Determinants of attitudes towards professional mental health care, informal help and selfreliance

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1 University of Groningen Determinnts of ttitudes towrds professionl mentl helth cre, informl help nd selfrelince vn Zoonen, Kim ; Kleiboer, Annet; Cuijpers, Pim; Smit, Jn; Penninx, Brend; Verhk, Petrus; Beekmn, Artjn Published in: Interntionl journl of socil psychitry DOI: / IMPORTANT NOTE: You re dvised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Plese check the document version below. Document Version Publisher's PDF, lso known s Version of record Publiction dte: 2016 Link to publiction in University of Groningen/UMCG reserch dtbse Cittion for published version (APA): vn Zoonen, K., Kleiboer, A., Cuijpers, P., Smit, J., Penninx, B., Verhk, P., & Beekmn, A. (2016). Determinnts of ttitudes towrds professionl mentl helth cre, informl help nd self-relince. Interntionl journl of socil psychitry, 62(1), DOI: / Copyright Other thn for strictly personl use, it is not permitted to downlod or to forwrd/distribute the text or prt of it without the consent of the uthor(s) nd/or copyright holder(s), unless the work is under n open content license (like Cretive Commons). Tke-down policy If you believe tht this document breches copyright plese contct us providing detils, nd we will remove ccess to the work immeditely nd investigte your clim. Downloded from the University of Groningen/UMCG reserch dtbse (Pure): For technicl resons the number of uthors shown on this cover pge is limited to 10 mximum. Downlod dte:

2 597014ISP / Interntionl Journl of Socil Psychitryvn Zoonen et l. reserch-rticle2015 Originl Article E CAMDEN SCHIZOPH Determinnts of ttitudes towrds professionl mentl helth cre, informl help nd self-relince in people with subclinicl depression Interntionl Journl of Socil Psychitry 2016, Vol. 62(1) The Author(s) 2015 Reprints nd permissions: sgepub.co.uk/journlspermissions.nv DOI: / isp.sgepub.com Kim vn Zoonen 1,2, Annet Kleiboer 1,2, Pim Cuijpers 1,2, Jn Smit 2,3, Brend Penninx 2,3,4,5, Peter Verhk 6,7 nd Artjn Beekmn 2,3 Abstrct Bckground: Although little is known bout which people with subclinicl depression should receive cre to prevent the onset of depression, it is cler tht remediting symptoms of depression is importnt. However, depending on the beliefs people hold bout help, some people will seek professionl help, while others seek informl help or solve problems on their own. Aims: This study exmined ssocitions between ttitudes bout help nd socio-demogrphic vribles, mstery, severity of depressive symptoms, ccessibility to cre, nd helth cre utiliztion t bseline nd 4-yer follow-up. Methods: Dt were derived from lrge cohort study, the Netherlnds Study of Depression nd Anxiety (NESDA). A totl of 235 respondents with subclinicl depression completed questionnires t bseline nd follow-up. Attitude ws ssessed using short version of the Trust in mentl helth cre questionnire. Results: Positive ttitude towrds professionl cre ws ssocited with being mle, younger ge, higher mstery nd esy ccessibility to cre. Positive ttitude towrds informl help ws ssocited with higher mstery nd unemployment. Older ge, less ccessibility to cre nd lower mstery were ssocited with positive ttitude towrds self-relince. A chnge in cre utiliztion ws ssocited with positive ttitudes towrds professionl cre t follow-up. Conclusions: People differ in the wy they cope with symptoms which my influence their preferred cre. Higher levels of mstery were positively ssocited with professionl nd informl cre, but negtively ssocited with self-relince. Both ge nd mstery showed reltively lrge effect sizes. Keywords Attitude towrds cre, mentl helth cre, informl cre, subclinicl depression Introduction Subclinicl depression is common (Cuijpers, de Grf, & vn Dorsseler, 2004; Horwth, Johnson, Klermn, & Weissmn, 1992), impirs the helth-relted qulity of life of individuls substntilly (Chchmovich, Fleck, Lidlw, & Power, 2008) nd is ssocited with lrge societl burden (Brodhed, Blzer, George, & Tse, 1990). It cn be defined s score bove threshold for depressive symptoms tht fil to meet the dignostic criteri of mjor depression nd/or dysthymi (Cuijpers & Smit, 2004) or s depressed mood ccompnied with less severe symptoms thn those required for Dignostic nd Sttisticl Mnul of Mentl disorders fifth edition (DSM-V) dignosis. Estimtes of the prevlence rtes of subclinicl depression in smples rnge from 2% to 24% (Kessler, Zho, Blzer, & Swrtz, 1997; Rucci et l., 2003) depending on the definition, popultion nd instrument used. 1 Deprtment of Clinicl Psychology, VU University Amsterdm, Amsterdm, The Netherlnds 2 EMGO institute for Helth Cre nd Reserch, VU University Medicl Centre, Amsterdm, The Netherlnds 3 Deprtment of Psychitry, VU University Medicl Centre, Amsterdm, The Netherlnds 4 Deprtment of Psychitry, University Medicl Center Groningen, Groningen, The Netherlnds 5 Deprtment of Psychitry, Leiden University Medicl Center, Leiden, The Netherlnds 6 NIVEL, Netherlnds Institute for Helth Services Reserch, Utrecht, The Netherlnds 7 Deprtment of Generl Prctice, University Medicl Center Groningen, University of Groningen, Groningen, The Netherlnds Corresponding uthor: Kim vn Zoonen, Deprtment of Clinicl Psychology, VU University Amsterdm, vn der Boechorststrt 1, 1081 BT Amsterdm, The Netherlnds. Emil: k.vn.zoonen@vu.nl

3 vn Zoonen et l. 85 Subclinicl depression is n importnt risk fctor for developing mjor depression. Depending on the smple, 20% 34% of people with subclinicl depression develop mjor depression (Cuijpers, Beekmn, Smit, & Deeg, 2006; Hill, Pettit, Lewinsohn, Seeley, & Klein, 2014). Rndomized controlled trils hve shown tht the onset of depression cn be prevented by preventive interventions (Vn Zoonen, Buntrock, et l., 2014). However, few people with subclinicl depression seek help for their symptoms; the number of people tht seeks professionl help is estimted t 1%. Three ctegories of determinnts of help-seeking behviour re often distinguished: need fctors such s severity nd durtion of symptoms, enbling fctors such s orgniztionl fctors, nd predisposing fctors such s personlity nd ttitudinl fctors (Andersen & Newmn, 2005; Anderson, 1973). Need fctors re often less pronounced in people with subclinicl depression, which is n importnt reson for people not to seek help, despite potentil benefits. Thus, people re unlikely to seek help unless other indictors of need become more prominent such s exposure to mjor stressful life event (Druss et l., 2007). Those who perceive need for help without receiving ny re often hindered by ttitudinl brriers (Mckenzie, Erickson, Dene, & Wright, 2014; Vn Zoonen, Kleiboer, et l., 2014). Attitudinl brriers towrds help-seeking include stigm-relted concerns, fers or embrrssment bout reveling personl detils, beliefs tht one should hndle problems by oneself nd beliefs bout the probbility tht service will help resolve problem (Mckenzie et l., 2014). Reserch indictes tht ttitudinl brriers towrds mentl helth services hve become more negtive over time which stresses the need to develop our understnding of help-seeking ttitudes to improve ccess to professionl help (Mckenzie et l., 2014). This study hs exmined determinnts of ttitude towrds mentl helth cre (e.g. professionl mentl helth cre, informl help nd self-relince) in people with subclinicl depression. First, we exmined the reltionship between vrious fctors (e.g. ge, gender, eduction level, mritl sttus, employment sttus, severity of symptoms, mstery, ccessibility to professionl cre, whether or not people hd used professionl cre in the pst) nd ttitudes towrds mentl helth cre. Bsed on the literture, we expected tht older people, femles, people who were mrried, employed, suffered from more severe symptoms nd people who hd lredy used professionl cre in the pst would hve more positive ttitude towrds professionl cre nd/or informl help. Second, we exmined whether chnge in ttitudes between bseline nd follow-up ws relted to chnge in mstery, severity of depressive symptoms nd use of cre. We expected tht chnge in severity of symptoms (e.g. more severe), lower mstery over time nd experience with mentl helth cre would be ssocited with ttitudes towrds professionl cre nd/or informl help. Methods Design, prticipnts nd procedure Dt from the Netherlnds Study of Depression nd Anxiety (NESDA) were used. Detils cn be found in nother pper (Penninx et l., 2008). NESDA ws designed to exmine the long-term course of nxiety nd depression in longitudinl cohort study. In this study, we used dt from wve 1 (bseline) nd wve 3 (4-yer follow-up). Respondents were recruited between September 2004 nd Februry 2007 from the generl popultion, generl prctices nd mentl helth cre centres in Amsterdm, Groningen nd Leiden. Recruitment procedures were the sme cross regions nd recruitment setting. Exclusion criteri included insufficient understnding of the Dutch lnguge nd primry clinicl dignosis of psychitric condition tht ws not the subject of NESDA (e.g. psychotic disorders). Written consent ws obtined from ll respondents. The NESDA protocol hs been pproved by the Ethicl Review Committee of the VU University Medicl Center nd locl bords of every prticipting centre. We included people with score bove 19 on the Kessler 10 (K10) screening instrument (Kessler et l., 2002) who did not meet the dignostic criteri for depression (e.g. dysthymi nd/or mjor depression) or nxiety in the pst 6 months ccording to the Composite Interntionl Dignostic Interview (CIDI) (Andrews & Peters, 1998; Kessler et l., 2002). Those with incomplete dt t one or both ssessments were excluded. A totl of 1089 respondents scored bove 19 on the K10; however, 561 of these respondents (52%) met the criteri for depression in 6 months prior to recruitment. Of the 528 respondents with subclinicl depression, 178 respondents met criteri for current nxiety disorders nd nother 115 respondents hd missing dt, resulting in 235 respondents with subclinicl depression. Instruments Depression screening instrument. The K10 ws used s screening instrument for depressive symptoms (15). This self-report questionnire hs shown to hve good sensitivity nd specificity for detecting people with mjor depressive disorder (Donker et l., 2010). The questionnire consists of 10 questions which re nswered on 5-point rting scle rnging from never to lwys. The Dutch version of the K10 hs good psychometric properties (α = 0.94) (Donker et l., 2010). Dignostic instrument. The CIDI version 2.0 ws used to estblish depression sttus (e.g. mjor depression nd/or dysthymi) in the pst 6 months (Andrews & Peters, 1998). This dignostic instrument ws developed by the World Helth Orgniztion (WHO) for reserch purposes nd ly

4 86 Interntionl Journl of Socil Psychitry 62(1) interviewers. The interview hs shown good psychometric properties for depressive disorders (Andrews & Peters, 1998). Attitude towrds mentl helth cre. To estblish people s ttitude towrds mentl helth cre, we used short version of the Trust in mentl helth cre questionnire (Friele, Verhk, & Andel, 2000). The questionnire consists of five questions: two mesured confidence in professionl help, two mesured confidence in help from fmily/friends nd one single item stting psychologicl problems re best kept to one s self (e.g. self-relince). Items were scored on 4-point rting scle with no (1) to yes (4), with 2.5 s the neutrl no opinion option. This resulted in three types of ttitudes: ttitude towrds professionl cre, ttitude towrds in informl help nd ttitude towrds self-relince (e.g. psychologicl problems cn be best kept to one s self). Demogrphic vribles. Demogrphic vribles (e.g. gender, ge, eductionl level, mritl sttus, employment sttus) were derived from the bseline mesure. Eductionl level ws divided into three ctegories: bsic (e.g. elementry eduction only), intermedite (e.g. lower level voctionl eduction, generl middle level eduction, middle level voctionl eduction, generl secondry eduction) nd high (e.g. higher level voctionl eduction, college/ university eduction). Mritl sttus ws divided into two ctegories: prtner/mrried (1) nd not mrried/no prtner (0). Employment sttus ws recoded into two ctegories: employed (currently employed, self-employed, on sickness benefit, pregnncy/mternity leve nd other) nd unemployed (occuptionlly disbled, erly retirement, unemployed nd other). The other option ws chosen 10 times nd referred to vritions of employed or unemployed. For exmple, officilly employed, but due to work relted conflict t home nd looking for new job. These nswers were recoded into either employed or unemployed. Depressive symptoms. Severity of depressive symptoms ws estblished using the Inventory of Depressive Symptoms (IDS) (Rush et l., 1986). This self-report questionnire contins 30 questions, with 4 nswering options to ech question (scored from 0 to 3). The psychometric properties of the IDS hve shown to be cceptble to good (Gili et l., 2011; Rush, Gullion, Bsco, Jrrett, & Trivedi, 1996). The internl consistency in this study ws good (Cronbch s lph α = 0.77). Accessibility to cre. To estblish perceived ccessibility to helth cre, we used questions from the first prt of the Qulity of cre Through the ptients Eye Questionnire (QUOTE) (Sixm, Kerssens, Cmpen, & Peters, 1998). The QUOTE mesures the qulity of cre s it is delivered from the ptient s point of view nd consists of 36 items. The first prt entils 18 items divided over 6 subscles, including ccessibility, generl prctitioner (GP) cre, ptient centeredness, explntion nd dvice, self-help, effective cre. Items were scored on 4-point rting scle from 1 ( no ) to 4 ( yes ), with the score 2.5 s the neutrl does not know option. This study used the ccessibility subscle tht consists of three items. Higher scores indicte better ccessibility to cre. The relibility in this study ws fir (Cronbch s lph α = 0.68). Cre utiliztion. To estblish whether people hd received cre for their mentl helth problems, question from the QUOTE determines whether respondents hd ever received cre from their GP or other therpist for their mentl helth problems. They could nswer with either yes or no. The sme question ws sked t follow-up. To exmine chnge in help-receiving between bseline nd follow-up, vrible with the possible combintions from the nswers on bseline nd follow-up ws creted. This leds to three possible ctegories: no help received t bseline, but help ws received t follow-up (0), no help received t bseline or follow-up (1) or help ws received t both bseline nd follow-up (2). Locus of control. To exmine locus of control (e.g. mstery), we used the 5-item Perlin nd Schooler (1978) mstery scle. Mstery refers to the feeling to which person perceives himself or herself to be in control of events nd on-going situtions. The questionnire consisted of five items which re rted on 5-point scle rnging from 1 ( strongly disgree ) to 5 ( strongly gree ). This results in totl score between 5 nd 25, where higher rtes indicte more feelings of mstery. In non-institutionlized smple, it hs shown resonble relibility (α = 0.67) (Penninx et l., 1997). However, this study showed good relibility (α = 0.81). Sttisticl nlysis To exmine the ssocition between the determinnts nd ttitude towrds cre (e.g. professionl informl help nd self-relince) t bseline, we first conducted univrite regression nlyses. We creted dummy vribles for eduction (reference ctegory ws bsic eduction). Next, we crried out multivrite multiple regression nlyses to investigte which vrible ws most strongly ssocited with ttitude t bseline. Furthermore, we conducted univrite multiple regression nlyses to exmine whether chnge in ttitude over time ws relted to chnge in other relevnt vribles (e.g. mstery, severity of depressive symptoms nd use of cre). In the regression nlyses, ttitude t 3-yer followup ws the dependent vrible nd bseline ttitude nd other vribles were included s the independent vribles.

5 vn Zoonen et l. 87 Tble 1. Descriptive chrcteristics of respondents. Totl respondents (n = 235) Bseline Follow-up Gender, n (%) Mle 60 (25.5) Femle 175 (74.5) Mritl sttus, n (%) Not mrried/no prtner 68 (28.9) Mrried/prtner 167 (71.1) Eduction, n (%) Bsic 12 (5.1) Intermedite 122 (51.9) High 101 (43.0) Employment sttus, n (%) Pid job 163 (69.4) No pid job 72 (30.6) Accessibility to cre, M (SD) 9.4 (1.8) Age, M (SD) 43.3 (13.4) Use of professionl cre, n (%) No cre used 64 (27.2) 144 (61.3) Cre used 171 (72.9) 91 (38.7) Severity of symptoms, M (SD) 18.8 (8.5) 15.8 (9.7) Mstery, M (SD) 17.7 (3.8) 18.2 (4.2) Not pplicble. We clculted chnge scores between bseline nd followup for mstery nd severity of depressive symptoms. We creted two dummy vribles for use of cre to indicte the direction of chnge between bseline nd follow-up. The reference ctegory ws received cre t follow-up, but not t bseline. Results Smple The verge ge of respondents ws 43 yers, with rnge of yers. Most respondents were femles (n = 175, 74%) nd 26% were mles (n = 60) (Tble 1). More thn hlf of the respondents hd n intermedite level of eduction (n = 122, 52%), 43% of the respondents (n = 101) hd high level of eduction nd only minority hd bsic level of eduction (n = 12, 5%). Most respondents indicted tht they hd used professionl cre for their mentl problems (n = 171, 73%) nd only 64 respondents (27%) indicted never to hve used professionl cre. Associtions between fctors nd ttitude towrds professionl cre t bseline Results showed tht respondents who were younger (b = 20, p <.01), experienced more control over their lives (b = 0.21, p <.01) nd hd high level of eduction (b = 0.37, p <.01) reported more positive ttitude towrds mentl helth cre t bseline (Tble 2). Results from the multiple liner regression showed tht respondents who were mle (b = 13, p <.05), younger (b = 02, p <.01), experienced more control over their lives (b = 0.06, p <.05) nd reported better ccessibility to cre (b = 0.19, p <.01) reported more positive ttitude towrds professionl mentl helth cre (Tble 2). The model ws good fit to the dt, F(10, 224) = 4.34, p <.001; however, only 16% of the vrince ws explined (R 2 =.16). Associtions between fctors nd ttitude towrds informl help t bseline Results of the univrite liner regression nlyses showed tht respondents who experienced more control over their lives (b = 0.17, p <.01) reported more positive ttitude towrds informl help t bseline (Tble 2). Multiple liner regression nlysis showed tht more positive ttitude towrds informl help is ssocited with being unemployed (b = 39, p <.05) nd experiencing more control over one s life (b = 0.04, p <.05) (Tble 2). However, the model ws not good fit to the dt (F(10, 224) = 1.87, p =.05) nd explined only 8% of the vrince (R 2 =.08). Associtions between fctors nd ttitude towrds self-relince t bseline The results of the univrite liner regression nlyses showed tht respondents who were older (b = 0.01, p <.001)

6 88 Interntionl Journl of Socil Psychitry 62(1) Tble 2. Univrite nd multivrite ssocitions with ttitude t bseline. (n = 235) Professionl cre Informl help Self-relince Univrite Multivrite Univrite Multivrite Univrite Multivrite B (SE) b B (SE) b B (SE) b B (SE) b B (SE) b B (SE) b Constnt 4.99 (0.61) *** 4.58 (0.64) *** 2.33 (0.31) *** Gender 0.24 (0.15) (0.14).13* 0.20 (0.15) (0.15) (0.10) (0.10).10 Mritl sttus 0.04 (0.15) (0.14) (0.15) (0.15) (0.10) (0.10).03 Employment sttus 0.24 (0.14) (0.14) (0.14) (0.15).18* 0.10 (0.10) (0.10).03 Age 0.02 (0.01).20** 0.02 (0.01).23** 0.00 (0.01) (0.01) (0.00).25*** 0.01 (0.00).27*** Eduction Intermedite 0.33 (0.30) (0.30) (0.31) (0.31) (0.20) (0.20).04 High 0.75 (0.30).37** 0.49 (0.30) (0.31) (0.32) (0.20) (0.20).11 Use of professionl cre 0.03 (0.15) (0.14) (0.15) (0.15) (0.10) (0.10).11 Mstery 0.06 (0.02).21** 0.04 (.02).16* 0.04 (0.02).16* 0.04 (0.02).16* 0.04 (0.01).20** 0.03 (0.01).17* Severity of symptoms 0.01 (0.01) (0.01) (0.01) (0.01) (0.01) (0.01).01 Accessibility 0.06 (0.04) (0.04).19** 0.01 (0.04) (0.04) (0.03) (0.02).17** Per regression nlyses, B rnged from 5.17 to 6.62 (professionl cre), 4.21 to 5.19 (informl help), 1.19 to 2.25 (self-relince). *p <.05;**p <.01;***p <.001.

7 vn Zoonen et l. 89 nd who experienced less control over their lives (b = 04, p <.01) reported more positive ttitude towrds self-relince (Tble 2). Multivrite nlysis showed tht respondents who were older (b = 0.01, p <.001), experienced less control over their lives (b = 17, p <.05) nd who indicted less ccessibility to professionl cre (b = 17, p <.01) reported more positive ttitude towrds self-relince (Tble 2). The model ws good fit to the dt, F(10, 224) = 4.11, p <.001. However, only 16% of the vrince ws explined by the model (R 2 =.16). Longitudinl descriptive chrcteristics When exmining the possible fctors ssocited with chnge in ttitude (e.g. mstery, severity of symptoms nd cre utiliztion in the pst), most people indicted tht they hd used cre t both bseline nd follow-up (73%), 23% indicted no use of cre t bseline or follow-up, wheres only 4% indicted tht they hd not used cre t bseline, but they hd used cre t follow-up. Most people reported n increse in mstery between bseline nd follow-up (52%), 37% reported lower mstery nd 11% did not report chnge in mstery. Furthermore, most people reported decrese in severity of depressive symptoms (64%), 32% reported n elevtion in depressive symptoms nd 4% reported no chnge in depressive symptoms between bseline nd follow-up. Longitudinl nlysis of vribles on ttitude towrds professionl cre Respondents who hd not used professionl cre (GP or other specilist for mentl problems) t bseline or follow-up reported more negtive ttitude towrds professionl cre t follow-up compred to respondents who hd not used professionl cre t bseline, but who indicted use of professionl cre t 4-yer follow-up (p <.05) (Tble 3). Multivrite stepwise nlysis showed similr results (Tble 3). Both models showed tht positive ttitude t bseline is ssocited with more positive ttitude t followup (p <.001, in both models). Furthermore, the second model, including ll vribles, showed tht respondents who indicted no use of professionl cre t bseline nd followup reported less positive ttitude towrds professionl cre t bseline. The first model ws good fit to the dt, F(1, 233) = 96.13, p <.001 nd explined 29% of the vrince (R 2 =.29). The second model ws good fit to the dt lso, F(5, 229) = 16.33, p <.001 nd explined 32% of the vrince (R 2 =.32). However, the R 2 chnge ws not significnt (p =.07), indicting the model with ll predictors does not explin more of the vrince thn our first model including ttitude t bseline only. Longitudinl nlysis of predictors on ttitude towrds informl help No significnt ssocitions with ttitude towrds informl help t follow-up were found, except for ttitude t bseline (p <.001) (Tble 3). Multivrite nlysis showed similr results, indicting tht ttitude towrds informl help t bseline ws ssocited with ttitude towrds informl help t follow-up (Tble 3). Both models showed good fit to the dt; model 1 F(1, 233) = 42.71, p <.001, nd model 2 F(5, 229) = 10.65, p <.001. The first model explined 16% of the vrince (R 2 =.16), while the second model explined 19% of the vrince (R 2 =.19). Agin, the R 2 chnge ws not significnt (R 2 chnge =.03, p =.05). Longitudinl nlysis of predictors on ttitude towrds self-relince None of the vribles (e.g. mstery, severity of symptoms nd use of professionl cre) were significntly ssocited with ttitude towrds self-relince t follow-up, except for ttitude t bseline (Tble 3). Multivrite nlysis showed n ssocition between ttitude towrds self-relince t bseline nd ttitude towrds self-relince t follow-up only (p <.001). However, both models seemed to be good fit to the dt; model 1, F(1, 233) = 45.55, p <.001, nd model 2, F(5, 229) = 11.31, p <.001). Model 1 explined 16% of the vrince (R 2 =.16) nd model 2 explined 20% (R 2 =.20). The chnge in R 2 of 3% (R 2 chnge =.03) ws significnt (p <.05), indicting the second model ws better fit to the dt thn model 1. Discussion Results Not everyone with subclinicl depression will develop depressive disorder. Therefore, it is importnt to gin better insight into their preferences of coping with their symptoms (Pietrzk et l., 2013). Attitude towrds cre (i.e. professionl cre, informl help or self-relince) is n importnt fctor tht will determine how people will cope with their symptoms. Since no reserch to dte hs focused on ttitudes towrds cre in people with subclinicl depression, this study exmined the influences on ttitude towrds professionl mentl helth cre, informl help nd self-relince in smple with subclinicl depression. Our results show tht being mle, being younger in ge, feeling more control over their lives nd hving esy ccess to professionl cre were relted to more positive ttitude towrds professionl mentl helth cre t bseline. Being mle nd hving more positive ttitude towrds professionl cre contrdicts previous findings tht mles re less likely to seek professionl cre in generl (Jgdeo, Cox, Stein, & Sreen, 2009; Jorm & Wright,

8 90 Interntionl Journl of Socil Psychitry 62(1) Tble 3. Univrite nd multivrite longitudinl nlyses of ttitude. Univrite Multivrite Multivrite B (SE) b Model 1 Model 2 B (SE) b B (SE) b Professionl mentl helth cre Attitude t bseline 0.56 (0.06)*** (0.06)*** 0.55 Chnge in mstery 0.01 (0.02) (0.02) 0.07 Chnge in severity of depressive symptoms 0.00 (0.01) (0.01) 0.04 Chnge in use of professionl cre No experience t bseline, but experience t follow-up No experience t bseline nd follow-up 0.68 (0.31)* (0.23)* 0.28 Experience t bseline nd follow-up 0.39 (0.30) (0.21) 0.17 Informl help Attitude t bseline 0.41 (0.06)*** (0.06)*** 0.38 Chnge in mstery 0.01 (0.02) (0.02) 0.06 Chnge in severity of depressive symptoms 0.01 (0.01) (0.01) 0.07 Chnge in use of professionl cre No experience t bseline, but experience t follow-up No experience t bseline nd follow-up 0.05 (0.35) (0.24) 0.04 Experience t bseline nd follow-up 0.44 (0.33) (0.23) 0.15 Self-relince Attitude t bseline 0.41 (0.06)*** (0.06)*** 0.39 Chnge in mstery 0.02 (0.01) (0.01) 0.07 Chnge in severity of depressive symptoms 0.01 (0.00) (0.01) 0.05 Chnge in use of professionl cre No experience t bseline, but experience t follow-up No experience t bseline nd follow-up 0.36 (0.22) (0.22) 0.20 Experience t bseline nd follow-up 0.12 (0.21) (0.21) 0.06 We controlled for ttitude t bseline. Per univrite regression nlyses, b rnged from: 0.54 to 0.56 (professionl cre); 0.38 to 0.40 (informl help) nd 0.39 to 0.40 (self-relince). *p <.05;**p <.01;***p <.001.

9 vn Zoonen et l ). However, this effect ws reltively smll nd the univrite nlysis did not show significnt effect, indicting tht this result might be cused by n interction with nother vrible. Furthermore, our results seem to support the finding tht younger dults hold more positive beliefs bout professionl cre lthough some inconsistencies in the literture regrding ge s predictor of coping exist (Andrews, Isskidis, & Crter, 2001; Blnd, Newmn, & Orn, 1997; Ten Hve et l., 2010; Verhk et l., 2009). Unemployment nd feelings of more control were ssocited with more positive ttitudes towrds informl help t bseline. Although reserch on informl help-seeking is scrce, previous reserch did not find ny influence of employment sttus (Brown et l., 2014). However, Brown nd collegues included more young dults nd students mong the economiclly inctive, wheres this study included mostly people who were economiclly ctive or employed. A positive ttitude towrds self-relince ws ssocited with older ge, lower feelings of control nd less ccessibility to professionl cre. No studies hve exmined ttitude towrds self-relince; however, the results seem to support findings tht older people prefer to solve problems on their own nd report less positive ttitude towrds professionl cre (Jgdeo et l., 2009; Vn Zoonen, Kleiboer, et l., 2014). Moreover, inccessibility to professionl cre ppers to hve negtive influence on ttitude towrds professionl cre (Fung & Wong, 2007; Mojtbi, 2007); however, it might lso mke people feel tht they should solve these problems on their own resulting in more positive ttitude towrds being self-relint. Respondents, who indicted to hve used professionl cre for their mentl helth problems t follow-up but not t bseline, reported more positive ttitude towrds professionl cre compred to respondents who hd not used professionl cre t either bseline or follow-up. This experience with cre might explin results from other reserch indicting tht people who report using professionl cre re more redily seek cre when they experience problems (Fung & Wong, 2007; Mojtbi, 2007; Verhk et l., 2009). However, these results should be interpreted with cution since this model did not explin more of the vrince thn the model with solely ttitude towrds professionl cre t bseline. Moreover, chnge in mstery, severity of depressive symptoms nd cre utiliztion when controlling for ttitude t bseline were not ssocited with neither ttitude towrds informl help nor ttitude towrds self-relince t follow-up. Since ttitude is very stble construct, it my be difficult to find n effect. Limittions This study hs some importnt strengths, including lrge smple size nd longitudinl design. As fr s we know, this is the first study tht exmines the ssocition in chnge of vribles cross time on chnge in ttitude towrds different types of cre cross time. Therefore, this study provides good first step in better understnding of ttitudes towrds cre in people with subclinicl depression. However, there were certin limittions to this study nd the results should be interpreted in light of these limittions. The definition of subclinicl depression s used in this study does not distinguish between depression in remission nd people who experience depressive symptoms for the first time. However, no cler consensus on the definition of subclinicl depression exists. This cn hve influenced the results since people who hve experienced depression might hve hd more experience with professionl cre. Furthermore, the scle on which the different types of ttitude were bsed ws derived from lrger questionnire, which might hve cused some informtion to get lost. More items my be needed to estblish different types of ttitudes; however, this is often chllenge in epidemiologicl studies. More importntly, this study exmines specific prt of ttitudes tht my be of influence on help-seeking. Finlly, the study uses longitudinl dt bsed on two mesurement points in time since ttitude is firly stble construct; however, it is difficult to identify cusl reltionships. For exmple, it is impossible to identify whether someone sought cre becuse they lredy hd positive ttitude or did the experience with cre positively influence the ttitude. Nonetheless, this study enhnces our understnding bout n importnt fcet of help-seeking tht hs not been exmined before in this high-risk group of people with subclinicl depression. Implictions nd future reserch People with subclinicl depression hve n incresed risk of developing mjor depression. Preventive interventions hve shown to be effective; however, people who re willing to seek cre re often hindered by ttitudinl brriers. It is therefore importnt to increse our understnding of how people with subclinicl depression will cope with their symptoms nd wht, if ny, cre will be sought. Future reserch should replicte the results from this study nd expnd knowledge by differentiting between people who suffer from first-time subclinicl depression nd people who report subclinicl depression fter hving suffered from depressive disorder s this is considered n indictor of need (Druss et l., 2007). This history of depression might influence whether or not people hve experience with different types of cre nd this, in turn, might influence people s ttitudes towrds tht cre. Furthermore, not everyone who suffers from subclinicl depression will need cre (e.g. not everyone will develop depressive disorder) (Cuijpers et l., 2006; Hill et l., 2014). Therefore, future reserch should focus on

10 92 Interntionl Journl of Socil Psychitry 62(1) exmining whether or not being self-relint will suffice in preventing the onset of depression in people with subclinicl depression who indicte more positive ttitude towrds being self-relint nd who hve not sought professionl help. Conclusion Prior reserch hs shown tht ttitude towrds mentl helth cre plys n importnt role in whether or not people seek help. This study shows tht mstery ws the most stble fctor ssocited with ll three ttitudes. Higher levels of mstery were positively ssocited with professionl nd informl cre, but negtively ssocited with self-relince. Both ge nd mstery showed reltively lrge effect sizes. Furthermore, it is importnt to exmine whether being self-relint is sufficient in preventing the depressive symptoms from converting into depressive disorder. Acknowledgements The infrstructure for the NESDA study is funded through the Geestkrcht progrm of the Netherlnds Orgniztion for Helth Reserch nd Development (Zon-MW, grnt number ) nd is supported by prticipting universities nd mentl helth cre orgniztions (VU University Medicl Center, GGZ ingeest, Arkin, Leiden University Medicl Center, GGZ Rivierduinen, University Medicl Center Groningen, Lentis, GGZ Frieslnd, GGZ Drenthe, IQ Helthcre, Netherlnds Institute for Helth Services Reserch (NIVEL), nd the Netherlnds Institute of Mentl Helth nd Addiction (Trimbos)). Declrtion of Conflicting Interests The uthor(s) declred no potentil conflicts of interest with respect to the reserch, uthorship, nd/or publiction of this rticle. 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