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.