Running Head: TREATING DEPRESSION AMONG ADOLESCENTS

Health Behavior Models and Theories:

Treating Depression Among Adolescents

Marie Pascua

California State University of Long Beach

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Health Behavior Models and Theories: Treating Depression Among Adolescents

Depression is a serious mental illness that affects one’s mood, behavior, thinking and

function. Unfortunately because of public stigma and limited knowledge of services surrounding

depression, it usually goes undetected and untreated. According to Mental Health America

(2017), ​64.1% of youth that suffer from major depression do not receive any mental health

treatment. This adversely affects six out of ten adolescents who suffer from depression, causing

them to live with the symptoms preventing them from deriving pleasure from life. According to

the National Institute for Health and Care Excellence [NICE] (2005), when left untreated,

depression can cause mental and psychological effects including feelings of hopelessness,

decrease in concentration, poor decision making, disinterest in physical appearance and self

harm. There can also be physical effects such as tiredness, insomnia or hypersomnia, and

apathy. ​When it is not properly treated, it can have serious consequences that can ultimately

lead to death. Fortunately when it is detected, there are many options on how to treat this mental

illness such as antidepressant drugs, psychological therapies, and social/environmental

interventions ​(NICE, 2005).

Significance to Public Health: ​ Being able to treat depression is important regarding public

health because it affects not only a person’s quality of life, but also those around them. Wisdom,

Clarke, & Green (2006) reveals that society’s view of depression and the views of family and

friends can determine whether or not someone reaches out for help. Currently, mental health has

not been taken seriously by the public especially depression among adolescents. Depression

within the youth is commonly seen as a phase and thus not taken as seriously as it should
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(Wisdom, Clarke, & Green, 2006). According to ​Weissman, Wolk, & Goldstein (1999), adults

who have a history of adolescent depression have a higher rate of suicide than those who do not.

Not seeking treatment especially when there are permanent consequences such as death, effects

both the victims and their families. This is why it’s important to educate the public regarding the

seriousness of depression, available treatments, destigmatize the idea around it, and make them

aware of the symptoms.

Relevance to HSC 421:​ Treating adolescents suffering from depression is relevant to Health

Science 421 because the theories and models discussed in the class can be applied in order to

discover the reasoning behind one’s behavior. This course explores ways to change behavior

and develop interventions. Through understanding the behavior theories, one can apply them in

research and practice (Garrido-Ortega, 2018a). In regards to this paper, the theories and topics

learned in HSC 421 can be used to explain why an adolescent may not seek treatment for

depression and help devise ways to change that behavior.

Focus and Original Thoughts:​ This paper will focus on the reasons why one does not seek

treatment for depression. It will discuss the impact one’s family, friends and society has on the

decision of getting help for this mental illness and the underlying effects of not doing so. By

applying the models and theories, this paper will hopefully bring awareness to the severity of

untreated depression and decrease public stigma surrounding mental illnesses.

Main Points:​ This research paper will focus on depressed adolescents and young adults.

Beginning with the introduction, the health behavior of not seeking treatment for depression will

be defined. Afterwards, its relation to public health and the course HSC 421 will be explained.

Then, a background of the health behavior and its determinants will be discussed in order to
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reveal the impact on adolescents specifically. The Theory of Planned Behavior and the Health

Belief model will then be defined, compared and applied to the behavior in order to understand

why individuals do not seek medical care. Two research studies will then be introduced to show

how researchers have applied both the TPB and HBM to explain and predict this health behavior.

This paper will end with a summary of the main points discussed and suggestions for additional

research.

Health Behavior Background:​ According to ​Pine, Cohen, Gurley, Brook, & Ma (1998),​ a

research study was conducted, where 776 youth received psychiatric assessments over a span of

several years. These assessments that were in the form of structured interviews, took place in

1983, 1985, and 1992. This study discovered that anxiety or depression within adolescence

predicted an approximate 2- to 3- fold increased risk of the mental illness being prevalent in

adulthood. If left untreated, symptoms during adolescence can become more severe over time

and can even lead to death (​Pine, Cohen, Gurley, Brook, & Ma, 1998). According to NICE

(2005), ​without treatment, those who suffer from depression will look for ways to deal with their

symptoms. This can lead to risky behaviors such as drugs and alcohol. In many cases, it can

lead to addiction and the development of other mental health illnesses (NICE, 2005). The U.S

Department of Health and Human Services​ (2018) states that ​suicide is the leading cause of

death among the youth aged 10 to 24. This statistic reveals the dangers of untreated mental

illnesses and how prevalent it is among the youth.

Determinants: ​Depression does not discriminate against sex, socioeconomic status, race, or

even age. Although, ​according to ​Weissman, Wolk, & Goldstein (1999), major depressive

disorder is increasingly having an onset in adolescence, across all countries. Mental health
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treatment is now offered by primary care providers, yet according to Wisdom, Clarke, & Green

(2006), only half of adolescents experiencing depressive symptoms confide in their health care

provider. The looked into the experiences of teenagers who seeked and received care and found

that there were many barriers that prevented them seeking the care in the first place. There

seemed to be a common fear within the young adults about confidentiality issues and sharing

such personal information with their primary care providers that can prevent them from doing so.

If a child chooses to confide in their parents instead, the parents may not have the knowledge on

how to deal with mental illnesses. They may even undermine their depression because of the

lack of physical and tangible symptoms. This can lead to the adolescent being declined

treatment. Socioeconomic status of the family can also affect the quality and types of treatments

available if they do seek it. There is also a fear of being isolated and rejected by society because

of the stigma surrounding mental illnesses. This is rooted in the stereotype that people suffering

from these illnesses are “crazy” or “weird”, thus creating a perception that they are dangerous

and should be isolated. Adolescents are more susceptible to being aware of what society

believes, which can influence how they personally treat their illness. In order to avoid being

outcasted, they will avoid seeking assistance and publicizing that they suffer from such illness.

(Wisdom, Clarke, & Green, 2006).

Overall, adolescents who are more likely to not seek treatment are those who come from

a lower socioeconomic background, have negative experiences with health care providers,

believe in the stigma around mental illnesses themselves, or come from an unsupportive or

uninformed environment (NICE, 2005).

Health Behavior Theories and Models

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The Theory of Planned Behavior: ​According to Garrido-Ortega (2018b), the Theory of

Planned Behavior uses an individual’s intention, attitude, norms, and control beliefs in order to

better understand their behavior. It looks at intrapersonal levels of influence, while also taking

into account outside factors. TPB states that an individual's behavior is a result of their intent,

which consists of their attitude towards that behavior, the subjective norm surrounding it, and

their perceived behavioral control. An individual’s attitude towards a behavior is made up of

their behavior beliefs and outcome evaluations. Behavioral beliefs is an individual’s

understanding that there will be a certain outcome if they perform a behavior. Whether or not

the individual believes the certain outcome has any value to them becomes their outcome

evaluation. Subjective norm includes the combination of normative beliefs and the motivation to

comply. Normative beliefs addresses how an individual believes the important people in their

life would want them act. Motivation to comply is the extent to which an individual wants to

behave in those ways in order to satisfy the significant people in their life. Lastly perceived

control, how much a person believes they are in control of performing a certain behavior, is a

result of control beliefs and perceived power. Control beliefs is one’s belief of internal and

external factors that will either encourage or prevent a behavior. Perceived power is a how easy

or challenging a person believes a behavior is under the internal and external factors from their

control beliefs (Garrido-Ortega, 2018b).

Health Belief Model: ​According to Garrido-Ortega (2018c), the Health Belief Model is based

on the understanding that an individual is motivated to take a health action if it can prevent their

health from being negatively impacted. The HBM focuses more on the intrapersonal level of

influence on behavior. Instead of external factors such as one’s community, it looks at an

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individual’s own knowledge, beliefs, personality traits and attitude. This model analyzes an

individual's perceived susceptibility, perceived severity, perceived threat, perceived benefits,

perceived barriers, cues to action and self-efficacy in order to determine why a person refuses to

engage in a certain behavior. Perceived susceptibility is how much at risk someone believes they

are of suffering from a health problem. Perceived severity includes how significant they believe

the health problem is. Perceived susceptibility and severity combine to make up perceived

threat, the overall perception of how harmful a behavior is to one’s health. Perceived benefits

are the benefits one believes they will gain by engaging in a certain behavior, while perceived

barriers will prevent them from doing so. Cues to action are internal and external signals that

compels someone to act a certain way. Lastly, self-efficacy is the belief and confidence one has

that they can perform a certain behavior (Garrido-Ortega, 2018c).

Compare and Contrast TPB and Health Belief Model: ​The Theory of Planned Behavior and

the Health Belief Model can be used to understand why people make certain health decisions. In

addition, they can also be used to transform a bad behavior into a more healthy and beneficial

one. Despite their similarities, a significant difference between the two theories is that only TPB

considers external factors when looking at behavior. The TPB describes why individuals engage

in certain health behaviors while also attempting to further increase their intent to do a given

behavior. This includes altering their attitudes and beliefs regarding outside factors because an

individual is more likely to do a behavior if they feel like they have high control over it. The

HBM, contrarily, focuses on changing an individual’s internal thoughts and beliefs regarding a

behavior in order to promote change. With the HBM, an individual is motivated to act when

they see themselves as susceptible to a threatening consequence.

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Theory of Planned Behavior Relevance: ​The Theory of Planned Behavior can be used to

combine the attitudes, subjective norms, and control beliefs of someone suffering from

depression in order to determine why they don’t seek treatment (Garrido-Ortega (2018b). For

example, one can have prior beliefs that if they were to seek help, they would be forced to take

numerous drugs or they may have had an a bad experience with health care providers. This

creates an overall negative feeling surrounding seeking treatment, thus discouraging them from

doing so. They may also be afraid of being labeled as a mentally ill person or “crazy” by their

loved ones and as a result be outcasted. This goes back to the subjective norms, where if a

person’s loved ones believe in the public stigma towards mental health, they will be less likely to

seek treatment to avoid backlash According to ​Bohon, Cotter, Kravitz, Cello & Garcia (2016),

public stigma can also be a external factor that affects one’s perceived behavioral control. If

they are surrounded by a mentality that one can easily stop being depressed by “just being

happy,” they will believe that treatment is a waste of time and money. Another factor that might

affect one’s control beliefs is that personal helplessness and low self-esteem are symptoms of

depression. This internal factor can physically inhibit and discourage them from getting help.

The TPB reveals that it is important to make these constructs positive and favorable towards

treating depression in order to overcome the negative attitudes, subjective norms, and control

beliefs of not doing so (​Bohon, Cotter, Kravitz, Cello & Garcia, 2016)​.

Health Belief Model Relevance:​ The Health belief model can be used to increase a person’s

awareness on how important it is to receive treatment for depression, since it discusses their

perceived threat and the benefits of doing so. For example, the perceived susceptibility can be

that the individual believes how they are feeling can not get any worse. In response, one should
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provide statistics like the one previously mentioned from ​Pine, Cohen, Gurley, Brook, & Ma

(1998)​ that depressive symptoms increase as one ages. This will increase the individual’s

perceived susceptibility. Perceived severity is an individual not being aware that depression is a

mental illness that can negatively impact their health especially symptoms usually are not visible.

One should present them physical consequences of untreated depression such as a weakened

immune system, increased pain sensitivity, and higher risks of cardiovascular disease

(Pietrangelo, & Cherney, 2011). The person’s perceived threat depends on how likely they think

they are to suffer from negative consequences by not seeking treatment. Along with increasing

these perceptions, it is important to address the individual’s perceived benefits and barriers.

In order to encourage an individual to get help, emphasizing on the benefits can give

them the hope and motivation to do so. Because one does not seek treatment, if may be because

their perceived barriers outweigh the benefits. Some barriers can include cost of treatment,

misinformation, not being able to recognize depression and even public stigma. Individuals

suffering from depression usually don’t seek out treatment unless they have cues to take action.

These can include family interventions, or they can even be forced into treatment after harming

themselves . One’s self-efficacy in being able to seek treatment may also be low because of the

low-self esteem issues that come with depression (Pietrangelo, & Cherney, 2011). The Health

Belief model is useful in helping the individual recognize the negative health consequences of

not treating depression and thus influencing them to take action.

Theory of Planned Behavior Application:​ The Theory of Planned Behavior states that

attitudes, subjective norms and perceived behavioral control predicts an individual's intention to

seek mental health treatment (Garrido-Ortega, 2018b). A study done by ​Bohon, Cotter, Kravitz,
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Cello, & Garcia (2016),​ looks at 845 students’ emotional health and depression through a survey.

They then use the results to relate their attitudes, social norms, and perceived behavioral control

to their intentions of getting mental health services. The study also aimed at examining the

student’s barriers to seek care.

The study found that the most common barrier that prevented them from receiving care

was that they were not aware they even had mental health issues. The students that were able to

recognize it, were either not aware that there were treatments available for dealing with

depression or that their perceived outcome of the treatment was not impactful enough. They also

discovered that some students perceived that their peers had positive attitudes regarding seeking

treatment, and as a result also had positive attitudes. Those who had less perceived barriers also

showed a higher intention of seeking medical care. In order to deal with this, the researchers

concluded that educating the youth is vital in changing their attitudes about depression and the

mental health services. They stated that it is important to also increase awareness and publicity

surrounding mental health services and the symptoms of the illnesses.

When looking at perceived behavior control, the researchers found that a majority of the

variables preventing them from seeking care were in regards to their personal situations. The

common barriers found among the students were cost, access to treatment, difficulty in making

an appointment, and being able to get to their appointments. With this information, the

researchers suggested that institutions and policy makers change these barriers in order to

increase intention and control among students. Long-term care could be made more affordable

so that the students are more aware of how to deal with depression as they get older and the

possibility of a recurrence. They also propose that funding be increased for staff and training
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specializing in mental health to help develop more effective outreach and treatment programs

(​Bohon, Cotter, Kravitz, Cello, & Garcia, 2016).

Health Belief Model Application: ​In a study done by ​Castonguay, Filer, & Pitts, (2016), the

Health Belief Model was used to gain a better understanding of behavior surrounding seeking

help for treating depression. They used in-depth and semi-structured interviews to retrieve

stories and experiences from 39 people living with depression The study suggested that within

those individuals, their uncertainty regarding treatment is what drove each of their perceptions

under the HBM. For example their perceived severities were very high when they first sought

out treatment. It was common for the individuals to feel certain that they needed help only after

an extreme experience such as a suicide attempt. This was because the dominant perceived

barrier among the individuals was the fear of the unknown. They were scared that the treatments

would make them worse or that it would be challenging. By combining that barrier with

unknown benefits, the study concluded that uncertainty mainly prevented the individuals from

seeking help. A common cue to action among the individuals was when a significant person in

their life or a medical care provider recommended that they seek help. Because of this,

researchers suggested that interventions focus on reducing that uncertainty while also

encouraging treatment. In addition, the interventions should also help educated ,not only the

depressed individuals,but also their friends and family. If an individual’s environment is

supportive and educated, it decreases their fear of the unknown and increases their self-efficacy

in being able to complete the treatment (Castonguay, Filer, & Pitts, 2016).
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Conclusion and Further Study

Seeking treatment for depression is beneficial for everyone who suffers from this mental

illness. It is especially crucial for adolescents to receive care because if left untreated, it can lead

to more severe symptoms later in life and even death. In order to promote individuals to engage

in this behavior, it is important to correct any misinformation re and continue to publicize the

available treatments. By using the Theory of Planned Behavior and the Health Belief Model,

interventions and treatments can be designed to address an individual's unique characteristics and

beliefs.

In regards to public health, additional research must be done to further determine what

causes depression among adolescents. This research can lead to the development of preventative

measures and other treatments that can effectively target the root of this illness.
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References

Bohon, L. M., Cotter, K. A., Kravitz, R. L., Cello P. C., & Garcia, E. (2016). The Theory of

Planned Behavior as it predicts potential intention to seek mental health services for

depression among college students. ​Journal of American College Health,​ ​64:​ 8, 593-603,

DOI: ​10.1080/07448481.2016.1207646

Castonguay, J., Filer, C. R., & Pitts, M. J. (2016) . Seeking help for depression: applying the

Health Belief Model to illness narratives. ​Southern Communication Journal​, ​81​:5,

289-303, DOI: ​10.1080/1041794X.2016.1165729

Garrido-Ortega, C. (2018a). ​Theory, research, practice and healthy people 2020 ​[PowerPoint

slides]. Retrieved from

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Garrido-Ortega, C. (2018b). ​Theory of reasoned action/theory of planned behavior [​ PowerPoint

slides]. Retrieved from

https://bbcsulb.desire2learn.com/d2l/le/content/465298/viewContent/4941965/View

Garrido-Ortega, C. (2018c). ​HBM ​[PowerPoint slides]. Retrieved from

https://bbcsulb.desire2learn.com/d2l/le/content/465298/viewContent/4941962/View

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