Negative Attitudes Toward Help Seeking for Mental Illness in 2 Population-Based Surveys From the United States and Canada

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1 Negative Attitudes Toward Help Seeking for Mental Illness in 2 Population-Based Surveys From the United States and Canada Amit Jagdeo, MD 1 ; Brian J Cox, PhD 2 ; Murray B Stein, MD, MPH, FRCPC, MPH 3 ; Jitender Sareen, MD, FRCPC 4 Objectives: To determine the prevalence and sociodemographic correlates of negative toward help seeking for mental illness among the general population in the United States and Ontario. Methods: Two contemporaneous population-based surveys (aged 15 to 54 years) were analyzed: the US National Comorbidity Survey (NCS) (n = 5877) and the Ontario Health Survey (OHS) (n = 6902). Multiple logistic regression analyses were used to examine the correlates of a derived negative composite variable obtained from questions assessing probability, comfort, and embarrassment related to help seeking for mental illness. Results: Negative toward help seeking for mental illness were prevalent in both countries. Fifteen percent of OHS and 20% of NCS respondents stated they probably or definitely would not seek treatment if they had serious emotional problems. Almost one-half of recipients in both surveys stated they would be embarrassed if their friends knew about their use of mental health services. Negative toward help seeking were highest among socioeconomically challenged young, single, lesser-educated men in Ontario and the United States. In both countries, substance abuse or dependence and antisocial personality disorder were associated with greater negative, as was not having sought treatment in the past. Conclusions: Negative toward mental health service use are prevalent in Ontario and the United States. They are most common in young adults, especially those with lower education and socioeconomic resources, and those with substance abuse or dependence problems. This information can be used to target educational efforts aimed at improving willingness to seek care for mental health problems. Can J Psychiatry. 2009;54(11): Clinical Implications Negative toward mental health service use are prevalent in the community. Young, single, socioeconomically challenged men with a mental disorder have the poorest toward mental health services. There is a need for targeted screening and intervention programs in young adults. Limitations The measurement of was brief. The surveys were collected in the early 1990s, and some of these findings might have changed over time. Mental disorders were assessed by lay interview-based diagnoses rather than by clinicians. The Canadian Journal of Psychiatry, Vol 54, No 11, November

2 Key Words: negative, mental illness, help seeking, mental disorders, United States, Canada Psychopathology has been well established regarding disability and costs to society yet untreated mental illness remains a significant problem. 1 The World Health Organization s WMH Survey Consortium reported on the prevalence and treatment of mental disorders across 14 countries. 2 The proportion of people meeting criteria for having at least 1 DSM-IV disorder assessed ranged from 4.3% to 26.4%. However, people receiving any treatment for emotional problems during the 12 months prior to the WMH surveys ranged from 0.8% to 15.3%. 2 Despite the availability of effective treatment regimens for most mental disorders, only a fraction receive appropriate care each year. 3 The WMH investigation confirmed numerous earlier findings that untreated mental illness remains a significant problem across the world. 2,4,5 Attitudes Toward Help Seeking Andersen s 6 behavioural model of health services use is commonly employed in the broader help-seeking literature as a guiding theoretical model. This model suggests that people s predisposing characteristics, enabling resources, and need (evaluated and perceived) determine health service use and, subsequently, health outcomes. A key predisposing factor considered by Andersen is the person s attitude toward mental health treatment. 6 9 Further, recent reports suggest a strong association between negative toward mental health care and treatment dropout. 3 Although severity of illness, individual predispositions, social environment, and the structure of the health care system present numerous hurdles in the help-seeking process for the mentally ill, negative are a critical area where public health interventions can be targeted. 7,10,11 Most of the studies exploring about mental health services have used small or large nonrepresentative samples, and focused on the relation between and service use. 3,8,12 21 Leaf et al 22 used a large population survey to correlate toward mental health services with service use. Abbreviations used in this article CCHS 1.2 CIDI DSM Disorders MHS NCS OHS PTSD WMH Canadian Community Health Survey: Mental Health and Well-Being Composite International Diagnostic Interview Diagnostic and Statistical Manual of Mental Mental Health Supplement National Comorbidity Survey Ontario Health Survey posttraumatic stress disorder World Mental Health Olfson et al s 19 report on barriers to treatment centred on social anxiety disorder. Diala et al s 18 assessment of toward professional mental health care focused primarily on racial differences and predictions of service use. Ross et al 14 restricted their analysis to people with substance abuse disorders. Van Voorhees et al 20 obtained data for their crosssectional study from an internet screening test for depression. Mojtabai s 2007 study 23 is the most recent report on the of a large general population for help seeking for mental illness but is limited to data from the United States. To the best of our knowledge, no studies have presented the prevalence and correlates of toward help seeking for mental illness in Canada or examined attitudinal differences across dissimilar health care systems. We selected 2 large population-based surveys to explore the relation between sociodemographics and toward help seeking in Canada and the United States. We chose to analyze the NCS and the MHS to the OHS, as both used parallel designs and instruments. 24 Kessler et al 25 have previously compared the 2 data sets and validated their comparability. The comparison was apt considering that Ontario comprises a significant portion (36%) of the Canadian population, approximates the Canadian health care system, and has sociodemographics very similar to the United States. 25 The NCS and OHS surveys collected extensive sociodemographic data and asked important questions pertaining to toward help seeking for mental illness. Respondents were asked if they were to experience emotional problems what would be their: likelihood of seeking care, comfort in speaking with a professional, and embarrassment if their friends knew about the help seeking. Understanding the population demographics of those reluctant to seek care can guide targeted public awareness campaigns to increase treatment. 26 The problem of negative toward mental health treatment can persist beyond initiation of treatment. It has been shown that certain demographics are more likely to feel uncomfortable speaking with a mental health professional and believe that treatment will be ineffective. 3 Similar demographics have been noted to exhibit higher treatment dropout rates. 3 We aimed was to identify demographics most likely to report elevated negative toward help seeking for mental illness. Two important questions were addressed: What is the prevalence of negative toward help seeking for mental illness in the United States and Canada? and, What are the sociodemographic, mental disorder, and help-seeking correlates of these negative? 758 La Revue canadienne de psychiatrie, vol 54, no 11, novembre 2009

3 Negative Attitudes Toward Help Seeking for Mental Illness in 2 Population-Based Surveys From the United States and Canada Methods Data Data came from the 1990 to 1991 MHS to the OHS (n = 6902) and the 1990 to 1992 US NCS (n = 5877). These surveys employed very similar sample designs and instruments. The NCS data set is available in the public domain. 27 The OHS data set was obtained by consent from the Government of Ontario. Analyses were performed using the statistical software SUDAAN, 28 version 9.0. Survey Design The total NCS sample consisted of 8098 people aged 15 to 54 years. 25 A response rate of 82.4% was observed. However, service use questions were only administered to 5877 respondents. The latter group comprises the base of analysis for our study. Participant cooperation did not vary by age or sex. 29 Weights supplied with the NCS dataset were used to compensate for any imbalances owing to nonresponse, selection bias, and demographic variations. 29 Information about the survey design of the OHS has been previously described in detail. 30 Only people who participated in the second half of the OHS were selected to participate in the MHS. From an eligible pool of households, participated in the second part of the OHS. The MHS selected 9953 of respondents for an overall response rate of 67.4%. Higher participation was seen from young women, physically ailed, born in Canada, and rural residents. Marital status and income had little effect on participation. For purposes of the current analysis, we used the same age range as the NCS data (aged 15 to 54 years), which included 6902 participants. Weighting adjustments were incorporated into the data set to compensate for response variations. 30 For both surveys, informed consent was obtained before beginning the interviews from all respondents in accordance with each country s federal legislative requirements Further details on the methodology of the 2 surveys are provided elsewhere. 29,30 All data were collected by trained lay interviewers through personal interviews with a probability sample of the general population in the United States and Ontario. 30 Attitudes Toward Help Seeking The assessment of toward help seeking for mental illness was identical across the NCS and OHS. Respondents were asked: If you had a serious emotional problem, would you definitely go for professional help, probably go, probably not go, or definitely not go for professional help? ; How comfortable would you feel talking about personal problems with a professional very comfortable, somewhat, not very, or not at all comfortable? ; How embarrassed would you be if your friends knew you were getting professional help for an emotional problem very embarrassed, somewhat, not very, or not at all embarrassed? Sociodemographics We selected sociodemographics for analysis that had been previously cited as significantly impacting mental health services: age, sex, marital status, education, and income. 7,18,19,22,32,33 For the NCS, health insurance was selected as an additional variable. 23 The continuous age variables in the OHS and NCS were categorized into 3 subgroups: 15 to 24 years; 25 to 34 years; and 35 to 54 years. 14 Analysis of both data sets was restricted aged to 54 years because of NCS survey limitations. The dichotomous sex variable was used directly from each data set. Marital status was categorized into 3 groups: single or never married; separated, divorced, or widowed; and married or common law. Education was dichotomized into education of 12 years or less and education of greater than 12 years. As per previously documented guidelines, income was categorized into 4 groups of personal income (low, low to average, average to high, and high) using ratios of median personal income levels from each country to reflect standardized measures. 11 Universal health insurance availability in Canada precluded such a measure in the OHS. The NCS data on respondent s health insurance were categorized appropriately into 3 categories (none, Medicaid, and health insurance not Medicaid). Mental Disorders Data in both surveys were collected according to the University of Michigan CIDI format encompassing DSM-III-R psychiatric diagnoses. 25 The University of Michigan CIDI is a modification of the CIDI format endorsed by the World Health Organization and verified for use by lay interviewers. 24,34 The modular CIDI questionnaire is adaptable to research needs and generates comprehensive diagnoses encompassing both DSM-III-R and International Classification of Diseases, Tenth Revision, criteria, allowing crosscultural comparisons. 25 The University of Michigan CIDI instrument has been organized for better interview flow, recall maximization, and ordered collection of diagnostic information. All the same mental disorders were assessed in both surveys except for PTSD, which was assessed only in the NCS. For the purposes of the current analyses, we created the following variables based on a lifetime diagnosis in each of the 2 surveys: any mood disorder (major depression, dysthymia, bipolar disorder), any anxiety disorder (social phobia, panic disorder, agoraphobia, specific phobia, generalized anxiety disorder), any substance use disorder (alcohol abuse or dependence, drug abuse or dependence), antisocial personality disorder, and any lifetime disorder (included all the diagnoses). For the NCS, PTSD was examined separately. The Canadian Journal of Psychiatry, Vol 54, No 11, November

4 Table 1 Prevalence of toward help seeking for mental illness in Ontario and the United States. Attitude MHS to the OHS n a (%) US NCS n a (%) Probably seek help Definitely 2548 (39) 2005 (34) Probably 3263 (45) 2663 (45) Probably not 897 (12) 938 (16) Definitely not 184 (3) 253 (4) Comfortable talking to professional Very 1959 (31) 1504 (26) Somewhat 3453 (49) 2780 (47) Not very 1124 (15) 1058 (18) Not at all 352 (5) 513 (9) Embarrassed if friends know Not at all 2388 (34) 1950 (33) Not very 1491 (21) 1413 (24) Somewhat 2491 (36) 1926 (33) Very 517 (8) 574 (10) Attitudes toward help seeking b Positive 5572 (82) 4396 (76) Negative 1306 (18) 1465 (24) a n values are unweighted and % values are from weighted calculations, owing to the design of the statistical weight b Derived variable was dichotomized to 1 SD above the mean toward negative Use of Mental Health Services A composite variable was derived to represent any lifetime mental health service use. Any hospitalization or outpatient service use for mental illness constituted having received treatment in the past. Hospitalization included the spending of at least one night in a hospital setting for emotional or substance abuse problems. Outpatient service use for emotional problems included, but was not limited to, a psychiatrist, psychologist, spiritual leader, self-help group, social worker, government agency, general medical practitioner, medical specialist, telephone hotlines, and any health professional. Analysis To assess the prevalence of negative toward help seeking, we combined 3 questions pertaining to probability, comfort, and embarrassment about seeking professional help for mental illness. Responses to each question were recorded on a 4-point scale. Three variables representing each question were created such that lower numbers (1 and 2) in each represented positive responses and higher numbers (3 and 4) signified negative responses. A composite score variable () was then derived from the sum of the 3 component variables; this variable ranged from 3 (very positive) to 12 (very negative). To compare respondents with negative that were out of the normative range to the rest of the sample, respondents were dichotomized such that scores from 3 to 7 were grouped as positive and 8 to 12 (that is, one standard deviation above the mean) were grouped as negative. The derived dichotomous variable was correlated with sociodemographic factors (age, sex, marital status, education, income, and insurance). Additional correlations in both data sets were determined using psychiatric diagnostic groups of: mood disorders, anxiety disorders, PTSD (NCS only), alcohol and substance abuse or dependence, antisocial personality disorder, any lifetime psychiatric diagnoses, and any lifetime use of mental health services. Binary logistic regression modelling was used to obtain unadjusted odds ratios for each variable. Odds ratios were calculated within 95% confidence intervals using a Taylor linearization method in the SUDAAN program based on stratification information available in the public use data set designated specifically for this purpose. 28,31 Statistical weights were employed to ensure that analyses of the data were representative. 31,35 Results Attitudes Toward Help Seeking The prevalence of toward help seeking for mental illness is presented in Table 1. Although most people stated that they would probably seek help for emotional problems, a significant number of people exhibited negative toward help seeking for emotional problems in both Canada and the United States. The trends show remarkable similarity between the 2 countries, with as many as 1 in 5 OHS and 1 in 4 NCS respondents harbouring negative. Sociodemographics Table 2 illustrates that the sociodemographic correlates of negative toward help seeking were consistent across the 2 surveys. Younger age, lower income, less education, and being single or living with a partner was associated with negative (OR 1.36 to 3.42). In the NCS, not having health insurance was associated with negative. Mental Disorders and Past Use of Mental Health Services Table 3 contains the correlates of negative toward help seeking for mental illness and mental disorders, lifetime psychiatric diagnoses, and prior use of mental health services. While the OHS data did not demonstrate an association between presence of mood or anxiety disorder with negative, the NCS data found a lower likelihood of negative 760 La Revue canadienne de psychiatrie, vol 54, no 11, novembre 2009

5 Negative Attitudes Toward Help Seeking for Mental Illness in 2 Population-Based Surveys From the United States and Canada Table 2 MHS to the OHS and NCS toward help seeking correlated with sociodemographics MHS to the OHS (n = 6902) a US NCS (n = 5877) b Sociodemographic Negative n = 1306 % Positive n = 5572 % Unadjusted OR (negative, compared with positive, ) Negative n = 1023 % Positive n = 4423 % Unadjusted OR (negative, compared with positive, ) Age, years ( ) c ( ) c ( ) c ( ) c Sex Male ( ) c ( ) c Female Marital status Single or never married ( ) c ( ) c Married or common law ( ) c ( ) c Separated or divorced or widowed Education, years Income ( ) c ( ) c Low ( ) c ( ) c Low to average ( ) ( ) Average to high ( ) ( ) High Health insurance None n/a n/a n/a ( ) c Medicaid n/a n/a n/a ( ) Health insurance (not Medicaid) n/a n/a n/a a Owing to the design of the statistical weight, n values are unweighted and % values are from weighted calculations b Total n value is weighted and includes some missing values c P < 0.05 n/a = not applicable, not measured among those with a mood disorder. In the NCS, history of anxiety disorder or PTSD diagnoses did not have any significant relation with toward help seeking. Lifetime diagnosis of substance use disorder, antisocial personality disorder, and any lifetime mental disorder were associated with negative toward mental health service use. Having sought help in the past for mental illness was correlated with positive toward help seeking. In both countries, the likelihood of having negative was diminished significantly among those who reportedly sought help in the past for emotional problems. Discussion To the best of our knowledge, our study is the first to examine general population Canadian data for toward help seeking for mental illness. The NCS data have been previously analyzed, albeit somewhat differently. 23 A major finding of our study highlights a significant prevalence of The Canadian Journal of Psychiatry, Vol 54, No 11, November

6 Table 3 MHS to the OHS and NCS toward help seeking correlated with any mood disorder, any anxiety disorder, alcohol and subtance abuse or dependence, antisocial personality disorder, any lifetime psychiatric disorder, and any lifetime mental health service use MHS to the OHS (n = 6902) a US NCS (n = 5877) b Variable Negative n = 1306 (%) Positive n = 5572 (%) Unadjusted OR (negative, compared with positive, ) Negative n = 1023 (%) Positive n = 4423 (%) Unadjusted OR (negative, compared with positive, ) Any mood disorder No Yes ( ) ( ) c Any anxiety disorder No Yes ( ) ( ) PTSD diagnosis No n/a n/a n/a Yes n/a n/a n/a ( ) Alcohol and substance abuse or dependance No Yes ( ) c ( ) c Antisocial personality disorder None Yes ( ) c ( ) c Any lifetime psychiatric disorder None ( ) c ( ) c Any lifetime mental health service use No Yes ( ) c ( ) c a Owing to the design of the statistical weight, n values are unweighted and % values are from weighted calculations b Total n value is weighted and includes some missing values c P < 0.05 n/a = not applicable negative toward help seeking in Canada and the United States. We recently reported that barriers to seeking care in both Canada and the United States were largely attitudinal. 11 Amato and Bradshaw 26 have previously shown that selflimiting barriers to seeking care are important determinants of treatment avoidance. The findings of our study complement earlier and more recent investigations of mental health service use and. 3,23,26,32,36 Attitudes toward mental health and treatment appear to be intimately related to perceived need, perceived barriers to seeking help, treatment avoidance, adherence, and dropout. 3,11,23,26,32,36,37 Our analyses agree with earlier conclusions where treatmentseeking behaviours have been associated with female sex, middle age, and marital status (separated, widowed, or divorced). 21,38 Recent studies have clearly identified that young people are less likely to seek help for mental illness. 20,39 41 The findings of our study complement earlier reports where young and socioeconomically challenged men were deemed least likely to receive mental health care. 36 The 762 La Revue canadienne de psychiatrie, vol 54, no 11, novembre 2009

7 Negative Attitudes Toward Help Seeking for Mental Illness in 2 Population-Based Surveys From the United States and Canada NCS finding that lack of health insurance was significantly associated with negative is also important and approximates, expectedly, parallel findings in the low income demographic most likely unable to afford insurance. Previously documented sociodemographics of people most likely to drop out of treatment are consistent with the correlates of negative reported in our study. 3 Crude drop out rates reported by Edlund et al 3 from the NCS (19%) and OHS (17%) closely mirror the prevalence trends of negative toward help seeking in the United States (24%) and Ontario (18%). It is possible that negative toward help seeking may contribute to higher treatment discontinuation. However, such a relation cannot be postulated from cross-sectional data. Another important finding of our study was that people with some mental disorders were more likely to have negative toward help seeking. Previous reports have documented highly prevalent mental disorders in the demographics identified by the current study to have significant negative toward help seeking. 5,21,42 Such findings suggest that people in the greatest need for services have the poorest. To the best of our knowledge, this is the first study in the general population to show this association across 2 surveys. A similar finding was noted in a large survey of US soldiers returning from Iraq. 43 Findings implied that there is a need for outreach to help anyone suffering with mental illness. Our finding that a mood disorder diagnosis among US respondents was associated with a lower prevalence of negative complements earlier reports that similar demographics show increased treatment-seeking behaviours. 21 However, our subgroup analyses did not reveal any statistically significant relation between toward help seeking and diagnoses of mood disorders in Canada. Recent findings from the CCHS 1.2 suggest that the presence of a mood disorder does not significantly impact service use. 44 Additionally, a 2007 report cites no difference between prevalence rates of Canadian and US respondents mental health service use by those with depression. 45 Lack of recent Canadian data about treatment (CCHS 1.2 did not include questions about treatment ) prevents pertinent comparisons. As mentioned earlier, the determinants of toward help seeking are complex but certain sociodemographics have proven to be consistently associated with negative toward help seeking. 2,21,23,36 Significant correlations in our study were shown to exist between alcohol and substance abuse or dependence and negative. The diagnosis of antisocial personality disorder was also associated with considerable propensity toward negative toward help seeking. A strong co-occurrence relation exists between antisocial personality disorder and alcohol and substance abuse or dependence. 46 Recent reports continue to indicate that younger men who never married or are separated, divorced, or widowed are most likely to have alcohol and substance abuse and dependence problems. 47 This group is at high risk for exhibiting overall negative about mental health and should remain a focus of intervention campaigns. People who had used mental health services were significantly more likely to have positive toward seeking care. Owing to the cross-sectional nature of the data, we cannot make causal inferences. However, it is possible that people who had better sought care. On the other hand, it is possible that seeking care improved. The most striking observation may be that despite different health care systems, attitudinal trends for both Canada and the United States appear remarkably similar. However, dissimilarity in mental health treatment seeking among patients with depression from the United States and Canada has previously been reported and postulated to result from differences in health care systems and awareness of available services. 21 While Americans toward help seeking have shown improvements in the previous decade, 23 findings from the CCHS 1.2 indicate that no appreciable increase in helpseeking behaviours took place among people with mood disorder diagnoses. 44 Further follow-up studies of Canadians toward mental health service are necessary to gauge whether similarities in these trends have persisted over time. Nonetheless, we found remarkably similar trends between the 2 countries where treatment were concerned, including concurrence with the earlier finding that Canadians have lower prevalence of negative than Americans. 21 The change in Americans over the last decade has been modestly positive and may herald optimism that an increase in education and availability of psychiatric services has, at least partly, been responsible for such transformations. 23 No recent data is available about help-seeking to suggest that similar changes have also taken place in Canada. Improvements in access as well as increased awareness of existing psychiatric services may be an area that has not yet reached its peak. 23 Policy-makers in both countries paying attention to people s perceptions of mental illness could implement regionally appropriate education, screening, and intervention campaigns to overcome attitudinal barriers to seeking care. The Mental Health Commission of Canada was created partly in response to Canada being the only G8 country without a national strategy to address mental illness. 48 According to The Mental Health Commission of Canada s September 2008 operational plan, a long overdue 10-year anti-stigma The Canadian Journal of Psychiatry, Vol 54, No 11, November

8 and discrimination-reduction campaign is being launched with carefully targeted focus to ensure that appropriate and effective use of resources results in appreciable changes in toward mental illness and services. 48 Future Canadian surveys should include measures of help-seeking to better understand prevalence and trends to increase the effectiveness of anti-stigma strategies. Limitations There are numerous limitations to our study. First, the NCS and the OHS were collected in the early 1990s. Since then, some studies have shown an increase in the number of people with depression seeking treatment. 44,45,49 Mojtabai 23 recently reported that Americans toward mental health treatment seeking have become modestly positive over time. To date, few epidemiologic surveys have collected systematic information about toward help seeking. Such information is particularly lacking for the Canadian population. The CCHS, completed more recently than the OHS, did not collect information about Canadians toward help seeking for mental illness. The most recent data about Canadians toward help seeking for mental illness is contained in the OHS. It would be very useful for future studies to consider the importance of collecting fresh data among the Canadian population to assess current toward help seeking for mental illness. Second, our findings show that having sought treatment in the past was associated with positive. Owing to the cross-sectional nature of the data sets, we could not assess the impact of longitudinal mental health service use on toward help seeking. Mojtabai s 23 findings about positive trends in over the previous decade were the result of a comparison between 2 separate cross-sectional data sets, the NCS and NCS-R (an NCS replication study, not a follow-up of the original sample) and therefore could not posit a causal relation. Analysis of longitudinal studies such as the NCS-2 (a follow-up survey of the original NCS respondents) would be very useful in determining the long-term effects of mental health service use on toward help seeking for mental illness among the same population. Third, cross-sectional data collected did not allow for determination of whether appropriate treatments were offered to, or received by, respondents for their emotional problems. Contact with mental health professionals is highly variable in quality and quantity; and this dimension was not captured in the NCS and OHS surveys. Understanding the true extent of this correlation would require additional inquiries into treatment histories and longitudinal data. Fourth, the applicability of our findings to other populations may be limited by ethnic as well as economic differences. The World Health Organization WMH Survey Consortium reported that the prevalence and unmet need for treatment of mental disorders differed greatly between developed and developing countries. 2 Greater psychopathology was observed in the developed world. 2 The data sets for our study represent the populations of 2 developed nations. Therefore, the findings of our study may not be directly applicable to developing countries. The use of survey data from developing countries would address this limitation. Conclusions Our study presents the prevalence and sociodemographic correlates of negative toward help seeking in 2 large population-based surveys and is the first to present Canadian data of such nature. Remarkably similar trends were observed for the 2 countries examined. Young people in Canada and the United States especially low income, low education, single men who have never sought help in the past for mental illness, have a substance abuse problem and (or) antisocial personality disorder are most likely to have negative toward help seeking for mental illness. We recommend that future studies use longitudinal surveys to explore the relation between sociodemographics, towards help seeking, and mental health service use. 23 The importance of collecting updated Canadian data regarding help-seeking cannot be overstated. Public awareness campaigns such as The Mental Health Commission s anti-stigma campaign are required to reduce negative toward help seeking for mental illness. Acknowledgements Preparation of this article was supported by a Canadian Institutes of Health Research New Investigator Grant (#152348) awarded to Dr Sareen, and a Career Development (K24) Award from the National Institutes of Health (MH64122) to Dr Stein. The authors thank Ms Shay-Lee Belik for her assistance in manuscript preparation. Funding and Support All authors report no conflicts of interest. References 1. Mojtabai R, Olfson M, Mechanic D. Perceived need and help-seeking in adults with mood, anxiety or substance use disorders. Arch Gen Psychiatry. 2002;59: World Health Organization World Mental Health Survey Consortium, Demyttenaere K, Bruffaerts R, et al. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA. 2004;291(21): Edlund MJ, Wang PS, Berglund PA, et al. Dropping out of mental health treatment: patterns and predictors among epidemiological survey respondents in the United States and Ontario. Am J Psychiatry. 2002;159(5): Murray CJL, Lopez AD, World B, et al. The global burden of disease a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020; summary. 1st ed. 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JAMA. 2003;289(23): Manuscript received September 2008, revised, and accepted February Postgraduate Year-3 Psychiatry Resident, University of Manitoba, Winnipeg, Manitoba. 2 Canada Research Chair in Mood and Anxiety Disorders and Professor, Departments of Psychiatry, Psychology and Community Health Sciences, Winnipeg, Manitoba. 3 Professor of Psychiatry and Family and Preventive Medicine and Director of Anxiety and Traumatic Stress Disorders Program, University of California San Diego, San Diego, California. 4 Director of Research; Director of Anxiety Services; Associate Professor of Psychiatry, Community Health Sciences and Psychology, Department of Psychiatry, Faculty of Medicine, University of Manitoba and Health Sciences Centre, Winnipeg, Manitoba. Address for correspondence: Dr J Sareen, PZ Bannatyne Avenue, Winnipeg, MB R3E 3N4; sareen@cc.umanitoba.ca The Canadian Journal of Psychiatry, Vol 54, No 11, November

10 Résumé : Les négatives envers la recherche d aide pour maladie mentale dans 2 sondages de la population aux États-Unis et au Canada Objectifs : Déterminer la prévalence et les corrélats sociodémographiques des négatives à l endroit de la recherche d aide pour maladie mentale dans la population générale aux États-Unis et en Ontario. Méthodes : Deux sondages contemporains menés dans la population (de 15 à 54 ans) ont été analysés : le United States National Comorbidity Survey (NCS) (n = 5877) et l Enquête sur la santé en Ontario (ESO) (n = 6902). Des analyses de régression multiple ont servi à examiner les corrélats d une variable composite des négatives, obtenue par des questions évaluant la probabilité, l aisance et l embarras liés à la recherche d aide pour maladie mentale. Résultats : Les négatives à l endroit de la recherche d aide pour maladie mentale étaient prévalentes dans les deux pays. Quinze pour cent des répondants à l ESO et 20 % des répondants de la NCS ont déclaré qu ils ne chercheraient probablement ou absolument pas de traitement s ils avaient de sérieux problèmes émotionnels. Presque la moitié de ceux qui utilisent des services de santé mentale dans les deux enquêtes ont dit qu ils seraient embarrassés si leurs amis savaient qu ils le font. Les négatives à l endroit de la recherche d aide étaient les plus élevées chez les jeunes hommes défavorisés sur le plan socio-économique, célibataires, et moins instruits en Ontario et aux États-Unis. Dans les deux pays, l abus de substances ou la dépendance à celles-ci et le trouble de la personnalité antisociale étaient associés à des négatives plus marquées, comme l était le fait de n avoir pas cherché de traitement dans le passé. Conclusions : Les négatives à l endroit des services de santé mentale sont prévalents en Ontario et aux États-Unis. Elles sont le plus fréquentes chez les jeunes adultes, surtout ceux au faible niveau d instruction et de ressources socio-économiques, et ceux ayant des problèmes d abus de substances ou de dépendance à celles-ci. Cette information peut servir à cibler les initiatives d éducation qui visent à susciter l accepatation de rechercher des soins pour des problèmes de santé mentale. 766 La Revue canadienne de psychiatrie, vol 54, no 11, novembre 2009