Intentions and barriers to help-seeking in children and adolescents differing in depression severity: Cross-sectional results from a school-based mental health project

Intentions and barriers to help-seeking in children and adolescents differing in depression severity: Cross-sectional results from a school-based mental health project | 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 Intentions and barriers to help-seeking in children and adolescents differing in depression severity: Cross-sectional results from a school-based mental health project Sabrina Baldofski, Jelena Scheider, Elisabeth Kohls, Sarah-Lena Klemm, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4003280/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Mental health problems, such as depression, have a high prevalence in children and adolescents (C&A). However, the majority of C&A suffering from depression do not seek professional help. In addition to general barriers, the specific psychopathology related to depressive symptoms may decrease their intentions to seek professional help. This study aimed to compare help-seeking behavior, intentions and perceived barriers between C&A with different levels of depressive symptoms. Methods: This cross-sectional study is part of a large-scale, multi-center project. Participants were N = 9,509 C&A who were recruited in German schools and completed a baseline screening questionnaire. Based on their depressive symptoms, C&A were allocated to the following three subgroups: a) without depressive symptoms, b) with subclinical symptoms, c) with clinical symptoms (measured by PHQ-A). Quantitative analyses compared previous help-seeking behavior (AHSQ), help-seeking intentions (GHSQ) and perceived barriers (Barriers questionnaire) between those different subgroups. A qualitative content analysis examined text answers on other perceived barriers to help-seeking. Results: Participants were mostly female ( n = 5,575, 58.6%) and 12 to 24 yearsold ( M =15.09, SD = 2.37). Participants with different levels of depressive symptoms differed significantly in help-seeking behavior, intentions and perceived barriers. Specifically, participants with clinical depressive symptoms reported more previous help-seeking, but lower intentions to seek help compared to participants without symptoms (all p < .05). Participants with subclinical depressive symptoms reported a similar frequency of previous help-seeking, but higher intentions to seek help compared to participants without symptoms (all p <.05). Perception of barriers was different across subgroups: participants with clinical and subclinical depressive symptoms perceived the majority of barriers such as stigma, difficulties in accessibility, and family-related barriers as more relevant than participants without depressive symptoms. Across all subgroups, participants frequently mentioned intrapersonal reasons, a high need for autonomy, and a lack of mental health literacy as barriers to help-seeking. Conclusions: C&A with higher levels of depressive symptoms are more reluctant to seek professional help and perceive higher barriers. This underlines the need for effective and low-threshold interventions to tackle barriers, increase help-seeking, and lower depressive symptoms in C&A differing in depression severity. Trial Registration: DRKS00014685 Help-seeking Children Adolescents Barriers Depression Mixed-Method Design Background Children and adolescent (C&A) are a vulnerable age group with up to 19% of adolescents from 12–17 years old in Germany suffering from mental health problems [ 1 ] and 11% of 12–17 year old Europeans experiencing suicidal ideation [ 2 ]. However, of all C&A with mental health problems, around 70–80% do not seek professional help and thus, do not receive treatment [ 3 – 5 ]. Even C&A experiencing mental crises delay seeking help (Lustig et al., 2022). This hesitant behavior might be a result of lower intentions to seek help. Specifically, adolescents experiencing higher levels of depressive symptoms reported lower intentions for potential help-seeking than those without depressive symptoms [ 6 – 9 ]. Different factors may hinder those in need to actually seek professional help. Two recent systematic reviews categorized barriers and facilitators that adolescents perceive in seeking help for a potential emotional problem [ 10 , 11 ]. On an individual level, a lack of mental health literacy and a high need for autonomy in coping with their problems may be reasons for low help-seeking intentions. Moreover, social factors such as fear of stigma were frequently reported barriers. Fear of lacking confidentiality and other obstructive perceptions of therapeutic relationships (e.g., fear of being judged or not taken seriously) may be other barriers to help-seeking in adolescents [ 10 , 11 ]. Besides these attitudinal barriers, structural factors such as lack of time and resources may also impede help-seeking [ 6 , 12 ]. In addition to the previously mentioned barriers, specific psychopathology may present another hindering factor towards seeking professional help. Specifically, experiencing clinical depressive symptoms could create distinct barriers. Depressive symptoms such as feelings of worthlessness, guilt, and hopelessness as well as a lack in energy [ 13 ] are likely to hinder individuals from perceiving themselves as being worthy of help, having hope in getting an adequate treatment and getting better, and having the energy to search for help [ 9 ]. While potentially hindering factors increase with higher depressive symptomatology, perception for a need for help also increases [ 14 ]. To date, few studies examined relevant barriers towards help-seeking in C&A with severe mental health conditions such as depression [ 9 , 11 , 15 , 16 ]. For adolescents experiencing depressive symptoms, lack of trust, stigma, and shame were shown to be barriers to help-seeking [ 16 ]. Moreover, similar to adolescents without depressive symptoms, adolescents with depressive symptoms reported self-reliance or a high need for autonomy as reasons for low intentions to seek help [ 10 ]. Further, first evidence suggests that some barriers, such as fear of stigma, may be more prevalent in students suffering from depression and suicidal ideation [ 6 ]. Nevertheless, this result is based on a limited sample of over 18 year old college students [ 6 ]. It remains unclear whether the presence of depressive symptoms is associated with different perceived barriers to help-seeking in comparison to adolescents without this symptomatology. To our knowledge, no other study systematically compared help-seeking intentions and perceived barriers to help-seeking between adolescents with different levels of depressive symptoms. The present study aimed to close this gap by comparing C&A with different levels of depressive symptoms regarding different aspects of help-seeking in a cross-sectional, mixed-method study. The study is based on a nationwide German multi-center school-based project (“Promoting Help-seeking using E-technology for Adolescents”: ProHEAD; 17). Help-seeking intentions and barriers were examined across three subgroups of adolescents without depressive symptoms, with subclinical depressive symptoms, and with clinical depressive symptoms, respectively. The goals of this study were to compare these subgroups regarding 1) previous help-seeking behavior, 2) intentions to seek help for a potential mental health problem, and 3) perception of barriers to professional help-seeking. Additionally, possible effects of previous help-seeking on perception of barriers were explored. Quantitative methods as well as a qualitative content analysis were used to examine barriers to professional help-seeking. Based on previous studies [ 18 ], it was hypothesized that the subgroup with clinical depressive symptoms shows higher previous help-seeking behavior compared to the other subgroups. In contrast, help-seeking intentions were expected to be negatively related to the different levels of depressive symptoms [ 6 – 8 ] with lower help-seeking intentions in the subgroup with clinical depressive symptoms compared to the other subgroups. With respect to the perception of barriers, no specific hypothesis was formulated. Methods Participants and Procedure Recruitment took place between November 2018 and February 2022 within the research project “Promoting Help-seeking using E-technology for Adolescents” (ProHEAD; 17). ProHEAD is a multi-center consortium and aims to improve help-seeking behavior in adolescents with clinical mental health symptoms, prevent mental disorders in adolescents with subclinical mental health symptoms, and strengthen their mental health. Participating students completed a baseline screening assessment, after which they were allocated to one of five online programs addressing mental health promotion, eating disorder symptoms, depressive symptoms, risky alcohol use, and promotion of help-seeking, respectively. Those RCTs as well as the study procedures are described in-depth elsewhere [ 17 , 19 – 23 ]. For the present sample, students were recruited in secondary schools in grades 6–13 as well as vocational schools located in five different regions of Germany (Hamburg, Heidelberg, Leipzig, Marburg, Schwäbisch Gmünd) and completed an online questionnaire. This study analyzed data obtained through this initial baseline screening. Ethical approval was granted by the ethics committees of the leading study site, the Medical Faculty at the University of Heidelberg (Study ID: S-086/2018) and of each participating study center [ 17 ]. Before participation in the study, written informed consent was given by parents (or other custodian) and the participants. In participants 18 years and older, only the participants themselves had to provide their consent. All students ≥ 12 years of age with an informed consent were included in the study. N = 9,954 students initiated the online screening. Participants who did not complete one of the questionnaires were excluded from the analyses ( n = 445), resulting in a final sample of N = 9,509 students. Measures Sociodemographic Variables. In the online questionnaire age, gender, migration background, family affluence, and family psychosocial risk factors were assessed. Migration background was operationalized through one question asking for parents’ country of birth. All participants with one parent or themselves being born outside of Germany were categorized as having a migration background. Family affluence was measured utilizing a German adaptation of the Family Affluence Scale [ 24 ]. The instrument consists of four items with different rating scales, asking for instance whether the participant has an own bedroom. Using the sum score of the four items, family affluence can be differentiated in low (0–2), medium (3–5), and high (6–9) family affluence [ 24 ]. Family psychosocial risk factors were measured using the Laucht-Index [ 25 ]. It consists of ten items that can be summarized to a sum score ranging from 0 to 10 with higher scores indicating higher psychosocial risk. Patient-Health-Questionnaire-9 for Adolescents (PHQ-A). The current level of depressive symptoms as well as suicidal ideation were assessed with the PHQ-A [ 26 ]. Nine items measured depressive symptoms. Utilizing a 4-point Likert scale ranging from 0 = “not at all” to 3 = “nearly every day”, those nine items assess the level of depressive symptoms within the last 14 days. A sum score of these items, reaching from 0 to 27, is computed, with higher scores indicating higher levels of depressive symptoms. Based on this score participants were categorized into three subgroups for the purpose of the present analysis: a) participants without depressive symptoms (PHQ score between 0 and 9; Group 0); b) participants with subclinical depressive symptoms (PHQ score between 10 and 14; Group 1); and c) participants with clinical depressive symptoms (PHQ score between 15 and 27; Group 2). This categorization was based on previous studies using the PHQ-A for identifying different levels of depressive symptoms in adolescents [ 27 , 28 ]. In addition this categorization reflects the cut-off values used in the ProHEAD project to assign students with different symptomatology into the respective RCTs: students with a PHQ-score between 10 and 14 were categorized as being at risk for developing depression, i.e., experiencing subclinical depressive symptoms, while students with a PHQ-score ≥ 15 were defined as having clinical depressive symptoms [ 17 ]. To screen for suicidal ideation, two items asked respondents about their current suicidal thoughts within the past month as well as lifetime suicide attempts. Answer options were dichotomous (yes/no). Actual Help Seeking Questionnaire (AHSQ). Previous help-seeking behavior was assessed using the AHSQ [ 29 ]. Participants are asked to indicate if they had sought help for a mental health problem in the past. Answer options were categorical: 0 = "no", 1 = "yes, during the last 12 months", 2 = "yes, but more than 12 months ago". If participants sought help in the past, they were then asked to report the source of help. Different sources were presented using 12 items, 11 of which each represented a different source of formal (e. g., school psychologist, teacher, psychiatrist) or informal help (e. g., friends, partner, parents). For the purpose of this study, the items were summarized in three different ways. First, a binary variable distinguished previous help-seeking or no previous help-seeking. Second, two binary variables categorized previous help-seeking from formal sources and from informal sources (participants answered to have sought help from any formal or informal source, respectively). In addition, a binary variable was computed to be used as a control variable and indicated formal or no formal previous help-seeking. General Help Seeking Questionnaire (GHSQ). The GHSQ [ 30 , 31 ] was used to assess the intentions to seek help for hypothetical mental health problems from different sources. The instrument consists of 14 items, with 12 items identifying different formal (e.g., general practitioner, C&A psychiatrist, psychotherapist) and informal (e.g., friends, parents) sources of help, one item being an additional free text field item and one item providing the option to indicate that one would not seek help at all. Participants indicated the likelihood of seeking help from different sources in the next four weeks if they were to suffer from mental health problems. Likelihood was rated on a 7-point scale, ranging from 0 = "extremely unlikely" to 7 = "extremely likely". The authors of the GHSQ propose using three metric subscales ranging from 0 to 7 each, with higher scores indicating higher intentions for the respective behavior: formal help-seeking, informal help-seeking, and no help-seeking, with the latter being derived from the item “I would not seek help from anyone” [ 30 ]. Barriers Questionnaire. The validated “Barriers to Adolescents Seeking Help Scale” (BASH-B, 32) was adapted and extended with additional items from the literature. While six items were derived from the original version of the BASH-B, six additional items on structural barriers, lack of mental health literacy, fear of being admitted to the (C&A) psychiatric ward and on fear that others will worry were constructed based on an extensive literature search. Participants were instructed to imagine suffering from mental health problems for a few weeks or months and were then asked if they would seek professional help in this case (i. e., from a psychiatrist or psychotherapist). If they indicated that they would not seek help, eleven items and one free text field item were used to evaluate potential reasons for not seeking professional help. Subjects rated to which degree each reason applied to them on a 4-point scale (1 = “does not apply” to 4 = “does apply”). To descriptively analyze frequencies of each item, items were binary coded into 1 = “barrier applies” (including answer options “does rather apply” and ”does apply”) and 0 = “barrier does not apply” (including answer options “does rather not apply” and “does not apply”). In addition, following suggestions in previous studies in adolescents and young adults [ 32 , 33 ], the items were summarized with respect to their content to six different categories (stigma, lack of mental health literacy, perceived family consequences, self-reliance and autonomy, difficulties in accessibility, fear of being admitted to a psychiatric ward). The free text field answers served as a basis for a qualitative content analysis to identify potential barriers that may not have been covered in the other items. Statistical Analysis Statistical analyses were performed using IBM SPSS Statistics version 27.0. Participants were allocated to one of three subgroups based on the PHQ-A (Group 0: without depressive symptoms; Group 1: with subclinical symptoms; Group 2: with clinical depressive symptoms) and were compared with respect to sociodemographic variables (age, gender, family affluence, psychosocial risk factors, migration background) and clinical characteristics (current suicidal ideation, lifetime suicide attempt; both based on PHQ-A). χ 2 -tests analyzed differences in categorical variables (gender, migration background, current suicidal ideation, lifetime suicide attempt) between the three subgroups. Due to non-normality of the data, continuous sociodemographic data (age, family affluence, psychosocial risk factors) were compared between subgroups using Kruskal-Wallis- H tests. To answer the first research question, previous help-seeking behavior (AHSQ) was compared between the three subgroups using χ 2 -tests. To answer the second research question, help-seeking intentions (GHSQ) were analyzed between the three subgroups. Three separate ANCOVAs compared the intentions to seek formal, informal, and no help (GHSQ), respectively. Separate ANCOVAs were conducted as assumptions for a MANCOVA were violated and ANCOVAs are considered as relatively robust for large sample sizes [ 34 ]. As significant differences in sociodemographic factors between the three subgroups with different levels of depressive symptoms appeared, age and family affluence were included as covariates in the ANCOVA, while gender represented another factor in the model instead of a covariate due to its categorical nature. To answer the third research question, perceptions of different barriers (Barriers Questionnaire) were compared between the three subgroups (PHQ-A). As the data again violated assumptions for a MANCOVA, several separate ANCOVAs were conducted. To control for potential effects of previous help-seeking on perceived barriers, previous help-seeking from formal sources (help-seeking from formal sources vs. no/other help-seeking; AHSQ) was added as another factor. Similar to the previous analyses, other covariates in the ANCOVAs were gender (added as another independent variable), age and family affluence. A two-tailed α = 0.05 was applied to statistical testing. For all analyses, post-hoc t - tests, post-hoc Dunn-Bonferroni tests and pairwise z -tests further compared subgroup differences for significant overall effects in ANCOVAs, in Kruskal-Wallis- H tests and in χ 2 -tests, respectively. For all ANCOVAs and post-hoc tests, Bonferroni correction was used to account for multiple testing. Further, effect sizes were reported and interpreted: for ANCOVAs an η²partial was used. An η²partial = .01 was considered as a small effect, η²partial = .06 as a medium effect and η²partial = .14 as a large effect [ 35 ]. For χ 2 -tests as well as Kruskal-Wallis- H tests, Cramer’s V was used to estimate small (V = 0.1), medium (V = 0.3), and large (V = 0.5) effects [ 36 ]. Finally, free text field answers on additional barriers were analyzed qualitatively using a qualitative content analysis. MAXQDA qualitative software (version 22.1.1) served as a coding tool. Following Mayring’s inductive content analysis approach [ 37 ], categories that emerged during the coding process were added to a coding dictionary. Using the final coding dictionary, two authors coded all free text field answers independently. Raters coded each free text answer with one category. Inter-rater reliability was good with κ = 0.75 [ 38 ]. Frequencies of coding categories were analyzed descriptively in the three subgroups. Results Sociodemographic Characteristics and Subgroup Differences The final sample size was N = 9,509. Of these, n = 5,575 (58.6%) indicated their gender as female, while n = 3,934 (41.4%) indicated their gender as male. Mean age was 15.09 years ( SD = 2.37), with a range from 12 to 24 years, while the majority of the sample ( n = 8,129, 85.5%) were minors. Family affluence was high for most participants ( n = 6,936, 72.9%) and the psychosocial risk in the majority of participants was low (no or low risk: n = 5,056, 53.2%). Participants mostly attended schools for a university entrance (“Gymnasium”; n = 5,042, 53.0%) or schools for all qualifications („Gemeinschafts-, Ober- and Stadtteilschule”; n = 1,660, 17.5%). In the total sample, participants showed an average PHQ-A score of M = 7.56 ( SD = 5.39), ranging from 0 to 27. The majority ( n = 6,688; 70.3%) were classified as “without depressive symptoms” (Group 0), whereas n = 1,706 (17.9%) were categorized into the second subgroup with subclinical depressive symptoms (Group 1). Finally, n = 1,115 (11.7%) reported clinical depressive symptoms (Group 2). The three subgroups were compared with respect to sociodemographic characteristics (see Table 1 ). They differed significantly in gender ( p < .001), with the percentage of female participants being significantly higher in the subgroup with clinical depressive symptoms (Group 2) compared to both other subgroups, and being higher in the subgroup with subclinical depressive symptoms (Group 1) compared to the subgroup without depressive symptoms (Group 0; all p < .001). Further, subgroups differed significantly in age ( p < .001): Post-hoc tests revealed that only Group 0 was significantly younger than both other subgroups ( p < .001), while the latter did not differ significantly ( p = .999). A similar pattern appeared for migration background: Group 0 reported significantly less migration background than both other subgroups ( p < .001), while the latter did not differ significantly ( p = .999). With respect to socioeconomic status, the three subgroups differed in family affluence and in the Laucht-index for psychosocial risk ( p < .001): Group 2 showed the lowest family affluence and highest psychosocial risk compared to both other groups, and Group 1 also showed a lower family affluence and higher psychosocial risk compared to Group 0 (all p < .001). Table 1 Sample characteristics and comparison of subgroups based on depressive symptomatology ( N = 9,509). Group 0: Without depressive symptoms ( n = 6688) Group 1: With subclinical depressive symptoms ( n = 1706) Group 2: With clinical depressive symptoms ( n = 1115) Test statistics p Effect size Female gender, n (%) 3469 (51.9) a 1203 (70.5) b 903 (81.0) c χ 2 (2) = 455.16 < .001 V = .22 Age, M ( SD ) 14.90 (2.36) a 15.53 (2.35) b 15.55 (2.28) b H (2) = 198.72 < .001 r = .11- .22 Family affluence (FAS), M (SD) 6.69 (1.76) a 6.13 (1.89) b 5.93 (1.85) c H (2) = 247,22 < .001 r = .06 − .15 Psychosocial risk factors, M (SD) 3.61 (1.15) a 4.09 (1.48) b 4.35 (1.60) c H (2) = 210.056 < .001 r = .04 − .19 Migration background, n ( % ) 1823 (27.3) a 602 (35.3) b 415 (37.2) b χ 2 (2) = 74.44 < .001 V = .09 Current suicidal ideation (PHQ-A), n ( % ) 168 (2.5) a 229 (13.4) b 506 (45.4) c χ 2 (2) = 2,080.83 < .001 V = .47 Lifetime suicide attempt (PHQ-A), n ( % ) 191 (2.9) a 175 (10.3) b 308 (27.6) c χ 2 (2) = 921.90 < .001 V = .31 Notes . Different superscript letters indicate significant subgroup differences in the respective variable. FAS, Family Affluence Scale; Psychosocial risk factors, Laucht-Index; PHQ-A, Patient-Health-Questionnaire-9 for Adolescents. Bonferroni corrected p -values. In the total sample, n = 903 (9.5%) reported suicidal ideation in the past month and n = 674 (7.1%) reported a past suicide attempt. These frequencies differed significantly between the three subgroups (all p < .001; see Table 2 ). Higher suicidal ideation and higher rates of previous suicide attempts were observed in Group 2 compared to both other subgroups, while Group 1 reported higher suicidal ideation and higher rates of previous suicide attempts than Group 0 (all p < .001). Table 2 Subgroup differences in previous help-seeking behavior and help-seeking intentions ( N = 9,509). Group 0: Without depressive symptoms ( n = 6688) Group 1: With subclinical depressive symptoms ( n = 1706) Group 2: With clinical depressive symptoms ( n = 1115) Test statistics p Effect size Previous help-seeking (AHSQ), n (%) 1416 (21.2) a 747 (43.8) b 680 (61.0) c χ 2 (2) = 1,054.07 .04 V = .31 Previous formal help-seeking, n (%) 502 (35.5) a 299 (40.0) a 317 (46.6) b χ 2 (2) = 24.21 < .001 V = .09 Previous informal help-seeking, n (%) 1357 (95.8) a 703 (94.1) a,b 635 (93.4) b χ 2 (2) = 6.55 .04 V = .05 Help-seeking intentions (GHSQ) Intentions to seek formal help, M ( SD ) 2.56 (1.37) a 2.28 (1.23) b 2.33 (1.21) b F (2, 9501) = 19.03 < .001 η² partial = .00 Intentions to seek informal help, M ( SD ) 4.62 (1.38) a 3.91 (1.38) b 3.33 (1.31) c F (2, 9501) = 331.11 < .001 η² partial = .07 Intentions to seek no help, M ( SD ) 2.45 (1.73) a 3.26 (1.88) b 3.88 (1.91) c F (2, 9501) = 225.70 < .001 η² partial = .05 Notes . Different superscript letters indicate significant subgroup differences in the respective variable. AHSQ, Actual Help Seeking Questionnaire; GHSQ, General Help Seeking Questionnaire. Controlled for age, family affluence, and gender. Bonferroni corrected p -values. ******* Please insert Table 1 here. ******* Previous Help-Seeking Behavior (AHSQ) In total, n = 2,843 (29.9%) participants reported to have sought help for mental health problems in the last year or before. Chi-square tests showed that the three subgroups differed significantly in the frequency of previous help-seeking ( p < .001; see Table 2 ). Bonferroni corrected pairwise comparisons showed that Group 2 had highest rates of previous help-seeking, followed by Group 1, while Group 0 sought help least often in the past (all p < .001). With respect to previous informal help-seeking, the three subgroups differed significantly ( p < .001): Groups 1 and 2 reported less often previous informal help-seeking compared to participants in Group 0 (both p .05). Regarding previous formal help-seeking, the three subgroups also differed significantly ( p < .001). Group 2 more often sought help from formal sources than Group 0 ( p .05). ******* Please insert Table 2 here. ******* Help-seeking intentions (GHSQ) An ANCOVA controlling for age, family affluence, and gender showed significant differences between all three subgroups in their intentions to seek formal, informal, and no help (all p < .001; see Table 2 ). Group 2 reported higher intentions to seek no help compared to Group 1 (all p < .001), while Group 0 reported lowest intentions to seek no help compared to both other groups ( p < .001). Regarding intentions to seek informal and formal help, respectively, Group 2 reported lower intentions to seek informal help compared to Group 1 ( p .05). Group 0 reported highest intentions to seek both formal and informal help ( p < .001). Barriers to Help-Seeking All participants who indicated in the barriers questionnaire that they would not seek professional help were analyzed regarding their perception of barriers. In total, n = 3,220 (33.9% of the total sample) negated possible professional help-seeking. Quantitative analysis of perceived barriers Seven ANCOVAs analyzed perception of barriers depending on the three subgroups of depressive symptoms. For all barrier categories, a main effect for subgroup appeared while controlling for previous help-seeking from formal sources, sex, age and socioeconomic status (Table 3 ). Table 3 Subgroup differences in perceived barriers to help-seeking (Barriers Questionnaire, N = 3,220 1 ). Group 0: Without depressive symptoms ( n = 1847) Group 1: With subclinical depressive symptoms ( n = 781) Group 2: With clinical depressive symptoms ( n = 592) Test statistic p Effect size M (SD) M (SD) M (SD) η² partial Stigma 2.01 (0.93) a 2.42 (0.94) b 2.81 (0.97) b F (2, 3206) = 9.91 < .001 .01 Lack of mental health literacy 2.06 (0.79) a 2.27 (0.81) a,b 2.52 (0.75) b F (2, 3206) = 7.40 .001 .01 Family-related barriers 2.06 (0.91) a 2.61 (0.90) b 3.04 (0.89) c F (2, 3206) = 31.16 < .001 .02 Self-reliance and autonomy 3.15 (0.53) a 2.97 (0.59) b 2.72 (0.56) b F (2, 3206) = 15.06 < .001 .01 Difficulties in accessibility 1.58 (0.66) a 1.77 (0.76) b 1.90 (0.82) b F (2, 3206) = 6.04 .002 .00 Fear of being admitted to a (children and adolescent) psychiatric ward 2.26 (1.09) a 1.85 (1.09) a,b 2.34 (1.20) b F (2, 3206) = 6.70 .001 .00 Notes . 1 Reduced sample size due to nature of the questionnaire. Different superscript letters indicate significant subgroup differences in the respective variable. Bonferroni corrected p -values. Controlled for age, family affluence, gender, and previous help-seeking from formal sources. Post-hoc tests showed that perception of some barriers like stigma, self-reliance and autonomy as well as perceived difficulties in accessibility did not differ between Groups 1 and 2 (all p > .05). Barriers related to stigma and difficulties in accessibility were rated lower by Group 0 compared to the other two subgroups (all p < .05). For self-reliance and autonomy, a contrary pattern appeared. Here, Group 0 rated this barrier as more prevalent compared to both other subgroups (all p .05), but were rated more prevalent by the Group 2 compared to Group 0 (all p < .001). However, some barriers were rated differently between the subgroups. Group 2 indicated barriers associated with family-related reasons as more prevalent compared to both other groups and Group 1 rated them as more prevalent than Group 0 (all p < .05). With respect to previous help-seeking from formal sources, which was included as a covariate, no significant main effect on perception of barriers appeared, but significant interaction effects with level of depressive symptoms emerged for stigma, F (2, 3206) = 6.76, p < .001, and for fear of being admitted to a (C&A) psychiatric ward, F (2, 3206) = 7.26, p = .001. Regarding effects between subgroups only participants who did not seek help from formal sources in the past rated stigma and fear of being admitted to the (C&A) psychiatric ward differently depending on the level of depressive symptoms: Group 2 rated these barriers lower than both other subgroups (all p < .001). Participants who did seek help from formal sources did not differ significantly in those ratings (all p < .001). Regarding effects within subgroups, Group 2 rated stigma and fear of being admitted to the (C&A) psychiatric ward as more prevalent when they had not sought help from formal sources compared to when they had ( p < .01). For stigma this effect was inverse in Group 0: those without previous help-seeking from formal sources rated stigma as less prevalent compared to those with previous help-seeking ( p = .037). ******* Please insert Table 3 here. ******* Qualitative content analysis of perceived barriers Among all participants who indicated that they would not seek professional help in the Barriers Questionnaire, n = 398 answered a free-text field to report additional barriers not measured in the questionnaire. In a qualitative content analysis, those answers were coded into nine categories consisting of 22 sub codes. The main categories included barriers related to stigma, lack of mental health literacy, family, self-reliance and autonomy, intrapersonal reasons, fear of consequences, negative experiences with therapy and perceived difficulties in accessibility. Out of all answers, n = 60 (15.1%) answers were jokes, random comments, unclear answers or remarks about previous or current diagnoses/treatment and therefore not assignable to any barrier category. Participants in Group 2 varied more in their answers than the other two subgroups (see Table 4 ). Most frequently mentioned main categories in Group 2 were barriers including intrapersonal reasons ( n = 18, 16.2% of all answers in this group) and barriers indicating a lack of mental health literacy ( n = 18, 16.2%). Another frequently reported main category in this subgroup were barriers related to the participant’s family ( n = 13, 11.7%), with subcategories including e. g. the fear that the family would know about the psychotherapy and would react negatively ( n = 7, 6.3%) or the fear that others might worry about oneself ( n = 6, 5.4%). Moreover, n = 12 (10.8%) participants reported negative previous experiences with psychotherapy. Less often, participants in Group 2 described barriers depicting the need for self-reliance and autonomy ( n = 11, 9.9%). Only n = 1 (1.0%) answer was coded as the subcategory ‘preference to talk to family or friends’. With respect to the subcategories of difficulties in accessibility, n = 3 (2.7%) participants mentioned difficulties to find a therapist, a barrier never reported by both other subgroups. Table 4 Frequencies of perceived barriers to professional help-seeking (free text field answers in the Barriers Questionnaire, n = 398). Categories and sub-categories, n (%) Group 0: Without depressive symptoms ( n = 194) Group 1: With subclinical depressive symptoms ( n = 93) Group 2: With clinical depressive symptoms ( n = 111) Stigma 3 (1.5) 3 (3.2) 7 (6.3) Shame 1 (0.5) 2 (2.2) 0 (0.0) Fearing reactions of others 2 (1.0) 1 (1.1) 7 (6.3) Lack of mental health literacy 45 (23.2) 22 (23.7) 18 (16.2) No perceived need for therapy or problems/relativization of problems 20 (10.3) 10 (10.8) 7 (6.3) Negative expectancies about effectiveness and psychotherapist 8 (4.1) 6 (6.5) 6 (5.4) Lack of knowledge 3 (1.5) 1 (1.1) 1 (0.9) Lack of motivation 14 (7.2) 5 (5.4) 4 (3.6) Family-related barriers 2 (1.0) 1 (1.1) 6 (5.4) Fear of parental reaction 0 (0.0) 3 (3.2) 7 (6.3) Fear that others might worry about oneself 2 (1.0) 1 (1.1) 6 (5.4) Self-reliance and autonomy 69 (35.6) 21 (22.6) 11 (9.9) Preference to handle problems alone 18 (9.3) 7 (7.5) 10 (9.0) Preference to talk to family or friends 51 (26.3) 14 (15.1) 1 (0.9) Intrapersonal reasons 25 (12.9) 23 (24.7) 18 (16.2) Difficulties talking about problems 18 (9.3) 14 (15.1) 11 (9.9) General mistrust in others 4 (2.1) 2 (2.2) 3 (2.7) Low self-esteem 3 (1.5) 7 (7.5) 4 (3.6) Fear of consequences 6 (3.1) 1 (1.1) 4 (3.6) Fear of being admitted to the psychiatric ward 2 (1.0) 0 (0.0) 1 (0.9) Fear of negative consequences (in general) 4 (2.1) 1 (1.1) 3 (2.7) Negative experience with therapy 10 (5.2) 6 (6.5) 12 (10.8) Perceived difficulties in accessibility 5 (2.6) 1 (1.1) 9 (8.1) No parental approval 3 (1.5) 1 (1.1) 5 (4.5) Financial reasons 2 (1.0) 0 (0.0) 0 (0.0) Time-related reasons 0 (0.0) 0 (0.0) 1 (0.9) Non assignable 19 (17.1) 12 (12.9) 29 (14.9) With respect to participants in Group 1, the most frequent main categories were barriers related to intrapersonal reasons ( n = 23, 24.7%), self-reliance and autonomy ( n = 21, 22.6%), and lack of mental health literacy ( n = 22, 23.7%). The most frequently reported subcategories were difficulties to talk about one’s own problems because of fear of opening up or not being able to express one’s feelings ( n = 14, 15.1%; subcategories of intrapersonal reasons) and the preference to talk to family or friends ( n = 14, 15.1%; subcategories of self-reliance and need for autonomy). Participants in Group 0 reported similar barriers as Group 1: the most frequent main category were barriers related to self-reliance and autonomy ( n = 69, 35.6%). Here, reported subcategories were the preference to talk to family or friends ( n = 51, 26.3%) or to handle problems alone ( n = 18, 9.3%). Another frequently reported main category were barriers related to a lack of mental health literacy ( n = 45, 23.2%). For instance, n = 20 (10.3%) would not perceive a need for therapy or would think that the problems were not severe (enough) and n = 14 (7.2%) reported a lack of motivation. The third most frequently mentioned main category were intrapersonal reasons mentioned in n = 25 (12.9%) answers with difficulties talking about one’s problem as the most common subcategory ( n = 18, 9.3%). ******* Please insert Table 4 here. ******* Discussion Using a mixed-methods approach, this study found that C&A differing in depression severity vary in their help-seeking behavior, intentions to seek help, and their perceptions of barriers to seek professional help. With respect to the first research question, the results support the hypothesized higher previous help-seeking behavior of adolescents with clinical depressive symptoms compared to others. Specifically, participants with clinical depressive symptoms reported to have sought help more often in the past compared to those without depressive symptoms. Participants with subclinical depressive symptoms, however, previously did not seek help more often than participants without symptoms. With respect to the second research question, the findings also confirm the hypothesized link between help-seeking intentions and depressive symptoms. Participants with clinical depressive symptoms reported lower intentions to seek further help in the future compared to both other subgroups, and participants with subclinical depressive symptoms had lower intentions to seek further help in the future compared to those without symptoms. The results further showed that those who were currently most in need of help due to high levels of depressive symptoms also reported to have sought more help in the past. This is especially relevant as those with higher depressive symptoms also reported more past suicide attempts than the other subgroups. However, an alarming finding was that the intentions for future help-seeking seem to be negatively associated with the current level of depressive symptoms, even though they also reported higher current suicidal ideation and therefore would be in urgent need of help. Overall, the findings of this study are in line with other studies, which found that depressive symptoms are associated with lower help-seeking intentions [ 6 – 8 ]. This study expands those results by including a wider range in age (12–25 years) and differentiating three subgroups of different levels of depressive symptoms. The fact that across a wider age range C&A with subclinical depressive symptoms report lower intentions to seek further help than those without depressive symptoms suggests that intentions to seek further help decrease with increasing depressive symptoms. The results suggest that differential perceptions of barriers could explain those differences in help-seeking intentions. Quantitative analyses showed that C&A with currently severe depressive symptoms and low intentions to seek professional help indicated for most barriers that they affected them more strongly compared to those without severe depressive symptoms. Interestingly, this difference also appeared in the qualitative content analyses. For C&A with lower levels of depressive symptoms, more than half of the mentioned barriers could be categorized as a need for autonomy, in particular as a preference to talk to their family or friends, or as a lack of mental health literacy, such as the negation of their potential problems. In comparison, C&A with clinical depressive symptoms did not often mention the preference to talk to their family and friends, but were more concerned about their family finding out about their problem and reacting negatively. In general, C&A with clinical depressive symptoms showed a broader variance of barriers which affected them. These differences in the perception of barriers and intentions could be a direct result of the psychopathology [ 9 , 14 ]. The feeling of hopelessness, a depressive symptom, for instance could diminish the confidence that a therapist could help, and the feeling of guilt may increase the perception that one could be a burden if talking to others about one’s problems. An alternative explanation for these findings could be that participants with higher levels of depressive symptoms rated barriers as more prevalent as it is not only a hypothetical case for them. More research is necessary to explore this relationship of psychopathology and perception of barriers. Despite various differences, some barriers seem to be prevalent in all C&A regardless of their current depressive symptoms. Consistent with previous studies [ 39 ], C&A perceived attitudinal barriers as more prevalent than structural barriers. Furthermore, across all subgroups a lack of mental health literacy, intrapersonal reasons such as difficulties to talk about one’s problems and a need for self-reliance and autonomy, reflected by the preference to handle problems alone or with support from family or friends, can be important barriers to seek professional help. Interestingly, previous professional help-seeking did only in some cases affect perception of barriers in quantitative analyses. Perceptions of stigma and fear of being admitted to the (C&A) psychiatric ward diminished when C&A affected by clinical depressive symptoms did not seek professional help previously. For those who were currently not reporting depressive symptoms on the other hand seeking help from a professional in the past might have enhanced the perception of stigma. A special link of treatment experience to stigma has also been found in previous research (McLaren et al., 2023). Further, especially participants with clinical depressive symptoms reported that negative previous experiences with therapy would hinder them from seeking help from a professional. Future longitudinal research which closely examines those associations and takes into account the valence of previous experience is needed to differentiate the results [ 40 ]. These results provide relevant implications for both research and practice. Most importantly, the findings highlight the need to pay attention to C&A who are experiencing depressive symptoms, but are reluctant to seek professional help, and to consider their social and individual barriers. This study further undermines the need for targeted interventions [ 7 ]. Programs should encourage help-seeking at different stages and in different ways. The differences in intentions and barriers between three levels of depressive symptoms found here implicate that prevention but also early and regular interventions, which consider help-seeking barriers in their design or encourage further help-seeking, are necessary. First, prevention for C&A currently not experiencing depressive symptoms can beforehand reduce barriers and enhance mental health literacy. This in turn could increase early and future help-seeking. Second, early interventions targeting C&A with subclinical depressive symptoms may reach those who are beginning to experience depressive symptoms and who already perceive higher barriers. For instance, early interventions may address help-seeking by delivering knowledge about when to seek help for depression and how to talk about one’s feelings and problems. They could also prevent a worsening of symptoms. Third, interventions in C&A with depressive symptoms can specifically address attitudinal barriers like stigma or the need to handle problems alone and negative treatment experiences. Especially for younger C&A, it is important to note that the parents play an important role in seeking and getting access to professional mental health care. Interventions should therefore also focus on the parents’ role in the help-seeking process. To consider many barriers and different target groups, online interventions can be useful. They can build a low-threshold first step for those who perceive high barriers like the fear talking to strangers. Furthermore, online interventions with self-management tools can address barriers like the need for self-reliance and autonomy. Especially for C&A, prevention and intervention in an online sphere could therefore be attractive [ 41 , 42 ]. Clinical practice should especially consider the role of family and friends in C&A help-seeking process. On the one hand, family members may be a first support for C&A and may represent trusted persons where C&A easily seek help [ 12 ]. Thereby, they can also promote further help-seeking as C&A stated that they relied on their family’s opinion. This facilitating role of the family is especially present for those with lower or without depressive symptoms. For those with clinical depressive symptoms on the other hand, relation to the family may present a barrier to seek help. Many children indicated that they fear a negative reaction of their parents, that they will worry or that they would not allow getting help from a professional. Online and low threshold services could be a good first contact point for C&A who fear consequences by their parents and would therefore not seek help at other help-services like a psychiatrist (like for instance the German chat counseling service “krisenchat”, 43). One of the main strengths of this study is that the data bases upon a large sample with a wide age range including children 12 years of age and older, adolescents, and young adult students (18–25 years). Moreover, validated, internationally used questionnaires measured depressive symptoms, previous help-seeking and help-seeking intentions. Qualitative analyses further add to the validity of the study. A first limitation of this study is a potential selection bias due to necessity of parents’ consent for minors, which was impossible to eliminate for a large school-based sample. Second, all data are based on self-report by C&A and not on clinical diagnoses or actual behavior. Even though questions were adapted to C&A, some children might have misunderstood the instruction, might have lacked mental health literacy. For instance, they could have had difficulties remembering their past behavior or could have not known what a mental health problem comprises. However, there is evidence that already children at the age of six can report on their health [ 44 ] and that the PHQ-A is a valid self-report measurement to detect depression in C&A [ 45 ]. Third, measuring intentions is only an approximation of actual help-seeking behavior [ 46 ], and a divergence of intentions and behavior is possible [ 40 ]. Nevertheless, only previously validated questionnaires have been used to measure intentions and previous behavior [ 29 – 31 ] and intentions are a potent predictor of future behavior [ 47 ]. Further research should also consider other potential mediators and moderators. First studies have already targeted this with respect to students or adults [ 6 , 40 ], but still other potentially influencing factors like suicidality has not been addressed yet in a younger sample. Conclusions Overall, this study shows the high need of effective interventions in adolescents to promote help-seeking of those in need. Despite more help-seeking experience and need, C&A with higher levels of depressive symptoms appear to be more reluctant to seek help than C&A without depressive symptoms. Perceptions of barriers hindering to seek help from a professional vary with the level of depressive symptoms. Clinical interventions such as online services need to take those barriers and different target groups into account. Future longitudinal studies on associations between help-seeking behavior, intentions, barriers and depressive symptoms are needed. Abbreviations AHSQ = Actual Help Seeking Questionnaire C&A = children and adolescents GHSQ = General Help Seeking Questionnaire PHQ-A = Patient-Health-Questionnaire-9 for Adolescents Declarations Ethics approval and consent to participate Ethical approval was granted by the ethics committees of the leading study site, the Medical Faculty at the University of Heidelberg (Study ID: S-086/2018) and of each participating study center [17]. Before participation in the study, written informed consent was given by parents (or other custodian) and the participants. In participants 18 years and older, only the participants themselves had to provide their consent. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests SBal, JS, EK, S-LK, JK, SBau, MM, MK, HE, LL, JK, SD, and RT confirm no conflicting interests. CR-K received lecture honoraria from Recordati and Servier outside and independent of the submitted work. KB has received research grants by German Research Society, German Federal Ministry for Education and Research, Philipps-University Marburg, von Behring-Röntgen Foundation, German Ministry for Health, University Hospital Gießen and Marburg, Rhön Klinikum AG. She receives honorary from Georg Thieme Publisher during the last five years. Funding The ProHEAD project was funded by the German Federal Ministry of Education and Research (BMBF) Grant (01GL1744E). Authors' contributions SBal, EK, and CR-K designed the study. JS performed the statistical analysis, SBal and JS drafted the article. S-LK and JS performed the qualitative analysis. SBal, JS, EK, and CR-K discussed the results and contributed to the final manuscript. SBau, MK, HE, KB, RT, and CR-K obtained funding for the ProHEAD Consortium. MK and SBau are the coordinators of the ProHEAD Consortium. All authors read and revised the manuscript carefully and approved the final manuscript. Acknowledgments We acknowledge support by the Open Access Publishing Fund of Leipzig University supported by the German Research Foundation within the program Open Access Publication Funding. The ProHEAD Consortium The ProHEAD consortium comprises six study sites in Germany. Site leaders are: Michael Kaess (University Hospital Heidelberg), Stephanie Bauer (University Hospital Heidelberg), Rainer Thomasius (University Medical Center Hamburg-Eppendorf), Christine Rummel-Kluge (University Leipzig), Heike Eschenbeck (University of Education Schwäbisch Gmünd), Hans-Joachim Salize (Medical Faculty Mannheim/Heidelberg University) and Katja Becker (Philipps-University Marburg). 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CR-K received lecture honoraria from Recordati and Servier outside and independent of the submitted work. KB has received research grants by German Research Society, German Federal Ministry for Education and Research, Philipps-University Marburg, von Behring-Röntgen Foundation, German Ministry for Health, University Hospital Gießen and Marburg, Rhön Klinikum AG. She receives honorary from Georg Thieme Publisher during the last five years. Cite Share Download PDF Status: Posted Version 1 posted 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. 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University","correspondingAuthor":false,"prefix":"","firstName":"Jelena","middleName":"","lastName":"Scheider","suffix":""},{"id":275930399,"identity":"6b1b744c-1709-4284-a2e8-dcc8e32d96b5","order_by":2,"name":"Elisabeth Kohls","email":"","orcid":"","institution":"Leipzig University","correspondingAuthor":false,"prefix":"","firstName":"Elisabeth","middleName":"","lastName":"Kohls","suffix":""},{"id":275930400,"identity":"ac37b8d6-375f-4732-885c-c3adfd9c6fee","order_by":3,"name":"Sarah-Lena Klemm","email":"","orcid":"","institution":"Leipzig University","correspondingAuthor":false,"prefix":"","firstName":"Sarah-Lena","middleName":"","lastName":"Klemm","suffix":""},{"id":275930401,"identity":"827646a1-60e6-4bf8-a2f1-cd0eea605a13","order_by":4,"name":"Julian Koenig","email":"","orcid":"","institution":"University of Cologne, University Hospital Cologne","correspondingAuthor":false,"prefix":"","firstName":"Julian","middleName":"","lastName":"Koenig","suffix":""},{"id":275930402,"identity":"640c43e0-3144-4a03-b503-c5c5a0766b59","order_by":5,"name":"Stephanie Bauer","email":"","orcid":"","institution":"University Hospital Heidelberg","correspondingAuthor":false,"prefix":"","firstName":"Stephanie","middleName":"","lastName":"Bauer","suffix":""},{"id":275930403,"identity":"84db908f-5f89-431e-b357-b0bc31ee0764","order_by":6,"name":"Markus Moessner","email":"","orcid":"","institution":"University Hospital Heidelberg","correspondingAuthor":false,"prefix":"","firstName":"Markus","middleName":"","lastName":"Moessner","suffix":""},{"id":275930404,"identity":"0a384244-21f0-4982-b2f9-c082e0770bfe","order_by":7,"name":"Michael Kaess","email":"","orcid":"","institution":"University of Bern","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Kaess","suffix":""},{"id":275930405,"identity":"0849ffbe-1030-4b31-a280-ce715bb80f04","order_by":8,"name":"Heike Eschenbeck","email":"","orcid":"","institution":"University of Education Schwäbisch Gmünd","correspondingAuthor":false,"prefix":"","firstName":"Heike","middleName":"","lastName":"Eschenbeck","suffix":""},{"id":275930406,"identity":"6f39885c-1af0-4585-9075-b41286f73967","order_by":9,"name":"Laya Lehner","email":"","orcid":"","institution":"University of Education Schwäbisch Gmünd","correspondingAuthor":false,"prefix":"","firstName":"Laya","middleName":"","lastName":"Lehner","suffix":""},{"id":275930407,"identity":"982c0bd6-ecaf-4150-91ea-4788887a90a6","order_by":10,"name":"Katja Becker","email":"","orcid":"","institution":"Medical Faculty of the Philipps-University Marburg","correspondingAuthor":false,"prefix":"","firstName":"Katja","middleName":"","lastName":"Becker","suffix":""},{"id":275930408,"identity":"5107ef03-ad9f-400d-b16d-20ffc0ad341b","order_by":11,"name":"Jennifer Krämer","email":"","orcid":"","institution":"Medical Faculty of the Philipps-University Marburg","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Krämer","suffix":""},{"id":275930409,"identity":"ebeea735-4d53-485e-928c-516455f7d81e","order_by":12,"name":"Silke Diestelkamp","email":"","orcid":"","institution":"University Hospital Hamburg-Eppendorf","correspondingAuthor":false,"prefix":"","firstName":"Silke","middleName":"","lastName":"Diestelkamp","suffix":""},{"id":275930410,"identity":"31e63efb-2aa3-43ac-af09-d2bebca1d078","order_by":13,"name":"Rainer Thomasius","email":"","orcid":"","institution":"University Hospital Hamburg-Eppendorf","correspondingAuthor":false,"prefix":"","firstName":"Rainer","middleName":"","lastName":"Thomasius","suffix":""},{"id":275930411,"identity":"abd73faf-89a3-42fb-9d86-cc417798e8a3","order_by":14,"name":"Christine Rummel-Kluge","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABoklEQVRIie3Sv0vDQBQH8BcKcTm89WKq/gsnBREs9t8QXHIU4uKJ4OIgchKIS6Vr3fwTMlWdvHCgS7GrUpEWoXMLDhGK+q71RwXdRfKFJI8XPuTdXQDy5PmDoQ0ADcBs2bWNIrCqwmcZL6EgsL0COBo4gDsm7NaSwBLCbYMASy0JvxGYInzd3scvPoh3aIn5aE+iv0ruH/fS52xlmwJZnrvbKhPwndh72mtv0JlqNOidgzibQTLYua/M0lMHSfGaGxKwXU/Rvi+bIYEFJ/aLrY48qfUUFy0QFxFA2uD9gsu6OCNnIc4QMJFoGiMxpPKAxIs7MrkVKhAxiMTQgSHcuC7T7oSkGZJLTa6QvI4H872XG3mJRE8ILm2Ew7yT9RA0sV8BEiLRdvmxN1RaJkwcqk8C3DCXKtduMg5GQiYahpRWZbNqNzlahauqbLR6EYiYlSxJa7zPXeZE9ijDwjArH4j6UW2pI5trC3iU6V22vybrR5uPw+e4PJ+0tdPNRveVxbpJp/+DwnRNvmo2dTRMqN9+Iyf7oYmE6h/6efLkyfPv8wYOTp7fnsSwCwAAAABJRU5ErkJggg==","orcid":"","institution":"Leipzig University","correspondingAuthor":true,"prefix":"","firstName":"Christine","middleName":"","lastName":"Rummel-Kluge","suffix":""}],"badges":[],"createdAt":"2024-03-01 13:15:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4003280/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4003280/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57141010,"identity":"9619b116-b1dd-4d94-8019-c135976f86c3","added_by":"auto","created_at":"2024-05-25 15:14:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1026622,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4003280/v1/2317bdf9-bc76-4f43-8be6-5f6fdfe64c6a.pdf"}],"financialInterests":"Competing interest reported. CR-K received lecture honoraria from Recordati and Servier outside and independent of the submitted work. KB has received research grants by German Research Society, German Federal Ministry for Education and Research, Philipps-University Marburg, von Behring-Röntgen Foundation, German Ministry for Health, University Hospital Gießen and Marburg, Rhön Klinikum AG. She receives honorary from Georg Thieme Publisher during the last five years.","formattedTitle":"Intentions and barriers to help-seeking in children and adolescents differing in depression severity: Cross-sectional results from a school-based mental health project","fulltext":[{"header":"Background","content":"\u003cp\u003eChildren and adolescent (C\u0026amp;A) are a vulnerable age group with up to 19% of adolescents from 12\u0026ndash;17 years old in Germany suffering from mental health problems [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and 11% of 12\u0026ndash;17 year old Europeans experiencing suicidal ideation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, of all C\u0026amp;A with mental health problems, around 70\u0026ndash;80% do not seek professional help and thus, do not receive treatment [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Even C\u0026amp;A experiencing mental crises delay seeking help (Lustig et al., 2022). This hesitant behavior might be a result of lower intentions to seek help. Specifically, adolescents experiencing higher levels of depressive symptoms reported lower intentions for potential help-seeking than those without depressive symptoms [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDifferent factors may hinder those in need to actually seek professional help. Two recent systematic reviews categorized barriers and facilitators that adolescents perceive in seeking help for a potential emotional problem [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. On an individual level, a lack of mental health literacy and a high need for autonomy in coping with their problems may be reasons for low help-seeking intentions. Moreover, social factors such as fear of stigma were frequently reported barriers. Fear of lacking confidentiality and other obstructive perceptions of therapeutic relationships (e.g., fear of being judged or not taken seriously) may be other barriers to help-seeking in adolescents [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Besides these attitudinal barriers, structural factors such as lack of time and resources may also impede help-seeking [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to the previously mentioned barriers, specific psychopathology may present another hindering factor towards seeking professional help. Specifically, experiencing clinical depressive symptoms could create distinct barriers. Depressive symptoms such as feelings of worthlessness, guilt, and hopelessness as well as a lack in energy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] are likely to hinder individuals from perceiving themselves as being worthy of help, having hope in getting an adequate treatment and getting better, and having the energy to search for help [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While potentially hindering factors increase with higher depressive symptomatology, perception for a need for help also increases [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo date, few studies examined relevant barriers towards help-seeking in C\u0026amp;A with severe mental health conditions such as depression [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. For adolescents experiencing depressive symptoms, lack of trust, stigma, and shame were shown to be barriers to help-seeking [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Moreover, similar to adolescents without depressive symptoms, adolescents with depressive symptoms reported self-reliance or a high need for autonomy as reasons for low intentions to seek help [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Further, first evidence suggests that some barriers, such as fear of stigma, may be more prevalent in students suffering from depression and suicidal ideation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Nevertheless, this result is based on a limited sample of over 18 year old college students [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. It remains unclear whether the presence of depressive symptoms is associated with different perceived barriers to help-seeking in comparison to adolescents without this symptomatology. To our knowledge, no other study systematically compared help-seeking intentions and perceived barriers to help-seeking between adolescents with different levels of depressive symptoms.\u003c/p\u003e \u003cp\u003eThe present study aimed to close this gap by comparing C\u0026amp;A with different levels of depressive symptoms regarding different aspects of help-seeking in a cross-sectional, mixed-method study. The study is based on a nationwide German multi-center school-based project (\u0026ldquo;Promoting Help-seeking using E-technology for Adolescents\u0026rdquo;: ProHEAD; 17). Help-seeking intentions and barriers were examined across three subgroups of adolescents without depressive symptoms, with subclinical depressive symptoms, and with clinical depressive symptoms, respectively. The goals of this study were to compare these subgroups regarding 1) previous help-seeking behavior, 2) intentions to seek help for a potential mental health problem, and 3) perception of barriers to professional help-seeking. Additionally, possible effects of previous help-seeking on perception of barriers were explored. Quantitative methods as well as a qualitative content analysis were used to examine barriers to professional help-seeking. Based on previous studies [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], it was hypothesized that the subgroup with clinical depressive symptoms shows higher previous help-seeking behavior compared to the other subgroups. In contrast, help-seeking intentions were expected to be negatively related to the different levels of depressive symptoms [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] with lower help-seeking intentions in the subgroup with clinical depressive symptoms compared to the other subgroups. With respect to the perception of barriers, no specific hypothesis was formulated.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eParticipants and Procedure\u003c/p\u003e\n\u003cp\u003eRecruitment took place between November 2018 and February 2022 within the research project \u0026ldquo;Promoting Help-seeking using E-technology for Adolescents\u0026rdquo; (ProHEAD; 17). ProHEAD is a multi-center consortium and aims to improve help-seeking behavior in adolescents with clinical mental health symptoms, prevent mental disorders in adolescents with subclinical mental health symptoms, and strengthen their mental health. Participating students completed a baseline screening assessment, after which they were allocated to one of five online programs addressing mental health promotion, eating disorder symptoms, depressive symptoms, risky alcohol use, and promotion of help-seeking, respectively. Those RCTs as well as the study procedures are described in-depth elsewhere [\u003cspan\u003e17\u003c/span\u003e, \u003cspan\u003e19\u003c/span\u003e\u0026ndash;\u003cspan\u003e23\u003c/span\u003e]. For the present sample, students were recruited in secondary schools in grades 6\u0026ndash;13 as well as vocational schools located in five different regions of Germany (Hamburg, Heidelberg, Leipzig, Marburg, Schw\u0026auml;bisch Gm\u0026uuml;nd) and completed an online questionnaire.\u003c/p\u003e\n\u003cp\u003eThis study analyzed data obtained through this initial baseline screening. Ethical approval was granted by the ethics committees of the leading study site, the Medical Faculty at the University of Heidelberg (Study ID: S-086/2018) and of each participating study center [\u003cspan\u003e17\u003c/span\u003e]. Before participation in the study, written informed consent was given by parents (or other custodian) and the participants. In participants 18 years and older, only the participants themselves had to provide their consent. All students\u0026thinsp;\u0026ge;\u0026thinsp;12 years of age with an informed consent were included in the study. \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9,954 students initiated the online screening. Participants who did not complete one of the questionnaires were excluded from the analyses (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;445), resulting in a final sample of \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9,509 students.\u003c/p\u003e\n\u003cp\u003eMeasures\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSociodemographic Variables.\u003c/strong\u003e In the online questionnaire age, gender, migration background, family affluence, and family psychosocial risk factors were assessed. Migration background was operationalized through one question asking for parents\u0026rsquo; country of birth. All participants with one parent or themselves being born outside of Germany were categorized as having a migration background. Family affluence was measured utilizing a German adaptation of the Family Affluence Scale [\u003cspan\u003e24\u003c/span\u003e]. The instrument consists of four items with different rating scales, asking for instance whether the participant has an own bedroom. Using the sum score of the four items, family affluence can be differentiated in low (0\u0026ndash;2), medium (3\u0026ndash;5), and high (6\u0026ndash;9) family affluence [\u003cspan\u003e24\u003c/span\u003e]. Family psychosocial risk factors were measured using the Laucht-Index [\u003cspan\u003e25\u003c/span\u003e]. It consists of ten items that can be summarized to a sum score ranging from 0 to 10 with higher scores indicating higher psychosocial risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient-Health-Questionnaire-9 for Adolescents (PHQ-A).\u003c/strong\u003e The current level of depressive symptoms as well as suicidal ideation were assessed with the PHQ-A [\u003cspan\u003e26\u003c/span\u003e]. Nine items measured depressive symptoms. Utilizing a 4-point Likert scale ranging from 0 = \u0026ldquo;not at all\u0026rdquo; to 3 = \u0026ldquo;nearly every day\u0026rdquo;, those nine items assess the level of depressive symptoms within the last 14 days. A sum score of these items, reaching from 0 to 27, is computed, with higher scores indicating higher levels of depressive symptoms. Based on this score participants were categorized into three subgroups for the purpose of the present analysis: a) participants without depressive symptoms (PHQ score between 0 and 9; Group 0); b) participants with subclinical depressive symptoms (PHQ score between 10 and 14; Group 1); and c) participants with clinical depressive symptoms (PHQ score between 15 and 27; Group 2). This categorization was based on previous studies using the PHQ-A for identifying different levels of depressive symptoms in adolescents [\u003cspan\u003e27\u003c/span\u003e, \u003cspan\u003e28\u003c/span\u003e]. In addition this categorization reflects the cut-off values used in the ProHEAD project to assign students with different symptomatology into the respective RCTs: students with a PHQ-score between 10 and 14 were categorized as being at risk for developing depression, i.e., experiencing subclinical depressive symptoms, while students with a PHQ-score\u0026thinsp;\u0026ge;\u0026thinsp;15 were defined as having clinical depressive symptoms [\u003cspan\u003e17\u003c/span\u003e]. To screen for suicidal ideation, two items asked respondents about their current suicidal thoughts within the past month as well as lifetime suicide attempts. Answer options were dichotomous (yes/no).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eActual Help Seeking Questionnaire (AHSQ).\u003c/strong\u003e Previous help-seeking behavior was assessed using the AHSQ [\u003cspan\u003e29\u003c/span\u003e]. Participants are asked to indicate if they had sought help for a mental health problem in the past. Answer options were categorical: 0 = \u0026quot;no\u0026quot;, 1 = \u0026quot;yes, during the last 12 months\u0026quot;, 2 = \u0026quot;yes, but more than 12 months ago\u0026quot;. If participants sought help in the past, they were then asked to report the source of help. Different sources were presented using 12 items, 11 of which each represented a different source of formal (e. g., school psychologist, teacher, psychiatrist) or informal help (e. g., friends, partner, parents). For the purpose of this study, the items were summarized in three different ways. First, a binary variable distinguished previous help-seeking or no previous help-seeking. Second, two binary variables categorized previous help-seeking from formal sources and from informal sources (participants answered to have sought help from any formal or informal source, respectively). In addition, a binary variable was computed to be used as a control variable and indicated formal or no formal previous help-seeking.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGeneral Help Seeking Questionnaire (GHSQ).\u003c/strong\u003e The GHSQ [\u003cspan\u003e30\u003c/span\u003e, \u003cspan\u003e31\u003c/span\u003e] was used to assess the intentions to seek help for hypothetical mental health problems from different sources. The instrument consists of 14 items, with 12 items identifying different formal (e.g., general practitioner, C\u0026amp;A psychiatrist, psychotherapist) and informal (e.g., friends, parents) sources of help, one item being an additional free text field item and one item providing the option to indicate that one would not seek help at all. Participants indicated the likelihood of seeking help from different sources in the next four weeks if they were to suffer from mental health problems. Likelihood was rated on a 7-point scale, ranging from 0 = \u0026quot;extremely unlikely\u0026quot; to 7 = \u0026quot;extremely likely\u0026quot;. The authors of the GHSQ propose using three metric subscales ranging from 0 to 7 each, with higher scores indicating higher intentions for the respective behavior: formal help-seeking, informal help-seeking, and no help-seeking, with the latter being derived from the item \u0026ldquo;I would not seek help from anyone\u0026rdquo; [\u003cspan\u003e30\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers Questionnaire.\u003c/strong\u003e The validated \u0026ldquo;Barriers to Adolescents Seeking Help Scale\u0026rdquo; (BASH-B, 32) was adapted and extended with additional items from the literature. While six items were derived from the original version of the BASH-B, six additional items on structural barriers, lack of mental health literacy, fear of being admitted to the (C\u0026amp;A) psychiatric ward and on fear that others will worry were constructed based on an extensive literature search. Participants were instructed to imagine suffering from mental health problems for a few weeks or months and were then asked if they would seek professional help in this case (i. e., from a psychiatrist or psychotherapist). If they indicated that they would \u003cem\u003enot\u003c/em\u003e seek help, eleven items and one free text field item were used to evaluate potential reasons for not seeking professional help. Subjects rated to which degree each reason applied to them on a 4-point scale (1 = \u0026ldquo;does not apply\u0026rdquo; to 4 = \u0026ldquo;does apply\u0026rdquo;). To descriptively analyze frequencies of each item, items were binary coded into 1 = \u0026ldquo;barrier applies\u0026rdquo; (including answer options \u0026ldquo;does rather apply\u0026rdquo; and \u0026rdquo;does apply\u0026rdquo;) and 0 = \u0026ldquo;barrier does not apply\u0026rdquo; (including answer options \u0026ldquo;does rather not apply\u0026rdquo; and \u0026ldquo;does not apply\u0026rdquo;). In addition, following suggestions in previous studies in adolescents and young adults [\u003cspan\u003e32\u003c/span\u003e, \u003cspan\u003e33\u003c/span\u003e], the items were summarized with respect to their content to six different categories (stigma, lack of mental health literacy, perceived family consequences, self-reliance and autonomy, difficulties in accessibility, fear of being admitted to a psychiatric ward). The free text field answers served as a basis for a qualitative content analysis to identify potential barriers that may not have been covered in the other items.\u003c/p\u003e\n\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n \u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics version 27.0. Participants were allocated to one of three subgroups based on the PHQ-A (Group 0: without depressive symptoms; Group 1: with subclinical symptoms; Group 2: with clinical depressive symptoms) and were compared with respect to sociodemographic variables (age, gender, family affluence, psychosocial risk factors, migration background) and clinical characteristics (current suicidal ideation, lifetime suicide attempt; both based on PHQ-A). \u0026chi;\u003csup\u003e2\u003c/sup\u003e-tests analyzed differences in categorical variables (gender, migration background, current suicidal ideation, lifetime suicide attempt) between the three subgroups. Due to non-normality of the data, continuous sociodemographic data (age, family affluence, psychosocial risk factors) were compared between subgroups using Kruskal-Wallis-\u003cem\u003eH\u003c/em\u003e tests.\u003c/p\u003e\n \u003cp\u003eTo answer the first research question, previous help-seeking behavior (AHSQ) was compared between the three subgroups using \u0026chi;\u003csup\u003e2\u003c/sup\u003e-tests. To answer the second research question, help-seeking intentions (GHSQ) were analyzed between the three subgroups. Three separate ANCOVAs compared the intentions to seek formal, informal, and no help (GHSQ), respectively. Separate ANCOVAs were conducted as assumptions for a MANCOVA were violated and ANCOVAs are considered as relatively robust for large sample sizes [\u003cspan\u003e34\u003c/span\u003e]. As significant differences in sociodemographic factors between the three subgroups with different levels of depressive symptoms appeared, age and family affluence were included as covariates in the ANCOVA, while gender represented another factor in the model instead of a covariate due to its categorical nature.\u003c/p\u003e\n \u003cp\u003eTo answer the third research question, perceptions of different barriers (Barriers Questionnaire) were compared between the three subgroups (PHQ-A). As the data again violated assumptions for a MANCOVA, several separate ANCOVAs were conducted. To control for potential effects of previous help-seeking on perceived barriers, previous help-seeking from formal sources (help-seeking from formal sources vs. no/other help-seeking; AHSQ) was added as another factor. Similar to the previous analyses, other covariates in the ANCOVAs were gender (added as another independent variable), age and family affluence.\u003c/p\u003e\n \u003cp\u003eA two-tailed \u0026alpha;\u0026thinsp;=\u0026thinsp;0.05 was applied to statistical testing. For all analyses, post-hoc \u003cem\u003et\u003c/em\u003e- tests, post-hoc Dunn-Bonferroni tests and pairwise \u003cem\u003ez\u003c/em\u003e-tests further compared subgroup differences for significant overall effects in ANCOVAs, in Kruskal-Wallis-\u003cem\u003eH\u003c/em\u003e tests and in \u0026chi;\u003csup\u003e2\u003c/sup\u003e-tests, respectively. For all ANCOVAs and post-hoc tests, Bonferroni correction was used to account for multiple testing. Further, effect sizes were reported and interpreted: for ANCOVAs an \u0026eta;\u0026sup2;partial was used. An \u0026eta;\u0026sup2;partial\u0026thinsp;=\u0026thinsp;.01 was considered as a small effect, \u0026eta;\u0026sup2;partial\u0026thinsp;=\u0026thinsp;.06 as a medium effect and \u0026eta;\u0026sup2;partial\u0026thinsp;=\u0026thinsp;.14 as a large effect [\u003cspan\u003e35\u003c/span\u003e]. For \u0026chi;\u003csup\u003e2\u003c/sup\u003e-tests as well as Kruskal-Wallis-\u003cem\u003eH\u003c/em\u003e tests, Cramer\u0026rsquo;s V was used to estimate small (V\u0026thinsp;=\u0026thinsp;0.1), medium (V\u0026thinsp;=\u0026thinsp;0.3), and large (V\u0026thinsp;=\u0026thinsp;0.5) effects [\u003cspan\u003e36\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eFinally, free text field answers on additional barriers were analyzed qualitatively using a qualitative content analysis. MAXQDA qualitative software (version 22.1.1) served as a coding tool. Following Mayring\u0026rsquo;s inductive content analysis approach [\u003cspan\u003e37\u003c/span\u003e], categories that emerged during the coding process were added to a coding dictionary. Using the final coding dictionary, two authors coded all free text field answers independently. Raters coded each free text answer with one category. Inter-rater reliability was good with \u0026kappa;\u0026thinsp;=\u0026thinsp;0.75 [\u003cspan\u003e38\u003c/span\u003e]. Frequencies of coding categories were analyzed descriptively in the three subgroups.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSociodemographic Characteristics and Subgroup Differences\u003c/p\u003e\n\u003cp\u003eThe final sample size was \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9,509. Of these, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5,575 (58.6%) indicated their gender as female, while \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3,934 (41.4%) indicated their gender as male. Mean age was 15.09 years (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.37), with a range from 12 to 24 years, while the majority of the sample (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;8,129, 85.5%) were minors. Family affluence was high for most participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6,936, 72.9%) and the psychosocial risk in the majority of participants was low (no or low risk: \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5,056, 53.2%). Participants mostly attended schools for a university entrance (\u0026ldquo;Gymnasium\u0026rdquo;; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5,042, 53.0%) or schools for all qualifications (\u0026bdquo;Gemeinschafts-, Ober- and Stadtteilschule\u0026rdquo;; \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1,660, 17.5%). In the total sample, participants showed an average PHQ-A score of \u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.56 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;5.39), ranging from 0 to 27. The majority (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6,688; 70.3%) were classified as \u0026ldquo;without depressive symptoms\u0026rdquo; (Group 0), whereas \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1,706 (17.9%) were categorized into the second subgroup with subclinical depressive symptoms (Group 1). Finally, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1,115 (11.7%) reported clinical depressive symptoms (Group 2).\u003c/p\u003e\n\u003cp\u003eThe three subgroups were compared with respect to sociodemographic characteristics (see Table\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e). They differed significantly in gender (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), with the percentage of female participants being significantly higher in the subgroup with clinical depressive symptoms (Group 2) compared to both other subgroups, and being higher in the subgroup with subclinical depressive symptoms (Group 1) compared to the subgroup without depressive symptoms (Group 0; all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Further, subgroups differed significantly in age (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001): Post-hoc tests revealed that only Group 0 was significantly younger than both other subgroups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), while the latter did not differ significantly (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.999). A similar pattern appeared for migration background: Group 0 reported significantly less migration background than both other subgroups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), while the latter did not differ significantly (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.999). With respect to socioeconomic status, the three subgroups differed in family affluence and in the Laucht-index for psychosocial risk (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001): Group 2 showed the lowest family affluence and highest psychosocial risk compared to both other groups, and Group 1 also showed a lower family affluence and higher psychosocial risk compared to Group 0 (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eSample characteristics and comparison of subgroups based on depressive symptomatology (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9,509).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eGroup 0: Without depressive symptoms\u003cbr\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6688)\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eGroup 1: With subclinical depressive symptoms\u003cbr\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1706)\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eGroup 2: With clinical depressive symptoms\u003cbr\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1115)\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eTest statistics\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u003cem\u003ep\u003c/em\u003e\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eEffect size\u003cbr\u003e\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eFemale gender, \u003cem\u003en\u003c/em\u003e (%)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e3469 (51.9)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e1203 (70.5)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e903 (81.0)\u003csup\u003ec\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026chi;\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e (2)\u0026thinsp;=\u0026thinsp;455.16\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026lt;\u0026thinsp;.001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eV\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.22\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eAge, \u003cem\u003eM\u003c/em\u003e (\u003cem\u003eSD\u003c/em\u003e)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e14.90 (2.36)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e15.53 (2.35)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e15.55 (2.28)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eH\u003c/em\u003e (2)\u0026thinsp;=\u0026thinsp;198.72\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026lt;\u0026thinsp;.001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.11- .22\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eFamily affluence (FAS), \u003cem\u003eM (SD)\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e6.69 (1.76)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e6.13 (1.89)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e5.93 (1.85)\u003csup\u003ec\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eH\u003c/em\u003e (2)\u0026thinsp;=\u0026thinsp;247,22\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026lt;\u0026thinsp;.001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.06 \u0026minus;\u0026thinsp;.15\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003ePsychosocial risk factors, \u003cem\u003eM (SD)\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e3.61 (1.15)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e4.09 (1.48)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e4.35 (1.60)\u003csup\u003ec\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eH\u003c/em\u003e (2)\u0026thinsp;=\u0026thinsp;210.056\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026lt;\u0026thinsp;.001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.04 \u0026minus;\u0026thinsp;.19\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eMigration background, \u003cem\u003en\u003c/em\u003e (\u003cem\u003e%\u003c/em\u003e)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e1823 (27.3)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e602 (35.3)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e415 (37.2)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026chi;\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e (2)\u0026thinsp;=\u0026thinsp;74.44\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026lt;\u0026thinsp;.001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eV\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.09\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eCurrent suicidal ideation (PHQ-A), \u003cem\u003en\u003c/em\u003e (\u003cem\u003e%\u003c/em\u003e)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e168 (2.5)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e229 (13.4)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e506 (45.4)\u003csup\u003ec\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026chi;\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e (2)\u0026thinsp;=\u0026thinsp;2,080.83\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026lt;\u0026thinsp;.001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eV\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.47\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eLifetime suicide attempt (PHQ-A), \u003cem\u003en\u003c/em\u003e (\u003cem\u003e%\u003c/em\u003e)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e191 (2.9)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e175 (10.3)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e308 (27.6)\u003csup\u003ec\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026chi;\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e (2)\u0026thinsp;=\u0026thinsp;921.90\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026lt;\u0026thinsp;.001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eV\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.31\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003cem\u003eNotes\u003c/em\u003e. Different superscript letters indicate significant subgroup differences in the respective variable. FAS, Family Affluence Scale; Psychosocial risk factors, Laucht-Index; PHQ-A, Patient-Health-Questionnaire-9 for Adolescents. Bonferroni corrected \u003cem\u003ep\u003c/em\u003e-values.\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eIn the total sample, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;903 (9.5%) reported suicidal ideation in the past month and \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;674 (7.1%) reported a past suicide attempt. These frequencies differed significantly between the three subgroups (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; see Table\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e). Higher suicidal ideation and higher rates of previous suicide attempts were observed in Group 2 compared to both other subgroups, while Group 1 reported higher suicidal ideation and higher rates of previous suicide attempts than Group 0 (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eSubgroup differences in previous help-seeking behavior and help-seeking intentions (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9,509).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eGroup 0: Without depressive symptoms\u003cbr\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6688)\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eGroup 1: With subclinical depressive symptoms\u003cbr\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1706)\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eGroup 2: With clinical depressive symptoms\u003cbr\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1115)\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eTest statistics\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u003cem\u003ep\u003c/em\u003e\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eEffect size\u003cbr\u003e\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003ePrevious help-seeking (AHSQ), \u003cem\u003en\u003c/em\u003e (%)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e1416 (21.2)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e747 (43.8)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e680 (61.0)\u003csup\u003ec\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026chi;\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e (2)\u0026thinsp;=\u0026thinsp;1,054.07\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e.04\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eV\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.31\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003ePrevious formal help-seeking, \u003cem\u003en\u003c/em\u003e (%)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e502 (35.5)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e299 (40.0)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e317 (46.6)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026chi;\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e (2)\u0026thinsp;=\u0026thinsp;24.21\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026lt;\u0026thinsp;.001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eV\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.09\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003ePrevious informal help-seeking, \u003cem\u003en\u003c/em\u003e (%)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e1357 (95.8)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e703 (94.1)\u003csup\u003ea,b\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e635 (93.4)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026chi;\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e (2)\u0026thinsp;=\u0026thinsp;6.55\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e.04\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eV\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.05\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eHelp-seeking intentions (GHSQ)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eIntentions to seek formal help, \u003cem\u003eM\u003c/em\u003e (\u003cem\u003eSD\u003c/em\u003e)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.56 (1.37)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.28 (1.23)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.33 (1.21)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eF\u003c/em\u003e(2, 9501)\u0026thinsp;=\u0026thinsp;19.03\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026lt; .001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003e\u0026eta;\u0026sup2;\u003c/em\u003epartial\u0026thinsp;=\u0026thinsp;.00\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eIntentions to seek informal help, \u003cem\u003eM\u003c/em\u003e (\u003cem\u003eSD\u003c/em\u003e)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e4.62 (1.38)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e3.91 (1.38)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e3.33 (1.31)\u003csup\u003ec\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eF\u003c/em\u003e(2, 9501)\u0026thinsp;=\u0026thinsp;331.11\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026lt; .001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003e\u0026eta;\u0026sup2;\u003c/em\u003epartial\u0026thinsp;=\u0026thinsp;.07\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eIntentions to seek no help, \u003cem\u003eM\u003c/em\u003e (\u003cem\u003eSD\u003c/em\u003e)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.45 (1.73)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e3.26 (1.88)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e3.88 (1.91)\u003csup\u003ec\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eF\u003c/em\u003e(2, 9501)\u0026thinsp;=\u0026thinsp;225.70\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026lt; .001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003e\u0026eta;\u0026sup2;\u003c/em\u003epartial\u0026thinsp;=\u0026thinsp;.05\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003cem\u003eNotes\u003c/em\u003e. Different superscript letters indicate significant subgroup differences in the respective variable. AHSQ, Actual Help Seeking Questionnaire; GHSQ, General Help Seeking Questionnaire. Controlled for age, family affluence, and gender. Bonferroni corrected \u003cem\u003ep\u003c/em\u003e-values.\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e******* Please insert Table\u0026nbsp;\u003cspan\u003e1\u003c/span\u003e here. *******\u003c/p\u003e\n\u003cp\u003ePrevious Help-Seeking Behavior (AHSQ)\u003c/p\u003e\n\u003cp\u003eIn total, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2,843 (29.9%) participants reported to have sought help for mental health problems in the last year or before. Chi-square tests showed that the three subgroups differed significantly in the frequency of previous help-seeking (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; see Table\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e). Bonferroni corrected pairwise comparisons showed that Group 2 had highest rates of previous help-seeking, followed by Group 1, while Group 0 sought help least often in the past (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n\u003cp\u003eWith respect to previous informal help-seeking, the three subgroups differed significantly (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001): Groups 1 and 2 reported less often previous informal help-seeking compared to participants in Group 0 (both \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). No significant difference in informal help-seeking between Groups 1 and 2 emerged (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05).\u003c/p\u003e\n\u003cp\u003eRegarding previous formal help-seeking, the three subgroups also differed significantly (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Group 2 more often sought help from formal sources than Group 0 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), while Group 1 did not differ significantly from both other subgroups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05).\u003c/p\u003e\n\u003cp\u003e******* Please insert Table\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e here. *******\u003c/p\u003e\n\u003cp\u003eHelp-seeking intentions (GHSQ)\u003c/p\u003e\n\u003cp\u003eAn ANCOVA controlling for age, family affluence, and gender showed significant differences between all three subgroups in their intentions to seek formal, informal, and no help (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001; see Table\u0026nbsp;\u003cspan\u003e2\u003c/span\u003e). Group 2 reported higher intentions to seek no help compared to Group 1 (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), while Group 0 reported lowest intentions to seek no help compared to both other groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Regarding intentions to seek informal and formal help, respectively, Group 2 reported lower intentions to seek informal help compared to Group 1 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), but in the intentions to seek formal help they did not differ from Group 1 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05). Group 0 reported highest intentions to seek both formal and informal help (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n\u003cp\u003eBarriers to Help-Seeking\u003c/p\u003e\n\u003cp\u003eAll participants who indicated in the barriers questionnaire that they would not seek professional help were analyzed regarding their perception of barriers. In total, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3,220 (33.9% of the total sample) negated possible professional help-seeking.\u003c/p\u003e\n\u003cdiv id=\"Sec5\"\u003e\n \u003ch2\u003eQuantitative analysis of perceived barriers\u003c/h2\u003e\n \u003cp\u003eSeven ANCOVAs analyzed perception of barriers depending on the three subgroups of depressive symptoms. For all barrier categories, a main effect for subgroup appeared while controlling for previous help-seeking from formal sources, sex, age and socioeconomic status (Table\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cbr\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eSubgroup differences in perceived barriers to help-seeking (Barriers Questionnaire, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3,220\u003csup\u003e1\u003c/sup\u003e).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eGroup 0: Without depressive symptoms\u003cbr\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1847)\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eGroup 1: With subclinical depressive symptoms\u003cbr\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;781)\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eGroup 2: With clinical depressive symptoms\u003cbr\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;592)\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eTest statistic\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u003cem\u003ep\u003c/em\u003e\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eEffect size\u003cbr\u003e\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eM (SD)\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eM (SD)\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eM (SD)\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003e\u0026eta;\u0026sup2;\u003c/em\u003epartial\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eStigma\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.01 (0.93)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.42 (0.94)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.81 (0.97)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eF\u003c/em\u003e(2, 3206)\u0026thinsp;=\u0026thinsp;9.91\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026lt;\u0026thinsp;.001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e.01\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eLack of mental health literacy\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.06 (0.79)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.27 (0.81)\u003csup\u003ea,b\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.52 (0.75)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eF\u003c/em\u003e(2, 3206)\u0026thinsp;=\u0026thinsp;7.40\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e.001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e.01\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eFamily-related barriers\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.06 (0.91)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.61 (0.90)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e3.04 (0.89)\u003csup\u003ec\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eF\u003c/em\u003e(2, 3206)\u0026thinsp;=\u0026thinsp;31.16\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026lt;\u0026thinsp;.001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e.02\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eSelf-reliance and autonomy\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e3.15 (0.53)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.97 (0.59)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.72 (0.56)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eF\u003c/em\u003e(2, 3206)\u0026thinsp;=\u0026thinsp;15.06\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026lt;\u0026thinsp;.001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e.01\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eDifficulties in accessibility\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e1.58 (0.66)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e1.77 (0.76)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e1.90 (0.82)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eF\u003c/em\u003e(2, 3206)\u0026thinsp;=\u0026thinsp;6.04\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e.002\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e.00\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eFear of being admitted to a (children and adolescent) psychiatric ward\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.26 (1.09)\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e1.85 (1.09)\u003csup\u003ea,b\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e2.34 (1.20)\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eF\u003c/em\u003e(2, 3206)\u0026thinsp;=\u0026thinsp;6.70\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e.001\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"left\"\u003e.00\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u003cem\u003eNotes\u003c/em\u003e. \u003csup\u003e1\u003c/sup\u003e Reduced sample size due to nature of the questionnaire. Different superscript letters indicate significant subgroup differences in the respective variable. Bonferroni corrected \u003cem\u003ep\u003c/em\u003e-values. Controlled for age, family affluence, gender, and previous help-seeking from formal sources.\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\u003cbr\u003e\n \u003cp\u003ePost-hoc tests showed that perception of some barriers like stigma, self-reliance and autonomy as well as perceived difficulties in accessibility did not differ between Groups 1 and 2 (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05). Barriers related to stigma and difficulties in accessibility were rated lower by Group 0 compared to the other two subgroups (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05). For self-reliance and autonomy, a contrary pattern appeared. Here, Group 0 rated this barrier as more prevalent compared to both other subgroups (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05). Other barriers like lack of mental health literacy and fear of being admitted to the (C\u0026amp;A) psychiatric ward showed no difference between Group 1 compared to both other groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05), but were rated more prevalent by the Group 2 compared to Group 0 (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n \u003cp\u003eHowever, some barriers were rated differently between the subgroups. Group 2 indicated barriers associated with family-related reasons as more prevalent compared to both other groups and Group 1 rated them as more prevalent than Group 0 (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05).\u003c/p\u003e\n \u003cp\u003eWith respect to previous help-seeking from formal sources, which was included as a covariate, no significant main effect on perception of barriers appeared, but significant interaction effects with level of depressive symptoms emerged for stigma, \u003cem\u003eF\u003c/em\u003e\u003csub\u003e(2, 3206)\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;6.76, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, and for fear of being admitted to a (C\u0026amp;A) psychiatric ward, \u003cem\u003eF\u003c/em\u003e\u003csub\u003e(2, 3206)\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;7.26, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001.\u003c/p\u003e\n \u003cp\u003eRegarding effects between subgroups only participants who did \u003cem\u003enot\u003c/em\u003e seek help from formal sources in the past rated stigma and fear of being admitted to the (C\u0026amp;A) psychiatric ward differently depending on the level of depressive symptoms: Group 2 rated these barriers lower than both other subgroups (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Participants who \u003cem\u003edid\u003c/em\u003e seek help from formal sources did not differ significantly in those ratings (all \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n \u003cp\u003eRegarding effects within subgroups, Group 2 rated stigma and fear of being admitted to the (C\u0026amp;A) psychiatric ward as more prevalent when they had not sought help from formal sources compared to when they had (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01). For stigma this effect was inverse in Group 0: those without previous help-seeking from formal sources rated stigma as less prevalent compared to those with previous help-seeking (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.037).\u003c/p\u003e\n \u003cp\u003e******* Please insert Table\u0026nbsp;\u003cspan\u003e3\u003c/span\u003e here. *******\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\"\u003e\n \u003ch2\u003eQualitative content analysis of perceived barriers\u003c/h2\u003e\n \u003cp\u003eAmong all participants who indicated that they would not seek professional help in the Barriers Questionnaire, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;398 answered a free-text field to report additional barriers not measured in the questionnaire. In a qualitative content analysis, those answers were coded into nine categories consisting of 22 sub codes. The main categories included barriers related to stigma, lack of mental health literacy, family, self-reliance and autonomy, intrapersonal reasons, fear of consequences, negative experiences with therapy and perceived difficulties in accessibility. Out of all answers, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;60 (15.1%) answers were jokes, random comments, unclear answers or remarks about previous or current diagnoses/treatment and therefore not assignable to any barrier category.\u003c/p\u003e\n \u003cp\u003eParticipants in Group 2 varied more in their answers than the other two subgroups (see Table\u0026nbsp;\u003cspan\u003e4\u003c/span\u003e). Most frequently mentioned main categories in Group 2 were barriers including intrapersonal reasons (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18, 16.2% of all answers in this group) and barriers indicating a lack of mental health literacy (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18, 16.2%). Another frequently reported main category in this subgroup were barriers related to the participant\u0026rsquo;s family (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13, 11.7%), with subcategories including e. g. the fear that the family would know about the psychotherapy and would react negatively (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7, 6.3%) or the fear that others might worry about oneself (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6, 5.4%). Moreover, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12 (10.8%) participants reported negative previous experiences with psychotherapy. Less often, participants in Group 2 described barriers depicting the need for self-reliance and autonomy (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11, 9.9%). Only \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1 (1.0%) answer was coded as the subcategory \u0026lsquo;preference to talk to family or friends\u0026rsquo;. With respect to the subcategories of difficulties in accessibility, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3 (2.7%) participants mentioned difficulties to find a therapist, a barrier never reported by both other subgroups.\u003c/p\u003e\u003cbr\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eFrequencies of perceived barriers to professional help-seeking (free text field answers in the Barriers Questionnaire, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;398).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003eCategories and sub-categories, \u003cem\u003en\u003c/em\u003e (%)\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eGroup 0: Without depressive symptoms\u003cbr\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;194)\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eGroup 1: With subclinical depressive symptoms\u003cbr\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;93)\u003cbr\u003e\u003c/th\u003e\n \u003cth align=\"left\"\u003eGroup 2: With clinical depressive symptoms\u003cbr\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;111)\u003cbr\u003e\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eStigma\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e3 (1.5)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e3 (3.2)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e7 (6.3)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eShame\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e1 (0.5)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e2 (2.2)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e0 (0.0)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eFearing reactions of others\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e2 (1.0)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e1 (1.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e7 (6.3)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eLack of mental health literacy\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e45 (23.2)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e22 (23.7)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e18 (16.2)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eNo perceived need for therapy or problems/relativization of problems\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e20 (10.3)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e10 (10.8)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e7 (6.3)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eNegative expectancies about effectiveness and psychotherapist\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e8 (4.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e6 (6.5)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e6 (5.4)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eLack of knowledge\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e3 (1.5)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e1 (1.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e1 (0.9)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eLack of motivation\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e14 (7.2)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e5 (5.4)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e4 (3.6)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eFamily-related barriers\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e2 (1.0)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e1 (1.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e6 (5.4)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eFear of parental reaction\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e0 (0.0)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e3 (3.2)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e7 (6.3)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eFear that others might worry about oneself\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e2 (1.0)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e1 (1.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e6 (5.4)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eSelf-reliance and autonomy\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e69 (35.6)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e21 (22.6)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e11 (9.9)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003ePreference to handle problems alone\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e18 (9.3)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e7 (7.5)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e10 (9.0)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003ePreference to talk to family or friends\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e51 (26.3)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e14 (15.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e1 (0.9)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eIntrapersonal reasons\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e25 (12.9)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e23 (24.7)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e18 (16.2)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eDifficulties talking about problems\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e18 (9.3)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e14 (15.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e11 (9.9)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eGeneral mistrust in others\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e4 (2.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e2 (2.2)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e3 (2.7)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eLow self-esteem\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e3 (1.5)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e7 (7.5)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e4 (3.6)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eFear of consequences\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e6 (3.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e1 (1.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e4 (3.6)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eFear of being admitted to the psychiatric ward\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e2 (1.0)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e0 (0.0)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e1 (0.9)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eFear of negative consequences (in general)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e4 (2.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e1 (1.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e3 (2.7)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eNegative experience with therapy\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e10 (5.2)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e6 (6.5)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e12 (10.8)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003ePerceived difficulties in accessibility\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e5 (2.6)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e1 (1.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e9 (8.1)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eNo parental approval\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e3 (1.5)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e1 (1.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e5 (4.5)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eFinancial reasons\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e2 (1.0)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e0 (0.0)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e0 (0.0)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003eTime-related reasons\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e0 (0.0)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e0 (0.0)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e1 (0.9)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u003cem\u003eNon assignable\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e19 (17.1)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e12 (12.9)\u003cbr\u003e\u003c/td\u003e\n \u003ctd align=\"char\"\u003e29 (14.9)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\u003cbr\u003e\n \u003cp\u003eWith respect to participants in Group 1, the most frequent main categories were barriers related to intrapersonal reasons (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;23, 24.7%), self-reliance and autonomy (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;21, 22.6%), and lack of mental health literacy (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;22, 23.7%). The most frequently reported subcategories were difficulties to talk about one\u0026rsquo;s own problems because of fear of opening up or not being able to express one\u0026rsquo;s feelings (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14, 15.1%; subcategories of intrapersonal reasons) and the preference to talk to family or friends (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14, 15.1%; subcategories of self-reliance and need for autonomy).\u003c/p\u003e\n \u003cp\u003eParticipants in Group 0 reported similar barriers as Group 1: the most frequent main category were barriers related to self-reliance and autonomy (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;69, 35.6%). Here, reported subcategories were the preference to talk to family or friends (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;51, 26.3%) or to handle problems alone (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18, 9.3%). Another frequently reported main category were barriers related to a lack of mental health literacy (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;45, 23.2%). For instance, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;20 (10.3%) would not perceive a need for therapy or would think that the problems were not severe (enough) and \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;14 (7.2%) reported a lack of motivation. The third most frequently mentioned main category were intrapersonal reasons mentioned in \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25 (12.9%) answers with difficulties talking about one\u0026rsquo;s problem as the most common subcategory (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;18, 9.3%).\u003c/p\u003e\n \u003cp\u003e******* Please insert Table\u0026nbsp;\u003cspan\u003e4\u003c/span\u003e here. *******\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eUsing a mixed-methods approach, this study found that C\u0026amp;A differing in depression severity vary in their help-seeking behavior, intentions to seek help, and their perceptions of barriers to seek professional help. With respect to the first research question, the results support the hypothesized higher previous help-seeking behavior of adolescents with clinical depressive symptoms compared to others. Specifically, participants with clinical depressive symptoms reported to have sought help more often in the past compared to those without depressive symptoms. Participants with subclinical depressive symptoms, however, previously did not seek help more often than participants without symptoms. With respect to the second research question, the findings also confirm the hypothesized link between help-seeking intentions and depressive symptoms. Participants with clinical depressive symptoms reported lower intentions to seek further help in the future compared to both other subgroups, and participants with subclinical depressive symptoms had lower intentions to seek further help in the future compared to those without symptoms.\u003c/p\u003e \u003cp\u003eThe results further showed that those who were currently most in need of help due to high levels of depressive symptoms also reported to have sought more help in the past. This is especially relevant as those with higher depressive symptoms also reported more past suicide attempts than the other subgroups. However, an alarming finding was that the intentions for future help-seeking seem to be negatively associated with the current level of depressive symptoms, even though they also reported higher current suicidal ideation and therefore would be in urgent need of help.\u003c/p\u003e \u003cp\u003eOverall, the findings of this study are in line with other studies, which found that depressive symptoms are associated with lower help-seeking intentions [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This study expands those results by including a wider range in age (12\u0026ndash;25 years) and differentiating three subgroups of different levels of depressive symptoms. The fact that across a wider age range C\u0026amp;A with subclinical depressive symptoms report lower intentions to seek further help than those without depressive symptoms suggests that intentions to seek further help decrease with increasing depressive symptoms.\u003c/p\u003e \u003cp\u003eThe results suggest that differential perceptions of barriers could explain those differences in help-seeking intentions. Quantitative analyses showed that C\u0026amp;A with currently severe depressive symptoms and low intentions to seek professional help indicated for most barriers that they affected them more strongly compared to those without severe depressive symptoms. Interestingly, this difference also appeared in the qualitative content analyses. For C\u0026amp;A with lower levels of depressive symptoms, more than half of the mentioned barriers could be categorized as a need for autonomy, in particular as a preference to talk to their family or friends, or as a lack of mental health literacy, such as the negation of their potential problems. In comparison, C\u0026amp;A with clinical depressive symptoms did not often mention the preference to talk to their family and friends, but were more concerned about their family finding out about their problem and reacting negatively. In general, C\u0026amp;A with clinical depressive symptoms showed a broader variance of barriers which affected them. These differences in the perception of barriers and intentions could be a direct result of the psychopathology [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The feeling of hopelessness, a depressive symptom, for instance could diminish the confidence that a therapist could help, and the feeling of guilt may increase the perception that one could be a burden if talking to others about one\u0026rsquo;s problems. An alternative explanation for these findings could be that participants with higher levels of depressive symptoms rated barriers as more prevalent as it is not only a hypothetical case for them. More research is necessary to explore this relationship of psychopathology and perception of barriers.\u003c/p\u003e \u003cp\u003eDespite various differences, some barriers seem to be prevalent in all C\u0026amp;A regardless of their current depressive symptoms. Consistent with previous studies [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], C\u0026amp;A perceived attitudinal barriers as more prevalent than structural barriers. Furthermore, across all subgroups a lack of mental health literacy, intrapersonal reasons such as difficulties to talk about one\u0026rsquo;s problems and a need for self-reliance and autonomy, reflected by the preference to handle problems alone or with support from family or friends, can be important barriers to seek professional help.\u003c/p\u003e \u003cp\u003eInterestingly, previous professional help-seeking did only in some cases affect perception of barriers in quantitative analyses. Perceptions of stigma and fear of being admitted to the (C\u0026amp;A) psychiatric ward diminished when C\u0026amp;A affected by clinical depressive symptoms did not seek professional help previously. For those who were currently not reporting depressive symptoms on the other hand seeking help from a professional in the past might have enhanced the perception of stigma. A special link of treatment experience to stigma has also been found in previous research (McLaren et al., 2023). Further, especially participants with clinical depressive symptoms reported that negative previous experiences with therapy would hinder them from seeking help from a professional. Future longitudinal research which closely examines those associations and takes into account the valence of previous experience is needed to differentiate the results [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese results provide relevant implications for both research and practice. Most importantly, the findings highlight the need to pay attention to C\u0026amp;A who are experiencing depressive symptoms, but are reluctant to seek professional help, and to consider their social and individual barriers. This study further undermines the need for targeted interventions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Programs should encourage help-seeking at different stages and in different ways. The differences in intentions and barriers between three levels of depressive symptoms found here implicate that prevention but also early and regular interventions, which consider help-seeking barriers in their design or encourage further help-seeking, are necessary.\u003c/p\u003e \u003cp\u003eFirst, prevention for C\u0026amp;A currently not experiencing depressive symptoms can beforehand reduce barriers and enhance mental health literacy. This in turn could increase early and future help-seeking. Second, early interventions targeting C\u0026amp;A with subclinical depressive symptoms may reach those who are beginning to experience depressive symptoms and who already perceive higher barriers. For instance, early interventions may address help-seeking by delivering knowledge about when to seek help for depression and how to talk about one\u0026rsquo;s feelings and problems. They could also prevent a worsening of symptoms. Third, interventions in C\u0026amp;A with depressive symptoms can specifically address attitudinal barriers like stigma or the need to handle problems alone and negative treatment experiences. Especially for younger C\u0026amp;A, it is important to note that the parents play an important role in seeking and getting access to professional mental health care. Interventions should therefore also focus on the parents\u0026rsquo; role in the help-seeking process.\u003c/p\u003e \u003cp\u003eTo consider many barriers and different target groups, online interventions can be useful. They can build a low-threshold first step for those who perceive high barriers like the fear talking to strangers. Furthermore, online interventions with self-management tools can address barriers like the need for self-reliance and autonomy. Especially for C\u0026amp;A, prevention and intervention in an online sphere could therefore be attractive [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClinical practice should especially consider the role of family and friends in C\u0026amp;A help-seeking process. On the one hand, family members may be a first support for C\u0026amp;A and may represent trusted persons where C\u0026amp;A easily seek help [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Thereby, they can also promote further help-seeking as C\u0026amp;A stated that they relied on their family\u0026rsquo;s opinion. This facilitating role of the family is especially present for those with lower or without depressive symptoms. For those with clinical depressive symptoms on the other hand, relation to the family may present a barrier to seek help. Many children indicated that they fear a negative reaction of their parents, that they will worry or that they would not allow getting help from a professional. Online and low threshold services could be a good first contact point for C\u0026amp;A who fear consequences by their parents and would therefore not seek help at other help-services like a psychiatrist (like for instance the German chat counseling service \u0026ldquo;krisenchat\u0026rdquo;, 43).\u003c/p\u003e \u003cp\u003eOne of the main strengths of this study is that the data bases upon a large sample with a wide age range including children 12 years of age and older, adolescents, and young adult students (18\u0026ndash;25 years). Moreover, validated, internationally used questionnaires measured depressive symptoms, previous help-seeking and help-seeking intentions. Qualitative analyses further add to the validity of the study. A first limitation of this study is a potential selection bias due to necessity of parents\u0026rsquo; consent for minors, which was impossible to eliminate for a large school-based sample. Second, all data are based on self-report by C\u0026amp;A and not on clinical diagnoses or actual behavior. Even though questions were adapted to C\u0026amp;A, some children might have misunderstood the instruction, might have lacked mental health literacy. For instance, they could have had difficulties remembering their past behavior or could have not known what a mental health problem comprises. However, there is evidence that already children at the age of six can report on their health [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] and that the PHQ-A is a valid self-report measurement to detect depression in C\u0026amp;A [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Third, measuring intentions is only an approximation of actual help-seeking behavior [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], and a divergence of intentions and behavior is possible [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Nevertheless, only previously validated questionnaires have been used to measure intentions and previous behavior [\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and intentions are a potent predictor of future behavior [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Further research should also consider other potential mediators and moderators. First studies have already targeted this with respect to students or adults [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], but still other potentially influencing factors like suicidality has not been addressed yet in a younger sample.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOverall, this study shows the high need of effective interventions in adolescents to promote help-seeking of those in need. Despite more help-seeking experience and need, C\u0026amp;A with higher levels of depressive symptoms appear to be more reluctant to seek help than C\u0026amp;A without depressive symptoms. Perceptions of barriers hindering to seek help from a professional vary with the level of depressive symptoms. Clinical interventions such as online services need to take those barriers and different target groups into account. Future longitudinal studies on associations between help-seeking behavior, intentions, barriers and depressive symptoms are needed.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAHSQ = Actual Help Seeking Questionnaire\u003c/p\u003e\n\u003cp\u003eC\u0026amp;A = children and adolescents\u003c/p\u003e\n\u003cp\u003eGHSQ = General Help Seeking Questionnaire\u003c/p\u003e\n\u003cp\u003ePHQ-A = Patient-Health-Questionnaire-9 for Adolescents\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted by the ethics committees of the leading study site, the Medical Faculty at the University of Heidelberg (Study ID: S-086/2018) and of each participating study center [17]. Before participation in the study, written informed consent was given by parents (or other custodian) and the participants. In participants 18 years and older, only the participants themselves had to provide their consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSBal, JS, EK, S-LK, JK,\u0026nbsp;SBau, MM, MK, HE, LL,\u0026nbsp;JK, SD, and RT\u0026nbsp;confirm no conflicting interests. CR-K received lecture honoraria from Recordati and Servier outside and independent of the submitted work.\u0026nbsp;KB\u0026nbsp;has received research grants by German Research Society, German Federal Ministry for Education and Research, Philipps-University Marburg, von Behring-R\u0026ouml;ntgen Foundation, \u0026nbsp;German Ministry for Health, University Hospital Gie\u0026szlig;en and Marburg, Rh\u0026ouml;n Klinikum AG. She receives honorary from Georg Thieme Publisher during the last five years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ProHEAD project was funded by the German Federal Ministry of Education and Research (BMBF) Grant (01GL1744E).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSBal, EK, and CR-K designed the study. JS performed the statistical analysis, SBal and JS drafted the article. S-LK and JS performed the qualitative analysis. SBal, JS, EK, and CR-K discussed the results and contributed to the final manuscript.\u0026nbsp;SBau, MK, HE, KB, RT, and CR-K obtained funding for the ProHEAD Consortium. MK and SBau are the coordinators of the ProHEAD Consortium. All authors read and revised the manuscript carefully and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge support by the Open Access Publishing Fund of Leipzig University supported by the German Research Foundation within the program Open Access Publication Funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe ProHEAD Consortium\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ProHEAD consortium comprises six study sites in Germany. Site leaders are: Michael Kaess (University Hospital Heidelberg), Stephanie Bauer (University Hospital Heidelberg), Rainer Thomasius (University Medical Center Hamburg-Eppendorf), Christine Rummel-Kluge (University Leipzig), Heike Eschenbeck (University of Education Schw\u0026auml;bisch Gm\u0026uuml;nd), Hans-Joachim Salize (Medical Faculty Mannheim/Heidelberg University) and Katja Becker (Philipps-University Marburg). Further members of the consortium are: Sabrina Bonnet, Johannes Feldhege, Christina Gallinat, Stella Hammon, Julian Koenig, Sophia Lustig, Markus Moessner, Fikret \u0026Ouml;zer, Regina Richter, Johanna Stadler (all University Hospital Heidelberg), Steffen Luntz (Coordinating Center for Clinical Trials Heidelberg), Silke Diestelkamp, Anna-Lena Schulz (all University Medical Center Hamburg-Eppendorf), Sabrina Baldofski, Sarah-Lena Klemm, Elisabeth Kohls, Sophia M\u0026uuml;ller, Lina-Jolien Peter, Mandy Rogalla (all University Leipzig), Vera Gill\u0026eacute;, Johanna Jade, Laya Lehner (all University of Education Schw\u0026auml;bisch Gm\u0026uuml;nd), Elke Voss (Medical Faculty Mannheim/Heidelberg University), Alisa Hiery, Jennifer Kr\u0026auml;mer (all Philipps-University Marburg).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKlipker K, Baumgarten F, G\u0026ouml;bel K, Lampert T, H\u0026ouml;lling H. 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Crisis. 2018;39:175\u0026ndash;96. doi:10.1027/0227-5910/a000485.\u003c/li\u003e\n\u003cli\u003eKaess M, Ritter S, Lustig S, Bauer S, Becker K, Eschenbeck H, et al. Promoting Help-seeking using E-technology for ADolescents with mental health problems: study protocol for a randomized controlled trial within the ProHEAD Consortium. Trials. 2019;20:94. doi:10.1186/s13063-018-3157-7.\u003c/li\u003e\n\u003cli\u003eBauer S, Bilić S, Reetz C, Ozer F, Becker K, Eschenbeck H, et al. Efficacy and cost-effectiveness of Internet-based selective eating disorder prevention: study protocol for a randomized controlled trial within the ProHEAD Consortium. Trials. 2019;20:91. doi:10.1186/s13063-018-3161-y.\u003c/li\u003e\n\u003cli\u003eDiestelkamp S, Wartberg L, Kaess M, Bauer S, Rummel-Kluge C, Becker K, et al. Effectiveness of a web-based screening and brief intervention with weekly text-message-initiated individualised prompts for reducing risky alcohol use among teenagers: study protocol of a randomised controlled trial within the ProHEAD consortium. Trials. 2019;20:73. doi:10.1186/s13063-018-3160-z.\u003c/li\u003e\n\u003cli\u003eBaldofski S, Kohls E, Bauer S, Becker K, Bilic S, Eschenbeck H, et al. Efficacy and cost-effectiveness of two online interventions for children and adolescents at risk for depression (E.motion trial): study protocol for a randomized controlled trial within the ProHEAD consortium. Trials. 2019;20:53. doi:10.1186/s13063-018-3156-8.\u003c/li\u003e\n\u003cli\u003eEschenbeck H, Lehner L, Hofmann H, Bauer S, Becker K, Diestelkamp S, et al. School-based mental health promotion in children and adolescents with StresSOS using online or face-to-face interventions: study protocol for a randomized controlled trial within the ProHEAD Consortium. Trials. 2019;20:64. doi:10.1186/s13063-018-3159-5.\u003c/li\u003e\n\u003cli\u003eBoyce W, Torsheim T, Currie C, Zambon A. The Family Affluence Scale as a Measure of National Wealth: Validation of an Adolescent Self-Report Measure. Soc Indic Res. 2006;78:473\u0026ndash;87. doi:10.1007/s11205-005-1607-6.\u003c/li\u003e\n\u003cli\u003eLaucht M, Esser G, Schmidt MH. Psychisch auff\u0026auml;llige Eltern: Risiken f\u0026uuml;r die kindliche Entwicklung im S\u0026auml;uglings- und Kleinkindalter? Mannheim; 1992.\u003c/li\u003e\n\u003cli\u003eJohnson JG, Harris ES, Spitzer RL, Williams JB. The patient health questionnaire for adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients. Journal of Adolescent Health. 2002;30:196\u0026ndash;204. doi:10.1016/s1054-139x(01)00333-0.\u003c/li\u003e\n\u003cli\u003eKroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606\u0026ndash;13. doi:10.1046/j.1525-1497.2001.016009606.x.\u003c/li\u003e\n\u003cli\u003eTsai F-J, Huang Y-H, Liu H-C, Huang K-Y, Huang Y-H, Liu S-I. Patient health questionnaire for school-based depression screening among Chinese adolescents. Pediatrics. 2014;133:e402-9. doi:10.1542/peds.2013-0204.\u003c/li\u003e\n\u003cli\u003eRickwood DJ, Braithwaite VA. Social-psychological factors affecting help-seeking for emotional problems. Social Science \u0026amp; Medicine. 1994;39:563\u0026ndash;72. doi:10.1016/0277-9536(94)90099-x.\u003c/li\u003e\n\u003cli\u003eRickwood DJ, Deane FP, Wilson CJ, Ciarrochi J. Young people\u0026rsquo;s help-seeking for mental health problems. Australian e-Journal for the Advancement of Mental Health. 2005;4:218\u0026ndash;51. doi:10.5172/jamh.4.3.218.\u003c/li\u003e\n\u003cli\u003eWilson CJ, Deane F, Ciarrochi J, Rickwood DJ. Measuring help-seeking intentions: Properties of the General Help-Seeking Questionnaire. Canadian Journal of Counselling. 2005;39:15\u0026ndash;28.\u003c/li\u003e\n\u003cli\u003eKuhl J, Jarkon-Horlick L, Morrissey RF. Measuring Barriers to Help-Seeking Behavior in Adolescents. J Youth Adolesc. 1997;26:637\u0026ndash;50. doi:10.1023/A:1022367807715.\u003c/li\u003e\n\u003cli\u003eBaldofski S, Klemm S-L, Kohls E, Mueller SME, Bauer S, Becker K, et al. Reasons for non-participation of children and adolescents in a large-scale school-based mental health project. Front Public Health. 2023;11:1294862. doi:10.3389/fpubh.2023.1294862.\u003c/li\u003e\n\u003cli\u003eHuitema BE. The Analysis of Covariance and Alternatives: Wiley; 2011.\u003c/li\u003e\n\u003cli\u003eCohen J. Statistical Power Analysis for the Behavioral Sciences: Routledge; 2013.\u003c/li\u003e\n\u003cli\u003eCohen J. Statistical power analysis for the behavioral sciences. 2\u003csup\u003end\u003c/sup\u003e ed. Hove, London: Lawrence Erlbaum Associates; 1988.\u003c/li\u003e\n\u003cli\u003eMayring P. Qualitative Inhaltsanalyse. In: Mey G, Mruck K, editors. Handbuch Qualitative Forschung in der Psychologie. Wiesbaden: VS Verlag f\u0026uuml;r Sozialwissenschaften; 2010. p. 601\u0026ndash;613. doi:10.1007/978-3-531-92052-8_42.\u003c/li\u003e\n\u003cli\u003eFleiss JL, Levin B, Paik MC, editors. Statistical Methods for Rates and Proportions: Wiley; 2003.\u003c/li\u003e\n\u003cli\u003eAndrade LH, Alonso J, Mneimneh Z, Wells JE, Al-Hamzawi A, Borges G, et al. Barriers to mental health treatment: results from the WHO World Mental Health surveys. Psychol Med. 2014;44:1303\u0026ndash;17. doi:10.1017/S0033291713001943.\u003c/li\u003e\n\u003cli\u003eMcLaren T, Peter L-J, Tomczyk S, Muehlan H, Schomerus G, Schmidt S. The Seeking Mental Health Care model: prediction of help-seeking for depressive symptoms by stigma and mental illness representations. BMC Public Health. 2023;23:69. doi:10.1186/s12889-022-14937-5.\u003c/li\u003e\n\u003cli\u003eRickwood DJ, Mazzer KR, Telford NR. Social influences on seeking help from mental health services, in-person and online, during adolescence and young adulthood. BMC Psychiatry. 2015;15:40. doi:10.1186/s12888-015-0429-6.\u003c/li\u003e\n\u003cli\u003eLinardon J, Cuijpers P, Carlbring P, Messer M, Fuller-Tyszkiewicz M. The efficacy of app-supported smartphone interventions for mental health problems: a meta-analysis of randomized controlled trials. World Psychiatry. 2019;18:325\u0026ndash;36. doi:10.1002/wps.20673.\u003c/li\u003e\n\u003cli\u003eEckert M, Efe Z, Guenthner L, Baldofski S, Kuehne K, Wundrack R, et al. Acceptability and feasibility of a messenger-based psychological chat counselling service for children and young adults (\u0026ldquo;krisenchat\u0026rdquo;): A cross-sectional study. Internet Interv. 2022;27:100508. doi:10.1016/j.invent.2022.100508.\u003c/li\u003e\n\u003cli\u003eRiley AW. Evidence that school-age children can self-report on their health. Ambul Pediatr. 2004;4:371\u0026ndash;6. doi:10.1367/A03-178R.1.\u003c/li\u003e\n\u003cli\u003eRichardson LP, McCauley E, Grossman DC, McCarty CA, Richards J, Russo JE, et al. Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics. 2010;126:1117\u0026ndash;23. doi:10.1542/peds.2010-0852.\u003c/li\u003e\n\u003cli\u003eWilson CJ, Rickwood DJ, Bushnell JA, Caputi P, Thomas SJ. The effects of need for autonomy and preference for seeking help from informal sources on emerging adults\u0026rsquo; intentions to access mental health services for common mental disorders and suicidal thoughts. Advances in Mental Health. 2011;10:29\u0026ndash;38. doi:10.5172/jamh.2011.10.1.29.\u003c/li\u003e\n\u003cli\u003eAjzen I. The theory of planned behavior. Organizational Behavior and Human Decision Processes. 1991;50:179\u0026ndash;211. doi:10.1016/0749-5978(91)90020-T.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Help-seeking, Children, Adolescents, Barriers, Depression, Mixed-Method Design","lastPublishedDoi":"10.21203/rs.3.rs-4003280/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4003280/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Mental health problems, such as depression, have a high prevalence in children and adolescents (C\u0026amp;A). However, the majority of C\u0026amp;A suffering from depression do not seek professional help. In addition to general barriers, the specific psychopathology related to depressive symptoms may decrease their intentions to seek professional help. This study aimed to compare help-seeking behavior, intentions and perceived barriers between C\u0026amp;A with different levels of depressive symptoms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eThis cross-sectional study is part of a large-scale, multi-center project. Participants were \u003cbr\u003e\n \u003cem\u003eN\u003c/em\u003e = 9,509 C\u0026amp;A who were recruited in German schools and completed a baseline screening questionnaire. Based on their depressive symptoms, C\u0026amp;A were allocated to the following three subgroups: a) without depressive symptoms, b) with subclinical symptoms, c) with clinical symptoms (measured by PHQ-A). Quantitative analyses compared previous help-seeking behavior (AHSQ), help-seeking intentions (GHSQ) and perceived barriers (Barriers questionnaire) between those different subgroups. A qualitative content analysis examined text answers on other perceived barriers to help-seeking.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eParticipants were mostly female (\u003cem\u003en\u003c/em\u003e = 5,575, 58.6%) and 12 to 24 yearsold (\u003cem\u003eM\u003c/em\u003e =15.09, \u003cem\u003eSD \u003c/em\u003e= 2.37). Participants with different levels of depressive symptoms differed significantly in help-seeking behavior, intentions and perceived barriers. Specifically, participants with clinical depressive symptoms reported more previous help-seeking, but lower intentions to seek help compared to participants without symptoms (all \u003cem\u003ep\u003c/em\u003e \u0026lt; .05). Participants with subclinical depressive symptoms reported a similar frequency of previous help-seeking, but higher intentions to seek help compared to participants without symptoms (all \u003cem\u003ep\u003c/em\u003e \u0026lt;.05). Perception of barriers was different across subgroups: participants with clinical and subclinical depressive symptoms perceived the majority of barriers such as stigma, difficulties in accessibility, and family-related barriers as more relevant than participants without depressive symptoms. Across all subgroups, participants frequently mentioned intrapersonal reasons, a high need for autonomy, and a lack of mental health literacy as barriers to help-seeking.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e C\u0026amp;A with higher levels of depressive symptoms are more reluctant to seek professional help and perceive higher barriers. This underlines the need for effective and low-threshold interventions to tackle barriers, increase help-seeking, and lower depressive symptoms in C\u0026amp;A differing in depression severity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration:\u003c/strong\u003e DRKS00014685\u003c/p\u003e","manuscriptTitle":"Intentions and barriers to help-seeking in children and adolescents differing in depression severity: Cross-sectional results from a school-based mental health project","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-05 18:05:37","doi":"10.21203/rs.3.rs-4003280/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e686fddb-0762-4a50-a9c3-4051b948e1b0","owner":[],"postedDate":"March 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-25T15:06:01+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-05 18:05:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4003280","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4003280","identity":"rs-4003280","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}