Discussion
This study investigated the PtC for suicidal adolescents entering a tertiary suicide prevention service, and the impact of caregiver prior suicidality and mental health treatment on onset duration and treatment delay. Consistent with previous research (e.g., Hodgekins et al., 2017), participants experienced significant delays averaging 48.0 weeks from the onset of problem to obtaining suicide prevention treatment. Results revealed that most commonly there were three contacts in the PtC, with parents and the individual young people themselves most likely to recognise the onset of suicidality. The findings suggested that with regard to professional sources, the majority of young people seek help from their general practitioner, followed by psychologists and emergency services, indicating the important roles health services play in providing suicidal adolescents with treatment and/or onward referral. Additionally, longer treatment delays in reaching the suicide prevention service were related to higher numbers of contacts in the PtC. This suggests that attempts at addressing the young person’s difficulties through other sources may delay the overall time it takes to reach the specialist SP service. The current study cannot clarify whether these earlier contacts were appropriate or efficient, in that they promptly referred the young person to the next level of care if they were beyond the expertise of the contact or not making progress. Further, the current study does not account for those young people who were successfully supported by earlier sources of help before requiring referral to the specialist suicide prevention program. The current study only reveals information about those who needed further treatment.
Bivariate correlations indicated that young people whose caregivers had prior mental health treatment had lower numbers of contacts. This would be consistent with a situation where caregivers’ knowledge of the service system as a function of having navigated and utilised it themselves might mean that a more direct route to specialist suicide prevention program results. However, the multiple regressions indicated that the hypothesis that caregiver prior mental health treatment would be associated with shorter onset duration or delays in treatment was not supported. This may be due to the number of contacts being only weakly related to treatment delays. Instead, caregiver prior suicidality appeared to have a negative impact on the treatment delay, such that adolescents whose caregivers reported prior suicidality were more likely to experience longer treatment delays in reaching the SP service. It is unclear why this might be the case and in an effort to better understand these relationships we explored potential interactions with age and gender.
The current study found that the relationships between caregiver prior suicidality and both onset duration and treatment delays were moderated by age of the young person. In short, higher prior caregiver suicidality was related to higher delays but only for older age groups. It is possible that greater parental involvement with younger adolescents who have suicidality evokes greater urgency amongst parents which speeds the referral process.
Prior research has found that as a young person progresses through adolescence, their parents become less prominent and there is a greater need for autonomy and to handle their problems independently (Gould, et al., 2004; Wilson, Deane, & Ciarrochi, 2005a). Reduced parental involvement and greater independence may explain the longer delays in treatment for older adolescents but we can only speculate as to why caregiver prior suicidality is associated with higher treatment delay. It may be that older adolescents are more aware of their caregivers prior suicidality and they may perceive that prior professional help seeking was not helpful for them, so they delay their own treatment. Alternatively, older adolescents may have poorer communication with caregivers who have experienced suicidality which reduces any influence caregivers might have in the help seeking process. There is a need for future research to explore the potential dynamics that may be at play that determines why caregiver prior suicidality might be associated with longer treatment delays in older age groups. In the meantime, general strategies such as increasing young peoples’ mental health literacy including that treatment can be helpful may facilitate help-seeking behaviour (Logan & King, 2001; Rickwood, Deane, Wilson, & Ciarrochi, 2005).
Our results suggested that suicidal adolescents whose caregiver has a prior experience of suicidality or self-harm will experience longer durations between contact with other professionals and reaching a specialist suicide prevention service. A similar result was found in a population with psychosis (Norman et al., 2007), where a history of psychotic disorder in family relatives was associated with longer delays in treatment, despite the relative being more likely to recognise the need for help for the unwell individual. In contrast, Chen et al. (2005) looked at family relatives who had received psychiatric treatment, and found that previous family experience of treatment was related to reduced delays in Hong Kong adolescents accessing treatment for psychosis. This disparity may in part be due to the prominent role that families play in the lives of adolescents, even older adolescents in Hong Kong. Given our findings suggest that prior caregiver suicidality may have a negative role on the PtC of suicidal adolescents, future research is needed to clarify why prior experience of suicidality is related to longer delays. It may be that prior experiences are predominantly perceived as being negative or unhelpful which then increases the reluctance of parents to pursue professional services. Studies have found that the perceived helpfulness of prior help-seeking is related to future help-seeking intentions (e.g., Cusack et al., 2006,r = .32) and attitudes towards help-seeking .
Our results revealed that gender was significantly associated with onset duration and treatment delays with females having significantly longer delays than males. Moderation analyses also showed that relationship between number of contacts and treatment delays was significant for females but not males. Thus, the number of contacts appeared to increase delays for females. It is possible that the range of informal supports (e.g., friends/family) that females are willing or able to access is higher than for young males and this contributes to higher numbers of contacts and subsequent delays. In general, women and girls have more positive help seeking attitudes and are more like to seek help, it is possible that for young men they do not reveal their suicidality as early and wait to initiate help seeking only at the point where their suicidality is high and acute. This may result in higher perceived risk and a more direct route to tertiary suicide prevention programs.
Interestingly, caregivers with a prior experience of treatment did not have a significant impact on treatment delay, help-seeking delay or onset duration. We expected that greater familiarity with mental health service systems may be related to shorter delays in getting a young person to help. There are several possibilities for this lack of relationship. As noted above, it may be that prior help seeking was viewed as unhelpful. For example, Ten Have et al. (2010) found that 32% of a large European sample who had previously used mental health services perceived seeking professional help for serious mental health as worse than or equivalent to no help. Perceptions of treatment being unhelpful may nullify any effects of caregiver familiarity on help-seeking behaviour (Velasco, Santa Cruz, Billings, Jimenez, & Rowe, 2020). Future research should seek to assess the perceived helpfulness of prior help-seeking and professional service use, in order to determine the efficacy of treatments applied in the professional sector and to encourage providers to learn from patient’s experiences of care.
The results also identified a delay in treatment of over 9 months once engaged within professional/formal contacts. It could be argued that the greatest delay in the pathway to care for suicidal adolescents exists once they have engaged professional contacts. This delay may be a result of multiple processes, such as the lack of clarity professionals may have about the adolescent’s problem and what is required. Professional contacts attempting to treat the problem before recognising the need for tertiary referral to a specialist service may contribute to delays in treatment. As adolescents develop mental health problems, it is possible that emerging symptoms are interpreted as typical teenage behaviour, leading to inappropriate services or lack of onward referral . The role of professional services, particularly general practitioners, is well recognised and increased training and knowledge is vital to improve recognition and response to psychological distress (Pfaff, Acres, & McKelvey, 2001; Wilson, Deane, Marshall, & Dalley, 2010). Some initial contacts may also be more desirable to adolescents as they utilise lower intensity treatments. Professionals, such as school counsellors, may help many adolescents resolve the problems that underlie their suicidality, but there may also be a proportion where problems worsen such that suicide risk remains. Under these circumstances there are likely to be longer delays getting to specialist services.