Abstract
Efforts to prevent anxiety and depressive disorders are considered a public health priority. However, emerging adults (ages 18–25) have traditionally been overlooked in the prevention literature. Recent suggestions to improve the design and evaluation of prevention programs propose a shift toward targeting and assessing changes in underlying mechanisms and protective factors that might buffer against the onset or worsening of symptoms and promote emotional well-being. In this conceptual paper, we aim to further this discussion on the optimal targets and goals of prevention programs and how best to tailor these programs to meet the needs of emerging adults. We first provide a brief overview of the prevention literature for depressive and anxiety symptoms among emerging adults. We then present an argument for expanding the focus of prevention programs to include an emphasis on factors affecting help-seeking intentions and behaviors as explicit targets. We argue this could improve the effectiveness and long-term impact of prevention efforts and provide a way to tailor programs to the unique developmental period of emerging adulthood. We propose that prevention programs should strive to target both mechanisms underlying depressive and anxious symptomatology, as well as those affecting help-seeking behaviors to arm emerging adults with the knowledge and tools necessary to effectively manage their mental health needs. To this end, we outline a number of processes to prioritize and target in order to promote help-seeking in the context of prevention.
Anxiety and depressive disorders are the most prevalent psychological disorders across all developmental stages (Kessler et al., 2012; National Institute of Mental Health, 2017, 2019; Whiteford et al., 2013) and are associated with significant distress and impairment. Efforts to prevent depressive and anxiety disorders have been considered a public health priority for the past several decades (World Health Organization, 2008). A robust literature supports the effectiveness of prevention efforts, most of which focus on children and adolescents (Ahlen et al., 2015; Christensen et al., 2010; Feiss et al., 2019; García-Escalera et al., 2020; Neil & Christensen, 2009; Werner-Seidler et al., 2021). Universal, selective, and indicated prevention programs targeting symptoms of anxiety and depression in children and adolescents appear to be generally effective, with some evidence suggesting that targeted prevention programs (i.e., delivered among individuals who are at-risk or report symptoms) might be most effective (e.g., Werner-Seidler et al., 2021).
The past two decades have seen an increase in the recognition of another developmental period marked by heightened risk for the onset of depressive and anxiety disorders: emerging adulthood (Arnett, 2000; Kessler, Berglund, et al., 2005; Kessler, Chiu, et al., 2005). Considered a distinct developmental period from adolescence and adulthood, emerging adulthood spans the ages of 18 through 25 and is characterized by transition, change, and exploration in a number of areas of life (Arnett, 2000; Arnett et al., 2014). As defined in Western cultures, emerging adulthood is marked by the introduction of new stressors, which often include establishing autonomy from family systems, forming new relationships, adjusting to new social environments, coping with the demands of school or work, and independently managing these new personal, academic, and social demands (Arnett, 2000; Arnett & Mitra, 2020; Conley et al., 2013). Epidemiological data on the median age of onset of a majority of mental health disorders, including anxiety and depression, indicate that most mental health problems develop before or during emerging adulthood (Kessler, Berglund, et al., 2005). For many individuals, emerging adulthood will therefore coincide with the onset of depression and anxiety (Auerbach et al., 2016). Rates of depression, anxiety, and related problems are also high among this age group. Data from the 2021 American College Health Association National College Health Assessment Report (ACHA NCHA) indicate that 23.6% of college students reported receiving a lifetime diagnosis of a depressive disorder, 29.1% reported receiving a lifetime diagnosis of an anxiety disorder, and 19.3% reported receiving diagnoses of both (American College Health Association, 2021). Furthermore, in the 2019 ACHA NCHA Report, 65.7% of students reported feeling “overwhelming anxiety,” 70.8% reported feeling “very sad,” and 55.8% reported feeling “hopeless” sometime in the past 12 months (American College Health Association, 2019). These estimates are consistent with those from the National Comorbidity Survey Replication (NCS-R) Study, which included emerging adults outside of the college context (National Comorbidity Survey, 2007).
In light of these estimates, increasing calls for prevention efforts to specifically target this age group have been issued (Schwartz & Petrova, 2019). However, this developmental period has traditionally been overlooked in the prevention literature (Conley et al., 2013). Existing research on prevention programs for emerging adults focuses almost exclusively on college students and programs have historically placed a heavy emphasis on substance use, risky behaviors, body image, and eating concerns (Conley et al., 2013; Farrer et al., 2013; Reavley & Jorm, 2010). More recently, increasing attention has been placed on developing strategies to prevent the onset or worsening of depression and anxiety in this population. Several comprehensive systematic reviews and meta-analyses have concluded that, on average, prevention programs for anxiety, depression, and stress among college students during emerging adulthood are associated with moderate effect sizes (e.g., Conley et al., 2013, 2015; Rith-Najarian et al., 2019).
A common characteristic across prevention programs is their stated goal: to prevent the onset or reduce the worsening of depressive and anxious symptoms. However, more recent thinking on the goal of prevention programs has proposed a shift in (a) what the targeted mechanisms of these programs should be and (b) how to define program outcomes and assess effectiveness (Zalta & Shankman, 2016). This line of thinking is consistent with a shift away from categorical, disorder-based targets toward programs that target common underlying mechanisms that contribute to the onset and maintenance of a range of diagnoses. For example, difficulty identifying and regulating emotions has been proposed as a shared mechanism that explains the development and maintenance of both depression and anxiety (Berking et al., 2014; McLaughlin et al., 2011). Therefore, a prevention program could target a specific mechanism (i.e., emotion regulation) to improve a range of outcomes simultaneously (i.e., symptoms of depression and anxiety). This approach is rooted in a transdiagnostic framework to understanding and treating psychopathology (Zalta & Shankman, 2016). In addition to shifting the proposed targets, this approach offers a broader framework through which the effectiveness of prevention programs can be assessed. Traditionally, the effectiveness of prevention programs has been determined by measuring outcomes such as incidence rates of the onset of psychological disorders and the presence of symptoms of anxiety and depression following the program. Evaluating programs from a transdiagnostic perspective expands measured outcomes to include underlying mechanisms and protective factors that might buffer against the onset or worsening of psychopathology and promote emotional well-being.
In this conceptual paper, we aim to (a) further the discussion on the optimal targets and desired outcomes of prevention programs and (b) suggest ways to tailor these programs to best meet the needs of emerging adults. We first provide a brief overview of the prevention literature for depressive and anxiety symptoms among emerging adults. Specifically, we draw from published research studies, systematic reviews, and meta-analyses to comment on broad trends with regard to the types of programs used, their associated delivery formats, the targets of these programs, and the outcomes assessed to determine their effectiveness. Next, we propose that prevention programs should strive to target mechanisms that underlie depressive and anxious symptoms, as well as mechanisms that affect help-seeking behaviors, to arm emerging adults with the knowledge and tools necessary to effectively manage their mental health needs. We present an argument for expanding the focus of prevention programs to include an emphasis on help-seeking intentions and behaviors as desired outcomes. We argue that placing an emphasis on increasing help-seeking behaviors is a way to improve the effectiveness and long-term impact of prevention programs while simultaneously tailoring these programs to the unique developmental period of emerging adulthood.
A Brief Overview of the Literature on Preventing Anxiety and Depression in Emerging Adults
Program Types and Delivery Formats
Most prevention programs for depressive and anxiety symptoms for emerging adults are based on cognitive behavioral therapy (CBT) approaches, and available data supports the overall effectiveness of universal, selective, and indicated CBT-based programs in reducing symptoms of depression and anxiety for at least several months post-intervention (Buchanan, 2012; Conley et al., 2013, 2015; Reavley & Jorm, 2010; Rith-Najarian et al., 2019). Under the umbrella term of CBT, there are programs based on traditional CBT and other CBT-based programs that can be described as acceptance-based behavioral therapies (ABBTs; Roemer & Orsillo, 2020). ABBTs are CBT programs that include a focus on cultivating acceptance and mindfulness-based skills. Evidence supports the effectiveness of these programs as prevention interventions, including those based on acceptance and commitment therapy (ACT; e.g., Levin et al., 2016, 2017; Räsänen et al., 2016), an ABBT specifically developed for generalized anxiety disorder (e.g., Danitz et al., 2016; Danitz & Orsillo, 2014; Eustis et al., 2017, 2018), and mindfulness-based programs (e.g., Dvořáková et al., 2017). Among these CBT-based programs, skills-based programs that systematically teach cognitive and behavioral techniques to cope with emotions (as opposed to purely psychoeducational programs) offer the most promise in reducing symptoms of depression, anxiety, and stress, as well as improving social skills, enhancing self-perceptions, and improving academic behaviors and performance (Conley et al., 2013, 2015). Programs that provide supervised practice of new skills, which include facilitating behavioral rehearsal and providing supportive feedback, demonstrate the strongest benefits. Research suggests that these supervised programs are over seven times more likely to obtain significant positive results as compared to purely psychoeducational initiatives (Conley et al., 2013, 2015). The most commonly used practice elements in these programs include physiological skills (e.g., relaxation, physical exercise, biofeedback), metacognitive skills (e.g., cognitive restructuring, mindfulness, self-monitoring), and behavioral skills (e.g., problem-solving, communication skills, exposure, behavioral activation, values-based actions, time management, sleep hygiene, assertiveness training; Rith-Najarian et al., 2019). Non-CBT-based prevention programs have focused on peer support, psychoeducation, personalized feedback, expressive writing, exercise/physical activity, and meditation or relaxation. Evidence for the effectiveness of these non-CBT-based programs at reducing symptomatology and promoting well-being is mixed (Buchanan, 2012; Reavley & Jorm, 2010).
Across different modalities, the two most commonly used delivery formats are in-person, group-based programs and digital programs delivered via the internet (Conley et al., 2013; Davies et al., 2014; Farrer et al., 2013; Rith-Najarian et al., 2019). In-person group formats have demonstrated effectiveness in reducing symptoms of anxiety and depression and range from single-session workshops (e.g., Bentley et al., 2018; Danitz et al., 2016; Eustis et al., 2017) to multiple-session groups (e.g., Bettis et al., 2017; Dvořáková et al., 2017; Greeson et al., 2014; Kaya & Avci, 2016; Topper et al., 2017). Systematic reviews and meta-analyses of digital prevention programs report growing evidence to support the effectiveness of these programs in reducing symptoms of depression, anxiety, and stress, with slightly greater effect sizes among programs that target anxiety specifically (Davies et al., 2014; Farrer et al., 2013). The majority of these programs tend to be self-administered with varying levels of human support and are rated as highly usable, satisfactory, credible, and helpful by users (Davies et al., 2014).
Program Targets and Outcomes
In line with a recent shift in the prevention literature toward a more transdiagnostic approach (Zalta & Shankman, 2016), many studies target common risk factors for anxiety and depressive disorders and mechanisms that are believed to underlie depressive and anxious symptomatology. Rather than creating programs that target problem- or disorder-specific mechanisms, which can result in the need for multiple programs to target risk factors for co-occurring conditions, transdiagnostic efforts rely on the targeted modification of shared risk factors to prevent multiple manifestations of psychopathology with a single intervention (Feldner et al., 2004; Zalta & Shankman, 2016). Although anxiety prevention programs are often transdiagnostic in application (i.e., they address the range of anxiety disorders), this explicitly transdiagnostic approach to prevention is thought to be more effective and cost- and time-efficient. It also lends itself well to the widespread dissemination of prevention efforts (Zalta & Shankman, 2016).
Among published studies that are described as transdiagnostic, the shared underlying mechanisms that are targeted include emotion regulation difficulties, which the authors label as “neuroticism” (Bentley et al., 2018; Castro-Camacho et al., 2021; Sauer-Zavala et al., 2021), anxiety sensitivity (Kenardy et al., 2003), repetitive negative thinking (Topper et al., 2017), and a series of other risk factors (i.e., perfectionism, low self-esteem, trait anxiety/worry, emotion regulation difficulties; Musiat et al., 2014, 2019). Emotion regulation is a common transdiagnostic factor among these prevention programs, consistent with the literature identifying emotion regulation difficulties as a risk factor for depression and anxiety (Berking et al., 2014; McLaughlin et al., 2011). Under the umbrella of emotion regulation, certain programs target specific emotion regulation strategies (e.g., repetitive negative thinking, worry), whereas others focus more broadly on how individuals relate to and regulate their emotional experiences. This latter category includes mechanisms such as anxiety sensitivity (i.e., the belief that symptoms of anxiety are dangerous; Kenardy et al., 2003) and experiential avoidance (i.e., rigid attempts to control or avoid unwanted internal experiences; Eustis et al., 2018). Common components of these programs include CBT-based psychoeducation (e.g., highlighting connection between thoughts, physical sensations, and emotions) and awareness building, along with CBT skills to decrease experiential avoidance and promote emotion regulation, including mindfulness and acceptance practices, cognitive skills (e.g., cognitive restructuring, cognitive defusion), and behavior change skills (e.g., behavioral activation, values-based actions, and exposure practices).
Although not explicitly described as transdiagnostic, other programs also target mechanisms that are transdiagnostic, given that their conceptual models focus on helping individuals change how they respond to their internal experiences. These include ABBT-based programs (Danitz & Orsillo, 2014; Danitz et al., 2016; Eustis et al., 2017, 2018; Levin et al., 2016, 2017; Räsänen et al., 2016). Although some of these programs are described as focusing on a specific symptom area (e.g., anxiety), the conceptual model and skills within the programs could be applied more broadly to experiences with other emotions.
The shift toward a transdiagnostic approach to prevention holds implications for the selection of outcome criteria upon which prevention programs are evaluated (Zalta & Shankman, 2016). Prevention efforts that are based on categorical definitions of psychological diagnoses often define program success as a reduction in the incidence of, or a delay in the onset of, a particular set of diagnoses. Zalta and Shankman (2016) propose to expand these outcome criteria to include clinically significant reductions in symptomatology, reductions in factors that underlie psychopathology (referred to as a prevention-mechanism approach), and the strengthening of factors that protect against psychopathology and promote emotional well-being. When examining the stated outcomes of prevention efforts, a majority explicitly list symptoms of anxiety, depression, and stress as their primary outcomes (Rith-Najarian et al., 2019); others provide a broad overview of their intended outcomes, such as general psychological well-being, psychological distress, and a range of psychological problems (Danitz et al., 2016; Danitz & Orsillo, 2014; Levin et al., 2017). Nonetheless, many programs now also include measures of proposed mechanisms (e.g., emotion regulation difficulties) as part of their outcomes, in line with the abovementioned prevention-mechanism approach. Still other programs focus on related outcomes such as sleep difficulties (e.g., Greeson et al., 2014), positive mental health (e.g., Greeson et al., 2014; Levin et al., 2016), and academic difficulties (e.g., Melnyk et al., 2015).
Limitations of the Existing Literature
Despite increasing evidence of the effectiveness of prevention programs, reviews have highlighted multiple limitations of this literature. Two important limitations include a lack of data on the long-term efficacy of prevention efforts and the minimal tailoring of prevention programs to the specific needs of emerging adults. Although many studies show positive effects immediately after and for several months following the programs, most prevention programs do not include follow-up assessments (Christensen et al., 2010; Conley et al., 2013, 2015) and no studies to date extend assessments past 1 year after the end of the program. Additionally, few studies directly measure the retention of study-related information (e.g., remembering the content of psychoeducation or the skills taught over the course of a program) or the continued use of skills learned following the end of the program. Prior reviews of skill-based prevention programs for college students have pointed to skill acquisition as a potential mediator of program effectiveness, but their conclusions were limited by the relative dearth of studies that formally assess skill-use and its relationship to program outcomes (e.g., Conley et al., 2013, 2015). The absence of available data limits our ability to examine the long-term impact of these prevention initiatives. Furthermore, despite a push to tailor programs to meet the specific needs of emerging adults, most existing programs are not specifically designed for this age group and might not include content relevant to this population (e.g., coping with demands of school or work, identity exploration, establishing autonomy from family systems, striving for independence, forming new relationships; Farrer et al., 2013). Therefore, additional research is needed to assess and enhance the long-term impact of these programs, as well as to tailor them to the needs of emerging adults. Below, we discuss how targeting help-seeking intentions and behaviors in the context of prevention efforts might offer an opportunity to address these two limitations.
A Case for Targeting Help-Seeking in the Context of Prevention
Why Should We Target Help-Seeking in the Context of Prevention?
Help-seeking has been defined as “an adaptive coping process that is the attempt to obtain external assistance to deal with mental health concerns” (Rickwood & Thomas, 2012, p. 180) and can include informal (e.g., friends, family) or formal (e.g., mental health professionals, religious leaders, crisis helplines) sources. Given the effectiveness of formal mental health treatment for depression and anxiety (American Psychological Association, 2012), and among emerging adults specifically (e.g, Cuijpers et al., 2016; Huang et al., 2018), we propose expanding the focus of prevention programs to include help-seeking. This expansion is one potential pathway to improve prevention program effectiveness and the long-term impact of these programs, while simultaneously tailoring them to the needs of emerging adults.
Rates of Help-Seeking Among Emerging Adults Are Low
Targeting factors that impact help-seeking is especially relevant as ample data suggest that only a small proportion of emerging adults with mental health concerns seek help. Data from a large epidemiological survey of college student mental health across 21 countries reported that only 16.4% of students with a mental health concern sought help in the past year (Auerbach et al., 2016). Similarly, in a review of help-seeking among college students, Eisenberg et al. (2012) surveyed epidemiological data on student help-seeking and found rates of service use ranging from 18% to 36% among individuals with mental health concerns, a finding consistent with the broader literature (Gulliver et al., 2010; Hunt & Eisenberg, 2010; Lipson et al., 2019). Help-seeking behaviors were more common among women and White students, and seeking help from informal sources (e.g., peers and family members) was more common than seeking help from professionals (Eisenberg et al., 2012; Lipson et al., 2018; Yu et al., 2008). The underutilization of mental health services is especially common among minoritized and marginalized populations, including students of color, in part due to a lack of culturally responsive healthcare, experiences of racism and discrimination, a mistrust of mental health professionals based on a history of mistreatment of people of color in healthcare settings, higher levels of stigma, unfavourable attitudes toward seeking professional psychological help, and lower perceived need for treatment (e.g., Kam et al., 2019). These low rates of treatment-seeking and concerns about equity underscore the discrepancy between the need for effective and culturally responsive mental health care and help-seeking behaviors among emerging adults (e.g., Yu et al., 2008).
Targeting Help-Seeking Could Improve The Long-Term Impact of Prevention Programs
Data on prevention programs suggest that we cannot prevent the onset or worsening of psychological distress for all emerging adults (e.g., Buchanan, 2012; Conley et al., 2015; Reavley & Jorm, 2010; Rith-Najarian et al., 2019). As such, prevention programs should expand the scope of their targets to include factors that will help individuals better manage their mental health needs in the long term (i.e., if and when symptoms do develop or worsen). In doing so, these programs could improve their long-term impact by providing individuals with the tools and knowledge needed to seek help. If individuals understand how to connect with mental health resources prior to the onset of diagnosable depressive and anxiety disorders, it stands to reason that this knowledge would help improve long-term outcomes for emerging adults by preventing the worsening of symptoms over time while simultaneously empowering individuals to learn how to manage their mental health. As such, knowledge and skills associated with help-seeking can be conceptualized as protective factors against the onset, recurrence, or worsening of psychological distress over time. This conceptualization is consistent with Zalta and Shankman’s (2016) call to expand prevention program outcomes to not only include the reduction in symptoms and mechanisms that underlie psychopathology, but also the strengthening of factors that protect against psychopathology and promote emotional well-being over time by increasing the likelihood that emerging adults will seek out and receive effective interventions for anxiety and depression. To date, very few studies of prevention programs for depressive and anxiety disorders among emerging adults formally assess help-seeking intentions or behaviors following the end of the program. In one study that did assess help-seeking post-intervention, about one-third of individuals who participated in a self-help prevention program for depression reported seeking more information about depression and treatment, trying self-help interventions, and offering advice about depression to others following the program (Lintvedt et al., 2013). Although these preliminary data are promising, there is a relative dearth of data on help-seeking intentions and behaviors following prevention programs. Further, to our knowledge, no prevention programs explicitly target mechanisms that influence help-seeking. Nonetheless, there is increasing recognition of the importance of measuring help-seeking intentions and behaviors in the context of prevention efforts (Davies et al., 2014; Rüsch & Thornicroft, 2014).
Targeting Help-Seeking Could Help Tailor Prevention Programs to the Needs of Emerging Adults
Emerging adulthood marks a developmental period in which many individuals begin to experience independence in their help-seeking decision-making for the first time (Rickwood et al., 2007). College students report an understanding of how the transition from adolescence to adulthood is associated with increased responsibility for their own well-being and welfare (Laidlaw et al., 2016). However, this transition to emerging adulthood may come with a number of barriers to seeking appropriate care (Laidlaw et al., 2016; Yu et al., 2008), including gaps in insurance coverage, transitions away from established support systems (e.g., schools, families), difficulties establishing consistent care, and a general lack of knowledge and resources needed to independently make decisions about one’s own mental health needs. Evidence shows that rates of mental health care use are lower among young adults as compared to adolescents, suggesting that young adults face additional barriers to service use that may be rooted in the transition from adolescence to adulthood (Yu et al., 2008). Capitalizing on prevention programs to target individual factors that influence help-seeking could help facilitate this transition into emerging adulthood and represent a developmentally appropriate and needed intervention for this age group.
Targeting Help-Seeking Could Improve The Effectiveness of Prevention Programs
Emerging research suggests that some mechanisms underlying depressive and anxious symptomatology are also associated with help-seeking intentions and behaviors. For example, limited emotion awareness and limited perceived availability of emotional coping strategies are associated with lower levels of help-seeking intentions and greater symptoms of anxiety, depression, and stress (Ward-Ciesielski et al., 2019), such that emotional awareness and coping may affect both the need for help and a person’s ability or willingness to seek it out (Ward-Ciesielski et al., 2019). Similarly, higher levels of mental health self-stigma (i.e., when an individual identifies as a member of a stigmatized group, Vogel et al., 2013) are associated with more severe psychological symptoms (Busby Grant et al., 2015) and delayed help-seeking (González-Sanguino et al., 2021). Therefore, targeting these shared factors that influence help-seeking would likely have a positive impact on symptoms, with the added benefit of increasing the likelihood that individuals in need of additional services seek help. It is also possible that targeting factors associated with help-seeking could improve engagement with prevention programs. Some of these factors include attitudes toward mental health and treatment, including self-stigma (which is associated with lower self-efficacy and hope, Livingston & Boyd, 2010), and individuals’ perceived need for treatment. Taken together, targeting self-stigma in the context of prevention programs could improve the effectiveness of prevention programs by altering factors associated with individuals’ ability to engage with and learn from these programs (e.g., self-efficacy, hope, perceived need for help), as well as their perceptions of the utility of prevention programs (Rüsch & Thornicroft, 2014).
Summary
Targeting factors that influence help-seeking could improve the effectiveness of prevention efforts by improving factors associated with symptom reduction and program engagement. Targeting factors that influence help-seeking could also enhance the long-term impact of these programs by offering emerging adults the tools and knowledge needed to seek help, while simultaneously tailoring them to the needs of emerging adults by facilitating the transition into independence with regard to healthcare decision-making.
What Should We Target to Promote Help-Seeking in the Context of Prevention?
Models of the Help-Seeking Process
Understanding the various steps involved in help-seeking for mental health problems is necessary to identify potential mechanisms that can be targeted as part of prevention programs. Research suggests that intentions to seek help and actual help-seeking behaviors are related but distinct components of the help-seeking process, underscoring the importance of models that capture both factors. Saunders’ (1993) model outlines the process of seeking professional treatment for mental health problems, which unfolds over four steps: (a) recognizing the problem, (b) deciding that professional help is needed, (c) deciding to seek help, and (d) seeking treatment. Saunders and Bowersox (2007) expanded on this model to include three additional steps: (a) recognizing that the problem is mental health related, (b) deciding that change is necessary, and (c) engaging in self-help efforts prior to deciding to seek treatment. This model is consistent with other behavior change theories (e.g., information-motivation-behavioral skills model, Chang et al., 2014; theory of planned behavior, Tomczyk et al., 2020) of health behaviors (which include help-seeking). Each theory posits some combination of (a) problem recognition, (b) readiness and ability to seek help, (c) willingness to seek help, and (d) engaging in help-seeking behaviors. Studies examining how these steps unfold over time have highlighted that problem recognition, followed by the decision that professional help is needed, are the most difficult and time-consuming steps (i.e., taking more than a year; Elliott et al., 2015; Saunders, 1993). Prevention efforts are well-suited to facilitate these two steps of the help-seeking process through the use of psychoeducational and motivational interviewing strategies.
Individual Barriers and Facilitators to Help-Seeking
Each step of the multistage help-seeking process is associated with a series of barriers and facilitators that influence individuals’ ability to move from one step to the next, consistent with findings from the larger literature on correlates of help-seeking behaviors among emerging adults. The most commonly cited factors that influence help-seeking intentions and behaviors among emerging adult populations include (a) attitudes and beliefs about mental health; (b) knowledge about, and attitudes toward, treatment; (c) awareness of symptoms; and (d) the perceived need for treatment.
Attitudes and beliefs about mental health
When considering attitudes and beliefs about mental health, research shows that both public stigma (i.e., negative stereotypes and prejudices about individuals with mental illness, Corrigan, 2004) and self-stigma (i.e., the process through which individuals with mental health concerns endorse and subsequently identify with negative attitudes and stereotypes, Vogel et al., 2013) negatively influence help-seeking behaviors (Eisenberg et al., 2009, 2012) and predict negative attitudes toward treatment more broadly (Ross et al., 2019).
Knowledge about and attitudes toward treatment
Limited knowledge of mental health care and negative attitudes toward seeking mental health care hinder the help-seeking process (Eisenberg et al., 2012; Rickwood et al., 2007). These negative attitudes include worries about confidentiality and trust, as well as low perceived benefit and high perceived risk associated with treatment (Gulliver et al., 2010; Nam et al., 2013). Experiences with discrimination and a lack of culturally responsive mental health treatment impact help-seeking among communities of color and other minoritized and marginalized groups (e.g., Johnson et al., 2004; Pantalone et al., 2019). Mistrust of the mental health system among minoritized and marginalized groups has been well-documented (e.g., Alim et al., 2006; Pantalone et al., 2019; Whaley, 2001) and is largely explained by the role that experimental and clinical psychology have played in the systemic oppression of minoritized and marginalized groups over time (e.g., Suite et al., 2007).
Awareness of symptoms
Difficulty identifying symptoms of psychological distress is another common barrier to help-seeking (Gulliver et al., 2010; Salaheddin & Mason, 2016), and the ability to express emotional concerns and a certain level of emotional competence is considered necessary to facilitate help-seeking behaviors (Ciarrochi et al., 2003; Rickwood et al., 2007).
Perceived need for treatment
The perceived need for treatment has been established as one of the strongest correlates of help-seeking intentions and behaviors (Eisenberg et al., 2012; Rickwood et al., 2007; Yu et al., 2008). As Saunders and Bowersox’s (2007) model suggests, the identification of a problem and awareness of distress do not necessarily translate into the perceived need for treatment, and appraisals of a problem as something for which one may seek help represent a separate step in the help-seeking process. A number of factors explain this discrepancy between problem-identification and the perceived need for treatment, including beliefs that problems will resolve themselves over time, that symptoms are “normal,” that problems are not serious enough to warrant treatment, and a preference for handling mental health problems on one’s own (Eisenberg et al., 2012; Rickwood et al., 2007; Yu et al., 2008).
Structural Barriers and Facilitators to Help-Seeking
In addition to individual-level factors that influence help-seeking intentions and behaviors, it is important to acknowledge that other barriers to help-seeking are structural and cannot be addressed through person-centered interventions alone. Examples of structural-level factors include the availability and accessibility of culturally responsive mental health care (Eisenberg et al., 2012; Gulliver et al., 2010; Salaheddin & Mason, 2016) and the influence of larger systems (e.g., health, family, and educational systems) on individuals’ perceptions of psychological distress and treatment. Although it is not within the scope of prevention programs, which operate largely on an individual level to target structural determinants of help-seeking behaviors, it is important to note that prevention programs should be combined with larger structural-level initiatives to have the greatest impact on help-seeking and to address the mental health needs of emerging adults. Integrating prevention programs into larger healthcare systems and/or insurance providers and capitalizing on referral processes within those systems to inform individuals about the availability of prevention programs could represent examples of how best to increase access to and awareness of these programs among those who might benefit from them. Screening questionnaires for symptoms of depression and anxiety could be integrated into routine surveys and outcome monitoring systems to help identify individuals who might benefit from a referral to a prevention program. Other examples of reducing barriers to access prevention programs could include securing insurance coverage for prevention efforts, increasing the availability of culturally responsive programs, and partnering with communities to develop programs and identify the most effective delivery formats for them.
Summary
Taken together, the literature on factors associated with help-seeking behaviors highlights key mechanisms that could be targeted within the context of prevention programs: (a) attitudes and beliefs about mental health, (b) knowledge about and attitudes toward treatment, (c) awareness of symptoms, and (d) the perceived need for treatment. Although no studies to date discuss how to target these mechanisms within the context of prevention, several interventions that address these constructs have been developed and tested. We review key points from this literature below to inform how these interventions can be integrated into prevention programs for depressive and anxiety disorders.
What Strategies Can Target Help-Seeking Processes in the Context of Prevention?
There is a growing literature on interventions designed to target factors that influence help-seeking behaviors, although the majority of these programs do not target emerging adults specifically (Eisenberg et al., 2012). Nonetheless, a broader overview of these programs can provide insight into elements that can be integrated into prevention programs for emerging adults. In a review of interventions to increase help-seeking intentions and behaviors among college students, Eisenberg et al, (2012) identified three broad categories of interventions that have been implemented and evaluated.
Strategy 1: Psychoeducation and stigma reduction
The first and most common type of programs are focused on psychoeducation and stigma reduction. The goal of these programs is to educate individuals about mental health concerns and treatment, as well as to reduce various forms of stigma associated with these topics (Eisenberg et al., 2012). Psychoeducational and stigma-reduction programs have the potential to target a number of mechanisms associated with help-seeking behaviors, including awareness of symptoms, attitudes and beliefs about mental health concerns, knowledge about treatment, and attitudes toward treatment. Several reviews of programs targeting a reduction in stigma reveal small-to-moderate effects on public, personal, and self-stigma (Clement et al., 2013; Corrigan et al., 2012; Dalky, 2012; Griffiths et al., 2014; Tsang et al., 2016). These interventions most commonly take the form of educational or consumer contact programs, but other intervention formats have included elements of CBT, ABBTs, mindfulness, narrative enhancement, and motivational interviewing (Dalky, 2012; Griffiths et al., 2014; Tsang et al., 2016). Both digital and in-person group interventions have been shown to be effective in reducing levels of stigma (Griffiths et al., 2014). These programs are consistently associated with increases in knowledge of psychological diagnoses, improvements in attitudes toward individuals with mental health concerns and treatment, and decreases in social distance scores (Dalky, 2012). However, most studies do not demonstrate any significant behavioral changes associated with these interventions and fail to capture relationships between changes in stigma and subsequent translations into actions, such as seeking treatment (Dalky, 2012). This limitation of the literature points to the need for additional research to identify and subsequently target mechanisms linking changes in attitudes toward mental health and treatment to changes in behaviors associated with help-seeking. Although reductions in stigmatizing attitudes represent an important first step, additional processes outlined in behavior change models (e.g., Chang et al., 2014; Saunders & Bowersox, 2007; Tomczyk et al., 2020) point to the need for future research to also target individuals’ readiness, willingness, and ability to effect behavior change and seek help. Nonetheless, psychoeducation and stigma reduction interventions represent an effective preliminary approach to targeting knowledge and attitudes toward mental health concerns and treatment and could be easily integrated into psychoeducation components of prevention programs.
As many prevention programs include a psychoeducation component (e.g., about symptoms or specific treatment modalities), integrating additional psychoeducation about mental health stigma and treatment into existing programs would likely not require much additional time or resources. Additional psychoeducational content could include discussions of messages about mental health and treatment that individuals have received over their lifetime, common myths and stereotypes about mental health problems and treatment, the processes by which these stereotypes become internalized, and the consequence associated with public and internalized stigma. Accurate information about mental health problems and treatment could be offered to counter negative attitudes and beliefs, as well as to demystify the process of seeking help by outlining what to expect and what options are available. Furthermore, common skills that are included in prevention programs to date (e.g., mindfulness, cognitive restructuring, self-monitoring, behavior change strategies) could also be applied to help counter internalized stigma by helping individuals learn to become aware of and cultivate a non-judgmental stance toward self-stigmatizing thoughts, counter or re-structure self-stigmatizing beliefs, identify behavioral urges to avoid or suppress emotions related to self-stigma, and practice countering those urges.
In line with these approaches to addressing self-stigma, more recent work has sought to better understand and target the process of stigmatization itself, in addition to the content of stigmatizing thoughts. Chan and Mak (2017) outline how maladaptive coping with stigmatizing beliefs can further exacerbate the negative effects of stigma and lead to an increased frequency of stigmatizing thoughts. Directly targeting the psychological processes that contribute to stigmatization offers an approach to reducing the generalized process of stigma in addition to targeting the content of stigmatizing beliefs more specifically (Levin et al., 2014). One form of maladaptive coping is experiential avoidance: the excessive negative evaluation of and subsequent desire to reduce or avoid stigmatizing thoughts (Levin et al., 2014). Several studies have documented the mediating role experiential avoidance plays between stigma and negative mental health outcomes (Gaudiano et al., 2017; Lillis et al., 2011; Masuda et al., 2011; Nauphal et al., 2021). These relationships are further complicated for individuals with intersecting minoritized identities, among whom multiple experiences of discrimination, oppression, and internalized stigma might increase their use of experiential avoidance to cope with unwanted internal experiences (e.g., Martinez et al., 2020). Furthermore, interventions that target experiential avoidance related to stigma thoughts directly (e.g., through acceptance and mindfulness-based approaches) have been found to reduce stigma (Luoma et al., 2008; Luoma & Platt, 2015; Masuda et al., 2007). Given that experiential avoidance has been shown to play a significant role in the onset and maintenance of anxiety and depressive disorders (e.g., Hayes et al., 1996; Naragon-Gainey & Watson, 2018), many prevention programs already employ strategies to target this construct (e.g., ABBT-based approaches, including ACT programs). These intervention strategies could easily be adapted to target stigmatizing thoughts, thereby promoting acceptance in relation to one’s internal experiences more generally and stigma thoughts more specifically. For example, mindfulness skills could help individuals to build awareness of the impact self-stigmatizing thoughts have on their emotions (e.g., shame) and behaviors (e.g., avoidance), as well as help to cultivate an accepting and non-judgmental stance toward self-stigmatizing thoughts and associated emotions and behaviors. Values-clarification exercises and values-based actions can help individuals identify what is important to them in various life domains (e.g., personal growth, health, relationships, work, education, leisure) and then take actions in line with those values. These skills can be used to counter avoidance urges that arise in response to stigmatizing thoughts and to help individuals engage in personally meaningful activities instead. Given that many of these strategies are already utilized in prevention programs for anxiety and depression (e.g., Eustis et al., 2017; Levin et al., 2017), extending their application to self-stigmatizing thoughts offers an efficient way to integrate stigma-reduction work into existing prevention programs.
Strategy 2: Screening and Linkage Programs
The second intervention category is comprised of screening and linkage programs that are designed to screen individuals in distress and link them to appropriate behavioral health services (Eisenberg et al., 2012). These programs often include personalized feedback as part of the screening, which shows promise as an approach to increasing perceived need for treatment and promoting awareness of symptoms (Reavley & Jorm, 2010). Musiat et al. (2014, 2019) offered an example of how personalized feedback can be integrated into a prevention program. In their transdiagnostic web-based prevention program, participants are asked to complete a battery of questionnaires at the start of the first module and are then offered personalized feedback on their questionnaire responses in the following module. Feedback includes information about what scores on each questionnaire represent, as well as how participants’ scores compare with normative data from similar age groups. Participants have reported finding the automated feedback data helpful (Musiat et al., 2014), and the integration of screening and personalized feedback into prevention programs is consistent with larger initiatives advocating the use of personalized computerized feedback in the context of online mental health interventions to help increase awareness and knowledge about mental health symptoms and motivation for behavior change (Musiat et al., 2012).
The linkage component of these interventions additionally provides individuals with some knowledge about what treatment options are available to them. This intervention format is commonly delivered in the context of screening for individuals at risk for suicide, and data from these interventions suggest they are effective at increasing help-seeking intentions, readiness to seek help, and connecting individuals with mental health services if individuals complete the screens (e.g., Haas et al., 2008; King et al., 2015). However, only a small percentage of individuals complete the initial screens; therefore, an important avenue for future work could be to identify ways to increase the number of emerging adults who receive access to and complete online screening tools. Offering college students incentives for completing screening measures or embedding these measures within existing structures (e.g., orientation materials, psychology courses, student health portals) could reduce the barriers to engagement with these materials. Additionally, linking primary care or other routine medical practices to screening programs (e.g., new patient paperwork) that expand beyond university settings could facilitate reaching more of the emerging adult population. If delivered within the context of prevention programs, which often administer some kind of routine screening measures at either the start of the program (to determine who would most likely benefit from the program) or at the end (to evaluate participants’ need for additional services), these screening programs might hold promise to improve individuals’ awareness of their mental health and shape their perceived need for additional treatment. Based on participants’ responses to screening measures, recommendations for additional resources could be offered along with instructions on how to connect to mental health resources and what to expect from the process. This in turn can increase knowledge of available resources and facilitate the process of seeking help.
Strategy 3: Gatekeeper Training
The third type of program includes gatekeeper trainings that target and train individuals who are in frequent contact with their communities to identify mental health concerns and to refer individuals to treatment (Eisenberg et al., 2012). This intervention model can be used to facilitate an awareness of symptoms, increase individuals’ perceived need for treatment, and disseminate knowledge about treatment options. Available data on gatekeeper trainings in the context of university campuses focus largely on suicide prevention and suggest that these programs are effective at increasing participants’ self-perceived knowledge about mental health problems, ability to identify students in need of help, and confidence in one’s ability to help, as well as a greater likelihood of assisting others (Lipson et al., 2014; Reiff et al., 2019; Samuolis et al., 2020; Wolitzky-Taylor et al., 2020). However, additional research is needed on the impact of these interventions on help-seeking intentions and behaviors among the communities they serve (Eisenberg et al., 2012; Lipson et al., 2014). Furthermore, future studies should supplement measures of attitudes, knowledge, and self-efficacy with assessments of changes in actual performance and skills when interacting with individuals in need of mental health care (Wolitzky-Taylor et al., 2020). Finally, additional research is needed on the long-term impact of gatekeeper training and on how best to assure that these trainings are delivered in a culturally responsive manner (Holmes et al., 2021; Nasir et al., 2016).
Within the context of prevention work, in-person program facilitators or online support staff could play the role of gatekeepers who work to identify who might benefit from additional treatment and to help facilitate the process of connecting individuals to mental health resources. Following the end of prevention programs, questionnaire data and open-ended feedback from participants could help those in the gatekeeper role screen for who might benefit from additional services. Furthermore, positive past experiences with help-seeking have been shown to facilitate future help-seeking behaviors (Gulliver et al., 2010), and gatekeeper involvement in prevention programs could work to model positive experiences with help-seeking, thus encouraging individuals to seek help in the future if needed. Gatekeepers or support staff could help foster help-seeking by providing a model for what professional help-seeking might look like (e.g., having a safe and validating space to discuss personal experiences, modeling the limits of confidentiality, sharing skills to prevent or manage symptoms, etc.) or as a means to help reduce stigma associated with help-seeking. Gatekeepers or support staff might also provide a space for individuals to become more comfortable with self-disclosure, which in turn might increase help-seeking intentions (Nam et al., 2013). The use of gatekeepers in particular might be especially beneficial in helping prevention efforts reach communities that have been overlooked in prevention studies (e.g., minoritized and marginalized communities). Of note, the use of gatekeepers might be most relevant to prevention programs that include some element of human support (e.g., group facilitators, online supporters).
Summary
Taken together, these different intervention strategies hold promise for targeting many of the mechanisms associated with help-seeking, namely increasing knowledge and awareness of symptoms and treatment, shifting attitudes and beliefs about mental health concerns and treatment, and helping shape the perceived need for treatment. Psychoeducation initiatives, stigma reduction interventions that target experiential avoidance, screening and linkage programs, and gatekeeper trainings can all be easily integrated within the context of prevention programs for emerging adults (see Table 1 for a summary of these targets and strategies).
Targets and Strategies to Influence Help-Seeking Intentions and Behaviors in Prevention Programs for Emerging Adults
Conclusion
In light of the growing need for prevention efforts among emerging adults, we propose that expanding the focus of prevention programs to include an emphasis on help-seeking reflects an important next step for improving the effectiveness and long-term impact of prevention efforts while simultaneously tailoring these programs to the unique developmental period of emerging adulthood. Prevention programs for emerging adults should strive to target both shared mechanisms that underlie depressive and anxiety disorders as well as mechanisms that influence help-seeking behaviors. This approach is consistent with the shift toward a more transdiagnostic approach to prevention, one that argues for the need to target and assess shared mechanisms that underlie psychopathology and protective factors that protect against the future onset of psychopathology and promote overall well-being. Arming emerging adults with the tools and knowledge needed to seek help is developmentally appropriate, as only a small proportion of this age group with mental health concerns seeks help, yet many experience a shift toward increased independence in healthcare decision-making. In doing so, prevention programs can improve their long-term impact by increasing the chances that emerging adults seek help when needed, which in turn can be conceptualized as a protective factor against the return or worsening of mental health concerns over time.
We recommend that prevention efforts integrate processes that underlie help-seeking into their program targets, including individuals’ attitudes and beliefs about mental health concerns, knowledge about treatment, attitudes toward treatment, symptom awareness, and perceived need for treatment. Several strategies can be easily integrated into prevention programs to target these processes. Examples include psychoeducation and stigma-reduction interventions, promoting acceptance in relation to stigmatizing thoughts, screening and linkage programs that provide personalized feedback and information about treatment resources, and gatekeeper trainings that rely on individuals within communities to spread awareness of, and help connect individuals to, mental health resources.
When discussing the integration of these intervention strategies into prevention programs, it is important to consider that some of the barriers that prevent individuals from seeking help for mental health concerns (e.g., stigma, negative attitudes toward mental health care) might also interfere with their ability or willingness to participate in prevention efforts. Although it is unlikely that prevention programs will successfully recruit all individuals in potential need of treatment, several elements of prevention programs nonetheless may help reach emerging adults who might not otherwise seek treatment. Universal prevention efforts have the potential to be implemented at a large scale, either through group format or digital delivery. Recruitment can be framed in ways to reduce stigma, as these programs can be targeted to everyone, regardless of their mental health status. For example, prevention programs often market themselves as programs to help individuals cope with “stress” or “better manage emotions,” and shy away from the use of diagnostic labels or pathologizing language. Additionally, as many emerging adults show a preference for seeking help online (e.g., Wilks et al., 2019), digital prevention programs could represent a first step for emerging adults who are looking for help to manage their symptoms but are not ready to seek formal in-person treatment. This stepped-care approach could capitalize on emerging adults’ help-seeking preferences and represent a way to engage individuals in one type of psychological support that could help address psychological symptoms (or target underlying mechanisms). Digital prevention programs could also target mechanisms associated with help-seeking behaviors, so that individuals are well-prepared to both manage their mental health and seek a higher level of care in the future if needed.
Future research on disseminating prevention interventions to emerging adults should emphasize making programs accessible to populations that have been overlooked in prevention studies and who are less likely to seek help for mental health concerns more broadly. The majority of research on prevention among emerging adults is conducted with college students, graduate students, or professional students (Rith-Najarian et al., 2019). The focus on college populations, which is consistent with the broader emerging adult mental health literature, should be noted as a limitation of this research to date, and reinforces the need to increase efforts to reach emerging adults not enrolled in higher education. Additionally, existing literature shows that cisgender men and people of color are less likely to utilize mental health services due to a combination of individual and structural factors and barriers to seeking help (Cadigan et al., 2019; Eisenberg et al., 2012; Yu et al., 2008). Prevention programs need to consider how individuals’ intersecting identities influence their experiences of discrimination and marginalization in health care settings, as well as internalized stigma, attitudes toward treatment, and perceived need for treatment. A dual focus on addressing structural barriers to accessing culturally responsive prevention programs and mental health care more broadly, as well as on helping individuals navigate self-stigma and cultural messages and norms about mental health and treatment, is needed. Further, additional attention should be directed to ensure the cultural responsivity and relevance of prevention efforts and the tailoring of programs to reflect the experiences and meet the needs of individuals of different intersecting backgrounds and identities.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
