated with the past experience of psychiatric and psychological service use in the admission survey using a logistic regression model. The models included each factor as an independent variable (Model 1), and were mutually adjusted for independent and confounding demographic and psychosocial variables (Model 2). We applied a bi-directional stepwise method to model 2 using ‘MASS’ package version 7.3-60 [34].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Second, we tested whether stigma factors would be associated with psychiatric and psychological service use after admission using logistic regression models. The models included each factor as an independent variable (Model 1) and mutually adjusted for demographic, psychosocial, and stigma factors (Model 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, to see what variables from the significant factors would be a possible good predictor or whether the combined classification would be a best one for later service use, we obtained a cut-off point for each independent variable using a receiver operating characteristic (ROC) curve analysis and top-left criteria implemented in ‘pROC’ package version 1.18.5 [35]. After determining the cut-off points, we explored an ROC curve for combined predictors to see whether the surveys on admission would provide reliable information for service use after admission and what scales would be good predictors compared to the overall accuracy. The criteria of the area under the curve (AUC) were set at 0.5 \u0026lt; AUC \u0026lt; 0.7 as poor, 0.7 ≤ AUC \u0026lt; 0.8 as acceptable, 0.8 ≤ AUC \u0026lt; 0.9 as excellent, and AUC ≥ 0.9 as outstanding discrimination.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e3.1. Stigma factors associated with the experience of psychiatric and psychological service use in admission\u003c/p\u003e\n\u003cp\u003eThe correlation matrix is shown in \u003cstrong\u003eFigure 2\u003c/strong\u003e. In a cross-sectional survey, a logistic regression model showed that low MIDUS, high RIBS reported and intended behaviors, and high help-seeking intention scores were associated with the experience of any psychiatric and psychological service use (\u003cstrong\u003eTable 2\u003c/strong\u003e). After mutually adjusting for these factors and demographic and psychosocial variables, high RIBS reported behavior and help-seeking intention scores were associated with service use (\u003cem\u003eOR\u003c/em\u003e 1.560 [\u003cem\u003e95% CI\u003c/em\u003e 1.133―2.149], \u003cem\u003ep\u003c/em\u003e = 0.006; 1.634 [1.247―2.142], \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001; respectively). A model for the experience of psychiatric service use also showed significant stigma factors (RIBS reported behavior: 1.691 [1.124―2.545], \u003cem\u003ep\u003c/em\u003e = 0.012; help-seeking intention: 1.950 [1.322―2.876], \u003cem\u003ep\u003c/em\u003e = 0.001; \u003cstrong\u003eSupplementary\u003c/strong\u003e \u003cstrong\u003eTable S1\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.2. Stigma factors associated with the experience of psychiatric and psychological service use after admission\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA logistic regression model for psychiatric and psychological service use after admission showed significant factors for the MIDUS and RIBS reported and intended behavior scores (\u003cstrong\u003eTable 3\u003c/strong\u003e). After mutual adjustment, RIBS intended behavior (1.060 [1.003―1.120], \u003cem\u003ep\u003c/em\u003e = 0.037) and help-seeking intention (1.234 [1.029―1.479], \u003cem\u003ep\u003c/em\u003e = 0.023) were still significant factors. When the dependent variable limited to psychiatric service use after admission, a stepwise mutually adjusted logistic regression model showed non-significant stigma factors (\u003cem\u003ep\u003c/em\u003e \u0026gt; 0.001; \u003cstrong\u003eSupplementary\u003c/strong\u003e \u003cstrong\u003eTable S2\u003c/strong\u003e), although the MIDUS and RIBS reported and intended behavior scores were significant in a crude model.\u003c/p\u003e\n\u003cp\u003e3.3. ROC curve analysis\u003c/p\u003e\n\u003cp\u003eThe ROC model showed poor discrimination for each variable in any type of service use after admission. Of these, the K6 scale is one of the highest AUCs across the types of service use. Using a model combining all significant scales, The ROC models showed acceptable discrimination for psychiatric and psychological service use after admission (AUC = 0.713, \u003cstrong\u003eSupplementary\u003c/strong\u003e\u003cstrong\u003eFigure S1\u0026nbsp;\u003c/strong\u003eand\u003cstrong\u003e\u0026nbsp;Table S3\u003c/strong\u003e) and psychiatric service use (AUC = 0.715; \u003cstrong\u003eSupplementary\u003c/strong\u003e\u003cstrong\u003eFigure S2\u0026nbsp;\u003c/strong\u003eand\u003cstrong\u003e\u0026nbsp;Table S4\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn this study, we tested which stigma-related factors were associated with later psychiatric and psychological service use after admission in a five-year prospective follow-up. Service use was assessed using prospective follow-up questionnaire responses and medical records in department of psychiatry, and the reliability of the questionnaire responses was confirmed by the medical records. The mutually adjusted logistic regression models including various demographic and psychosocial variables as covariates showed that favorable behavioral intention with people with mental health problems and help-seeking intention about their own mental health problems were associated with psychiatric and psychological service use after admission. To the best of our knowledge, this is the first study to show a relationship of low stigma and high help-seeking intention with later psychiatric and psychological service use in a long-term prospective follow-up.\u003c/p\u003e\n\u003cp\u003eThis study showed that favorable behavioral intention in stigma scales was associated with later service use. Since the limitation of most RCTs targeting the decrease of public stigma is self-report outcome measures that may not accurately reflect actual service use in the follow-up assessment [11\u0026ndash;14], the results may be helpful in promoting anti-stigma campaigns and educational curriculum targeting on decreasing public stigma.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHelp-seeking intentions regarding their own mental health problems were also associated with later service use. Since systematic reviews of help-seeking behaviors have also raised the limitation of previous studies that assessed no actual behaviors but asked only self-reports retrospectively [7, 8, 15, 16], prospective and confirmed service use records may support the evidence of the relationship between self-reported help-seeking intention and later behaviors. Notably, literacy program interventions for mental health intend to increase awareness and help-seeking intention about the mental health problems of the participants. Therefore, the present findings may also help to improve early support for young people who have recently experienced psychological problems in the educational curriculum and specialized interventions on admission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the mutually adjusted models, we found no significant effect of other stigma measures such as practically useful knowledge and past experience with people with mental health problems. Both of the stigma factors are related to the recognition of mental health problems and are thought to be associated with mental health literacy. Prospective studies have suggested that public stigma also indirectly affects help-seeking behavior by helping with the recognition of mental health problems [18\u0026ndash;20]. Therefore, investigating the pathways of various stigma factors and service use in a longitudinal investigation is the next step.\u003c/p\u003e\n\u003cp\u003eThis study had several limitations. First, the participants were new students admitted in April of one year in the 2010s at a university in Tokyo, Japan. We need to conduct replicative studies using other datasets. In particular, the ROC curve analysis needs to be confirmed using an independent dataset from different admission periods at the university and the others, that is why we did not conduct a machine learning approach. Better and more reliable prediction for service use after admission can help better support systems and educational curricula in universities and better health outcomes for students. Second, only 44% of the students received two or more health checkups, and around 30% did not receive any health checkups for five years. The lack of information and unfollowed participants may miss their potential service uses and bias the present findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn conclusion, our five-year prospective study showed that favorable behavioral intention with people with mental health problems and help-seeking intention about their own mental health problems were associated with later psychiatric and psychological service use. To the best of our knowledge, this is the first prospective study using a large adolescent sample, a variety of demographic and psychosocial assessments, and later service use. The results suggest the importance of anti-stigma campaigns for reducing public stigma and mental health literacy programs regarding earlier service use for their own mental health problems. Future studies are needed to explore the changes of public stigma and help-seeking intention in a longitudinal investigation would effect on service use.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by grants from JSPS KAKENHI (No. JP22H05212 and JP24H00899 to SK).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe annual health check-up and medical record in the Health Service Center will not be provided to anyone outside of the affiliation due to the decision of the department. The stigma survey data may be provided after the revision of the ethical review committee in response to a request to the corresponding author. All analysis codes can be provided as requested.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eColizzi M, Lasalvia A, Ruggeri M (2020) Prevention and early intervention in youth mental health: is it time for a multidisciplinary and trans-diagnostic model for care? Int J Ment Health Syst 14:23. https://doi.org/10.1186/s13033-020-00356-9\u003c/li\u003e\n\u003cli\u003eSolmi M, Radua J, Olivola M, et al (2022) Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies. Mol Psychiatry 27:281\u0026ndash;295. https://doi.org/10.1038/s41380-021-01161-7\u003c/li\u003e\n\u003cli\u003eMcGrath JJ, Al-Hamzawi A, Alonso J, et al (2023) Age of onset and cumulative risk of mental disorders: a cross-national analysis of population surveys from 29 countries. Lancet Psychiatry 10:668\u0026ndash;681. https://doi.org/10.1016/S2215-0366(23)00193-1\u003c/li\u003e\n\u003cli\u003eSayal K, Yates N, Spears M, Stallard P (2014) Service use in adolescents at risk of depression and self-harm: prospective longitudinal study. Soc Psychiatry Psychiatr Epidemiol 49:1231\u0026ndash;1240. https://doi.org/10.1007/s00127-014-0843-y\u003c/li\u003e\n\u003cli\u003eJ\u0026ouml;rg F, Visser E, Ormel J, et al (2016) Mental health care use in adolescents with and without mental disorders. Eur Child Adolesc Psychiatry 25:501\u0026ndash;508. https://doi.org/10.1007/s00787-015-0754-9\u003c/li\u003e\n\u003cli\u003eClement S, Schauman O, Graham T, et al (2015) What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychol Med 45:11\u0026ndash;27. https://doi.org/10.1017/S0033291714000129\u003c/li\u003e\n\u003cli\u003eReardon T, Harvey K, Baranowska M, et al (2017) What do parents perceive are the barriers and facilitators to accessing psychological treatment for mental health problems in children and adolescents? A systematic review of qualitative and quantitative studies. Eur Child Adolesc Psychiatry 26:623\u0026ndash;647. https://doi.org/10.1007/s00787-016-0930-6\u003c/li\u003e\n\u003cli\u003eAguirre Velasco A, Cruz ISS, Billings J, et al (2020) What are the barriers, facilitators and interventions targeting help-seeking behaviours for common mental health problems in adolescents? A systematic review. BMC Psychiatry 20:293. https://doi.org/10.1186/s12888-020-02659-0\u003c/li\u003e\n\u003cli\u003eRadez J, Reardon T, Creswell C, et al (2021) Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies. Eur Child Adolesc Psychiatry 30:183\u0026ndash;211. https://doi.org/10.1007/s00787-019-01469-4\u003c/li\u003e\n\u003cli\u003eSchnyder N, Panczak R, Groth N, Schultze-Lutter F (2017) Association between mental health-related stigma and active help-seeking: Systematic review and meta-analysis. Br J Psychiatry 210:261\u0026ndash;268. https://doi.org/10.1192/bjp.bp.116.189464\u003c/li\u003e\n\u003cli\u003eThornicroft G, Mehta N, Clement S, et al (2016) Evidence for effective interventions to reduce mental-health-related stigma and discrimination. Lancet Lond Engl 387:1123\u0026ndash;1132. https://doi.org/10.1016/S0140-6736(15)00298-6\u003c/li\u003e\n\u003cli\u003eKoike S, Yamaguchi S, Ojio Y, et al (2018) A randomised controlled trial of repeated filmed social contact on reducing mental illness-related stigma in young adults. Epidemiol Psychiatr Sci 27:199\u0026ndash;208. https://doi.org/10.1017/S2045796016001050\u003c/li\u003e\n\u003cli\u003eYamaguchi S, Ojio Y, Ando S, et al (2019) Long-term effects of filmed social contact or internet-based self-study on mental health-related stigma: a 2-year follow-up of a randomised controlled trial. Soc Psychiatry Psychiatr Epidemiol 54:33\u0026ndash;42. https://doi.org/10.1007/s00127-018-1609-8\u003c/li\u003e\n\u003cli\u003eOjio Y, Yamaguchi S, Ohta K, et al (2020) Effects of biomedical messages and expert-recommended messages on reducing mental health-related stigma: a randomised controlled trial. Epidemiol Psychiatr Sci 29:e74. https://doi.org/10.1017/S2045796019000714\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;zparlak A, Karakaya D, \u0026Ouml;zer Z (2023) The association of mental health literacy with mental well-being and help-seeking in young people: A systematic review and meta-analysis. J Pediatr Nurs Nurs Care Child Fam 73:e243\u0026ndash;e250. https://doi.org/10.1016/j.pedn.2023.09.017\u003c/li\u003e\n\u003cli\u003eOsborn TG, Li S, Saunders R, Fonagy P (2022) University students\u0026rsquo; use of mental health services: a systematic review and meta-analysis. Int J Ment Health Syst 16:57. https://doi.org/10.1186/s13033-022-00569-0\u003c/li\u003e\n\u003cli\u003eLiu F, Zhou N, Cao H, et al (2017) Chinese college freshmen\u0026rsquo;s mental health problems and their subsequent help-seeking behaviors: A cohort design (2005-2011). PloS One 12:e0185531. https://doi.org/10.1371/journal.pone.0185531\u003c/li\u003e\n\u003cli\u003eDoll CM, Michel C, Rosen M, et al (2021) Predictors of help-seeking behaviour in people with mental health problems: a 3-year prospective community study. BMC Psychiatry 21:432. https://doi.org/10.1186/s12888-021-03435-4\u003c/li\u003e\n\u003cli\u003eSchomerus G, Stolzenburg S, Freitag S, et al (2019) Stigma as a barrier to recognizing personal mental illness and seeking help: a prospective study among untreated persons with mental illness. Eur Arch Psychiatry Clin Neurosci 269:469\u0026ndash;479. https://doi.org/10.1007/s00406-018-0896-0\u003c/li\u003e\n\u003cli\u003eYu BCL, Chio FHN, Chan KKY, et al (2023) Associations between public and self-stigma of help-seeking with help-seeking attitudes and intention: A meta-analytic structural equation modeling approach. J Couns Psychol 70:90\u0026ndash;102. https://doi.org/10.1037/cou0000637\u003c/li\u003e\n\u003cli\u003eTanaka G (2003) Development of the Mental Illness and Disorder Understanding Scale. Int J Jpn Sociol 12:95\u0026ndash;107. https://doi.org/10.1111/j.1475-6781.2003.00045.x\u003c/li\u003e\n\u003cli\u003eEvans-Lacko S, Rose D, Little K, et al (2011) Development and psychometric properties of the Reported and Intended Behaviour Scale (RIBS): a stigma-related behaviour measure. Epidemiol Psychiatr Sci 20:263\u0026ndash;271. https://doi.org/10.1017/s2045796011000308\u003c/li\u003e\n\u003cli\u003eYamaguchi S, Koike S, Watanabe K, Ando S (2014) Development of a Japanese version of the Reported and Intended Behaviour Scale: Reliability and validity. Psychiatry Clin Neurosci 68:448\u0026ndash;455. https://doi.org/10.1111/pcn.12151\u003c/li\u003e\n\u003cli\u003eR\u0026uuml;sch N, Evans-Lacko SE, Henderson C, et al (2011) Knowledge and attitudes as predictors of intentions to seek help for and disclose a mental illness. Psychiatr Serv Wash DC 62:675\u0026ndash;678. https://doi.org/10.1176/ps.62.6.pss6206_0675\u003c/li\u003e\n\u003cli\u003eCosta PT, McCrae RR (1992) Revised NEO Personality Inventory (NEO-PI-R) and NEO Five-Factor Inventory (NEO-FFI) professional manual. Psychological Assessment Resources, Odessa, FL\u003c/li\u003e\n\u003cli\u003eKessler RC, Barker PR, Colpe LJ, et al (2003) Screening for serious mental illness in the general population. Arch Gen Psychiatry 60:184\u0026ndash;189. https://doi.org/10.1001/archpsyc.60.2.184\u003c/li\u003e\n\u003cli\u003eFurukawa TA, Kawakami N, Saitoh M, et al (2008) The performance of the Japanese version of the K6 and K10 in the World Mental Health Survey Japan. Int J Methods Psychiatr Res 17:152\u0026ndash;158. https://doi.org/10.1002/mpr.257\u003c/li\u003e\n\u003cli\u003ePoulton R, Caspi A, Moffitt TE, et al (2000) Children\u0026rsquo;s self-reported psychotic symptoms and adult schizophreniform disorder: a 15-year longitudinal study. Arch Gen Psychiatry 57:1053\u0026ndash;1058. https://doi.org/10.1001/archpsyc.57.11.1053\u003c/li\u003e\n\u003cli\u003eNishida A, Tanii H, Nishimura Y, et al (2008) Associations between psychotic-like experiences and mental health status and other psychopathologies among Japanese early teens. Schizophr Res 99:125\u0026ndash;133. https://doi.org/10.1016/j.schres.2007.11.038\u003c/li\u003e\n\u003cli\u003eWakabayashi A, Tojo Y, Baron-Cohen S, Wheelwright S (2004) [The Autism-Spectrum Quotient (AQ) Japanese version: evidence from high-functioning clinical group and normal adults]. Shinrigaku Kenkyu 75:78\u0026ndash;84. https://doi.org/10.4992/jjpsy.75.78\u003c/li\u003e\n\u003cli\u003eAllison C, Auyeung B, Baron-Cohen S (2012) Toward brief \u0026ldquo;Red Flags\u0026rdquo; for autism screening: The Short Autism Spectrum Quotient and the Short Quantitative Checklist for Autism in toddlers in 1,000 cases and 3,000 controls. J Am Acad Child Adolesc Psychiatry 51:202-212.e7. https://doi.org/10.1016/j.jaac.2011.11.003\u003c/li\u003e\n\u003cli\u003eSarason IG, Levine HM, Basham RB, Sarason BR (1983) Assessing social support: The Social Support Questionnaire. J Pers Soc Psychol 44:127\u0026ndash;139. https://doi.org/10.1037/0022-3514.44.1.127\u003c/li\u003e\n\u003cli\u003eFurukawa TA, Harai H, Hirai T, et al (1999) Social Support Questionnaire among psychiatric patients with various diagnoses and normal controls. Soc Psychiatry Psychiatr Epidemiol 34:216\u0026ndash;222. https://doi.org/10.1007/s001270050136\u003c/li\u003e\n\u003cli\u003eVenables WN, Ripley BD (2002) Modern applied statistics with S, 4th Ed. Springer, New York\u003c/li\u003e\n\u003cli\u003eRobin X, Turck N, Hainard A, et al (2011) pROC: an open-source package for R and S+ to analyze and compare ROC curves. BMC Bioinformatics 12:77. https://doi.org/10.1186/1471-2105-12-77\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"social-psychiatry-and-psychiatric-epidemiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sppe","sideBox":"Learn more about [Social Psychiatry and Psychiatric Epidemiology](http://link.springer.com/journal/127)","snPcode":"127","submissionUrl":"https://submission.nature.com/new-submission/127/3","title":"Social Psychiatry and Psychiatric Epidemiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Mental illness, Adolescence, Service use, Help-seeking behaviors, Public stigma, Prospective study, Long-term follow-up","lastPublishedDoi":"10.21203/rs.3.rs-6425632/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6425632/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVarious barriers including public stigma and lack of mental health literacy have been identified to adolescent help-seeking intention for their mental health problems. However, few prospective studies have investigated whether adolescent public stigma and help-seeking intentions are associated with actual service use in a long-term prospective design including medical records.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis prospective study over a five-year period used questionnaire responses from 1919 students on admission (608 females [19.7%], mean age: 18.92 [SD 0.68] years), and follow-up information from annual health checkups and medical records from 1437 participants (74.9%). The baseline stigma questionnaire included practically useful knowledge of mental health problems, past experiences and behavioral intentions with people with mental health problems, and help-seeking intentions and disclosing comfortability questions about their own mental health problems. Logistic regression analyses were performed, including any psychiatric and psychological service use during the follow-up period as the dependent variable, baseline stigma measures as independent variables, and demographic and psychosocial factors as covariates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter mutually adjusted for independent and confounding variables, behavioral intention (\u003cem\u003eOR \u003c/em\u003e= 1.060 [\u003cem\u003e95%CI\u003c/em\u003e 1.003―1.120], \u003cem\u003ep\u003c/em\u003e = 0.037) and help-seeking intention (1.234 [1.029―1.479], \u003cem\u003ep\u003c/em\u003e = 0.023) were significantly associated with any psychiatric and psychological service use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur five-year prospective study showed that behavioral intention with people with mental health problems and help-seeking intention about their own mental health problems were associated with later service use in adolescents. The results suggest the importance of anti-stigma campaigns and mental health literacy programs for earlier service use in adolescents.\u003c/p\u003e","manuscriptTitle":"Adolescent public stigma and help seeking intention are associated with later service use: A five-year follow-up study using annual self-report surveys and medical records","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-28 08:48:57","doi":"10.21203/rs.3.rs-6425632/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-18T14:31:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"181453630720183316392107207401657727875","date":"2025-11-20T15:01:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-19T11:36:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-01T05:53:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-12T03:38:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"Social Psychiatry and Psychiatric Epidemiology","date":"2025-04-11T06:54:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"social-psychiatry-and-psychiatric-epidemiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sppe","sideBox":"Learn more about [Social Psychiatry and Psychiatric Epidemiology](http://link.springer.com/journal/127)","snPcode":"127","submissionUrl":"https://submission.nature.com/new-submission/127/3","title":"Social Psychiatry and Psychiatric Epidemiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"38f188eb-0141-4e79-9e40-c379643f89b8","owner":[],"postedDate":"November 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-28T08:48:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-28 08:48:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6425632","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6425632","identity":"rs-6425632","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}