A population-based study of help-seeking for

self-harm in young adults

Shyamala Nada-Raja, Dianne Morrison, Keren Skegg

Objective: To examine help-seeking for self-harm in a population-based sample of young

adults.
Method: Nine hundred and sixty-five participants aged 26 years were interviewed about
help-seeking and barriers to help-seeking for a range of self-harmful behaviours. Self-harm
included the traditional methods of suicide (ICD-9 self-harm) and other self-harmful behav-
iours such as self-battery and self-biting.
Results: Just over half of the 25 in the ICD-self-harm group (based on ICD-9 self-harm
criteria) and one-fifth of the 119 in the other self-harmful behaviour group had sought
professional help. Counsellors, psychologists, and general practitioners were the commonest
sources of help. Most participants rated help received from health services favourably,
however, emergency services were rated less favourably than other health services. Among
77 self-harm participants who did not seek help, just over one-third reported attitudinal
barriers.
Conclusions: To encourage help-seeking by young adults who self-harm, especially young
men who are at high risk for self-harm and suicide, it may be necessary to identify ways to
reduce attitudinal barriers.
Key words: young adults, help-seeking, self-harm, service use, population-based
sample.

Australian and New Zealand Journal of Psychiatry 2003; 37:600–605

Self-harm is an important public health problem in
New Zealand [1]. In 1998, there were 2596 hospital
discharges coded as non-fatal self-inflicted injury in
New Zealand, which accounted for 6% of all injury-
related hospitalizations in that year [2]. Studies of help-
seeking following self-harm are generally based on
Shyamala Nada-Raja, Principal Investigator, Self-harm Study (Corres-
pondence)
Injury Prevention Research Unit, Department of Preventive and Social
Medicine, Dunedin School of Medicine, PO Box 913, University of
Otago, Dunedin, New Zealand.
Email: shyamala.nada-raja@ipru.otago.ac.nz
Dianne Morrison, Assistant Research Fellow
Department of Psychology, University of Otago, Dunedin, New Zealand
Keren Skegg, Specialist Psychiatrist and Senior Lecturer
Department of Psychological Medicine, University of Otago, Dunedin,
New Zealand
Received 30 July 2002; second revision 24 July 2003; accepted 25 July
2003.
people who have presented to medical services [3]. Little
is known about help-seeking by people who self-harm
and are not known to medical services.
Appleby et al. highlighted the potential value of early
treatment for those who repeatedly self-harm [4]. Among
those not presenting to health services, there may be a
group who could be ‘caught early’, so it is important to
determine their patterns of help-seeking and barriers to
seeking help. A further gap in current knowledge is
related to help-seeking for self-harm that falls short of
the traditional definition for self-harm. Behaviours such
as deliberately hitting oneself (self-battery), although
often regarded as medically trivial, might repay early
intervention in the hope of averting more life-threatening
self-harm. Thus, it is desirable to assess help-seeking
for these behaviours in representative population-based
samples, not just in selected groups presenting to
medical services.
 S. NADA-RAJA, D. MORRISON, K. SKEGG
One reason it is desirable to know about help-seeking
among people who self-harm is because of the link
between self-harm and treatable psychiatric disorder. This
has been found in both hospital [5,6] and community-
based studies [7,8]. Many with mental health problems
do not seek or receive help [9,10]. One route to assessing
and treating them is if they seek help in relation to self-
harm, which may be the event that finally brings a
person to the attention of medical services.
The role of family and friends in providing help has
received some attention for mental health problems, in
general [11,12], but little is known about this aspect of
help-seeking among those who self-harm.
Given the high risk for repetition of self-harm and
suicide, by those who have made a prior suicide attempt
[13], it is important to identify barriers to seeking help
among those who engage in self-harm. Research into
barriers to help-seeking in people with lifetime mental
health problems has shown that they were often attitudi-
nal (e.g. a feeling that the problem would get better by
itself) rather than practical. Family or environmental
characteristics such as receiving household public assist-
ance have been found to predict service use particularly
in urban users [10], and low socioeconomic status was
found to predict help-seeking for emotional problems
[14]. Help-seeking for mental health problems was
found to be less likely among those with lower educa-
tional qualifications [15], but there have been conflicting
findings with regards to low income [15].
The aim of the present study was to examine help-
seeking behaviours not only for self-harm involving
traditional methods of suicide, but also for other self-
harm such as self-battery and self-biting in a represen-
tative population-based sample of young adults. The
specific aims were to: (i) determine the prevalence of
help-seeking for self-harm in the previous year; (ii)
identify sources of help, levels of satisfaction associated
with help received from each source, and correlates of
help-seeking; and (iii) identify barriers and correlates
of barriers to help-seeking.
Methods
Sample
The participants were aged 26 years and belong to a cohort of 1037
children born in Dunedin between 1 April 1972 and 31 March 1973
[16]. Since their birth they have completed a variety of health, behav-
iour, and background assessments. They were first followed-up at age
3 years, thereafter biennially until age 15 years, and later at ages 18,
21 and 26 years. The present study is based on 965 participants
(471 women and 494 men, representing 95% of the surviving cohort)
with complete data for self-harmful behaviours and help-seeking. The
601
sample adequately represents all socioeconomic levels in New Zealand
[17]. Seven percent of the sample self-identified as Mãori.
Measures
Participants completed a 20 minute semistructured interview on
self-harm thoughts and behaviours [18]. In face-to-face interviews, the
self-harm questions were asked in the context of dealing with mental or
psychological pain, emotions, or stress rather than using the term
‘suicide’ initially. At the end of their interviews, all participants
received a list of support services for self-harm and its related aspects.
Most self-harm interviews were conducted by the self-harm research
team members (including the first two authors), who have postgraduate
qualifications in psychology and counselling or clinical skills. The
interviewers were specially trained for the study.
Two categories of self-harmful behaviour reported in the previous
year were examined. The first category, ‘ICD-self-harm’, was defined
according to methods specified in International Classification of
Diseases (ICD-9) E-codes 950–958 for suicide and self-inflicted
injury. The second category, ‘other self-harmful behaviours’ or lesser
forms of self-harm, comprised deliberately hitting oneself or putting
one’s fist through a wall (i.e. self-battery), denying oneself a necessity
such as food as a means of punishment, exercising excessively to
deliberately hurt oneself, and self-biting or wounding. We also exam-
ined intoxication by alcohol or drugs to deal with emotional pain.
For any self-harm behaviours listed above, occurring in the year
prior to the interview, participants were asked if they received help for
either physical consequences or other aspects (generally psycho-
logical) related to those behaviours. Affirmative responses led to
further questions about formal (professional) and informal (family and/
or friends) sources of help consulted or received, satisfaction with help
received from each source, and main reasons for seeking help. Those
who had not sought help, but reported self-harm behaviour in the past
year were asked to indicate barriers to help-seeking from a list of
potential barriers [9].
Demographic measures from a separate assessment included level of
educational attainment, employment, and socioeconomic status in the
previous year.
Analyses
Chi-square tests or Fisher’s exact tests as appropriate were used to
examine associations between help-seeking and self-harm behaviours,
and gender differences.
Results
Of the 965 in the sample with data on self-harm behaviours and help-
seeking for the previous year, 25 (3%) reported one or more episodes
of ICD-self-harm. More than half in this group (n = 15) reported an
overdose and nine had deliberately cut themselves. A total of 119
(12%) reported one or more episodes of other (lesser forms of) self-
harmful behaviours in the past year. These comprised deliberately
hitting oneself or putting one’s fist through a wall (i.e. self-battery,
n = 92), denying oneself a necessity such as food as a means of punish-
ment (n = 27), exercising excessively to deliberately hurt oneself
(n = 8), and self-biting or wounding (n = 4). Of the remainder in the
602 HELP-SEEKING FOR SELF-HARMFUL BEHAVIOURS
sample, 138 (14%) only reported one or more episodes of intoxication
by alcohol or other drugs, specifically to deal with emotional pain. A
total of 683 (71%) reported no episodes of ICD-self-harm, other self-
harmful behaviours, or intoxication as a way of dealing with emotional
pain in the previous year. Of the total number of episodes reported for
each behaviour, suicidal intent was involved in 9% of the 213 ICD-self-
harm episodes, none of the 1573 other self-harmful behaviour episodes,
and 0.2% of the 2296 intoxication episodes. Similarly, an injury was a
consequence of 11% of the ICD-self-harm episodes, 15% of the other
self-harmful behaviour episodes, and 0.8% of the intoxication episodes.
Help-seeking for self-harm
A total of 80% of the ICD-self-harm group (7 of 10 women and 13
of 15 men) had consulted and/or received formal (professional) or
informal (from family or friends) help for either physical consequences
of self-harm or related aspects. This compared with 40% of the other
self-harmful behaviour group (23 of 46 women and 24 of 73 men) who
had sought help. The proportions of the two groups who had sought
help from any source on more than one occasion were similar (75% of
the ICD-self-harm group compared with 70% of the other self-harmful
behaviour group). The main reasons given for seeking help were similar
for both groups; emotional or psychological aspects related to self-harm
(e.g. depressed mood) was a reason given by 75% (n = 15) of the ICD-
self-harm group compared with 62% (n = 29) of the other self-harmful
behaviour group; specifically for self-harm reported by 30% (n = 6)
compared with 9% (n = 4); or for an injury following self-harm
reported by 25% (n = 5) compared with 6% (n = 3).
Formal help-seeking for self-harm
Formal help was defined as help received from health or other
professional services. Just over half the ICD-self-harm group (n = 14,
56%) and 20% (n = 24) of the other self-harmful behaviour group had
received formal help in the previous year. Overall, this represented 26%
of the combined self-harm groups.
Table 1 summarizes the types of health professionals consulted by
each of the two self-harm groups in the previous year. For both groups,
general practitioners were the most common health professional
Table 1. Type of health services consulted in the past year by women and men who reported ICD
self-harm and other self-harmful behaviours at age 26 years
Type of service† ICD-self-harm
Women
n = 10
Any health service 5 (50%)
General Practitioner 4 (40%)
Psychiatrist 1 (10%)
Emergency Services 1 (10%)
Psychologist/counsellor 2 (20%)
Hospitalized/Intensive care 0 (0%)
No health service 5 (50%)
†
Participants could report more than one service.
consulted, followed by counsellors or psychologists, and emergency
services. Significantly more women (59%) than men (21%) had con-
sulted a counsellor or psychologist (χ2 = 5.39, 1 df, p < 0.05), and
significantly more men (53%) than women (18%) had consulted an
emergency service (χ2 = 4.76, 1 df, p < 0.05). A total of 7 of the 25 in
the ICD-self-harm group and 6 of the 119 in the other self-harmful
behaviour group (9% overall) had consulted other professional ser-
vices such as social or educational services, government departments
(e.g. welfare services), telephone counselling, self-help or support
groups, and religious services.
Informal help-seeking for self-harm
Informal help (i.e. help received from family or friends) was reported
by 68% (n = 17) of the ICD-self-harm group and 30% (n = 36) of the
other self-harmful behaviour group. Combining data for both self-harm
groups, similar proportions had consulted family (22%) or friends
(29%). Significantly more women (32%) than men (16%) consulted
family (χ2 = 5.22, 1 df, p < 0.01). Those who reported informal help-
seeking (47%) were significantly more likely than those who did not
(14%) to also report formal help-seeking (i.e, from professional
services) (χ2 = 18.65, 1 df, p < 0.01).
Satisfaction with help received
Participants who sought help for self-harm in the previous year rated
their satisfaction with the help received from each source on a 4-point
scale of ‘very unhappy’ to ‘very happy’. Results are reported for the
combined two groups of self-harm because few in each group reported
seeking help from each source. General practitioners (84% or 16 of 19
who had sought help from a GP), psychiatrists (83% or 5 of 6), and
psychologists or counsellors (79% or 11 of 14) were rated favourably
by most who had sought help from each source. However, a lower pro-
portion of those attending emergency services (62% or 8 of 13) rated
the help they received favourably. Family were rated favourably by
91% (10 of 11 who consulted family) in the ICD-self-harm group and
95% (20 of 21) in the other self-harmful behaviour group. Similarly,
friends were rated favourably by 92% (12 out of 13) and 100% (all 28)
in the two self-harm groups, respectively.
Other self-harmful behaviours
Men Women Men
n = 15 n = 46 n = 73
8 (53%) 12 (26%) 11 (15%)
3 (20%) 7 (15%) 5 (7%)
3 (20%) 0 (0%) 2 (3%)
8 (53%) 2 (4%) 2 (3%)
2 (13%) 8 (17%) 2 (3%)
2 (13%) 0 (0%) 0 (0%)
7 (47%) 34 (74%) 62 (85%)
 S. NADA-RAJA, D. MORRISON, K. SKEGG
Demographic characteristics of formal help-seekers
for self-harm
Numbers in each group were too few to enable separate analyses to
be conducted for each self-harm group. Formal help-seekers for self-
harm (i.e ICD-self-harm or other self- harmful behaviours, 17 women
and 21 men) were compared on demographic characteristics with those
who did not seek formal help (39 women and 67 men). A higher pro-
portion of women formal help-seekers (65%) compared to 36% of those
who did not seek formal help were unemployed at the time of their
interview, but this difference was not statistically significant. The
groups did not differ significantly in educational achievement or
socioeconomic status. Significantly more men who reported formal
help-seeking (57%) were from a low socioeconomic status compared to
those who had not sought formal help (28%) (χ2 = 5.81, df = 1,
p < 0.05).
Help-seeking for intoxication
A total of 138 reported intoxication by alcohol or drugs to deal with
emotional pain in the previous year, but none of any of the other forms
of self-harmful behaviours enquired about in the self-harm interview.
About one-third (34%) of this group reported formal or informal help-
seeking. Eleven percent reported formal help-seeking. Almost 1 in 10
had consulted health services; the commonest sources of help were a
psychologist or counsellor (9 of 13) or a general practitioner (6 of 13).
Family was consulted by 17% and friends by 31%. Most (81%)
reported seeking help for emotional or psychological reasons rather
than intoxication per se or associated injury.
All who consulted a counsellor, psychologist, or general practitioner
rated them favourably, as did two of the three participants who had
consulted a psychiatrist. The only person who attended an emergency
service rated the service unfavourably. More than 80% of the 46 who
consulted family or friends rated the help they received from them
favourably.
Barriers to help-seeking
Five of the 25 in the ICD-self-harm group and 72 of the 119 in the
other self-harmful behaviour group reported not seeking any formal or
informal help in the previous year. Given the small numbers in the ICD-
self-harm group, results from the analyses examining potential barriers
to help-seeking are reported for the two self-harm groups combined for
women and men separately. Of the 144 in the combined self-harm
group, 77 (54%) had not sought any help for self-harm or related behav-
iours. Most (83%) considered it unnecessary to consult anyone. Attitu-
dinal barriers (e.g. thought should be strong enough to handle problem
on their own; thought problem would resolve itself; did not think
anyone could help; or too embarrassed to discuss it with anyone) were
reported by 39% each of the women and men (i.e. 10 and 20, res-
pectively). Practical barriers (e.g. lack of time; unable to get to health
service; could not afford to pay bill; did not know of any place to go for
help; inconvenient hours, or appropriate service did not exist) were
reported by 12% of the women (n = 3) and 10% (n = 5) of the men.
Barriers indicative of fear or stigma (e.g. afraid of what others may
think; afraid of being hospitalized; afraid of treatment; hated answering
603
personal questions; or a member of family objected) were reported by
8% (n = 2) of the women and 6% (n = 3) of the men. About 5% in the
group reported that although others thought it necessary for them to
seek help, they themselves considered it unnecessary.
In the intoxication group of 138, 66% reported no formal or informal
help-seeking in the previous year, mostly because they considered it
unnecessary. The proportions of women (53%, n = 19) and men (38%,
n = 21) who reported attitudinal barriers did not differ significantly.
Practical barriers were reported by 14% (n = 5) of the women and 2%
(n = 1) of the men. Fear or stigma-related barriers were reported by
none of the women and 7% (n = 4) of the men.
Discussion
In this population sample of young adults, nearly half
of those who reported self-harm (i.e. ICD-self-harm or
other forms of self-harmful behaviours) had sought help
either from professionals or from family or friends in the
past year. Formal help-seeking was quite common, being
reported by one in four in the self-harm group as a
whole, and half of the ICD self-harm group. It was
encouraging to find that many young adults who self-
harmed had actively sought assistance from a variety of
professional and other sources. This may have provided
an opportunity for receiving advice and treatment and
might even have prevented progression to more serious
self-harm.
Young adults who reported self-harm, which was most
often minor, were more likely to have consulted general
practitioners, counsellors, and psychologists than psychi-
atrists or emergency services. The finding that this group
of professionals was generally rated favourably supports
the importance of this group in the assessment and
prevention of self-harm by young adults (e.g. guidelines
recently developed by the Royal New Zealand College
of General Practitioners for the detection and manage-
ment of young people at risk of suicide).
Medically serious self-harm is more likely to come to
the attention of emergency services than general prac-
titioners or counsellors. Thirteen young adults in our
study, mostly men, reported having attended an emer-
gency service in the past year after self-harm. It was of
concern to note that nearly one-third of them, all men,
rated the help they received unfavourably. No data were
collected on the reasons for unfavourable ratings, how-
ever, it may be reasonable to speculate that resource and
staff constraints of many emergency services and the
need for triage may result in more dissatisfaction with
the service received from emergency services than from
general practitioners or counsellors. Attendees may be
more unwell than self-harmers who present to other
health services, another factor that may influence the
perception of emergency service attendees’ ratings of
help or support received. The small number reporting
604 HELP-SEEKING FOR SELF-HARMFUL BEHAVIOURS
emergency service use suggests that the above findings
should be interpreted with caution.
Studies that focus only on formal help-seeking cannot
consider the contributions that informal help-seeking can
make to support those who self-harm. In the present
study, just over one-third in the combined self-harm
group had consulted family or friends, with friends being
the preferred source. Furthermore, those who reported
informal help-seeking were significantly more likely to
also report formal help-seeking for self-harm. These
findings support those from a study of French adoles-
cents’ help-seeking behaviours for psychiatric problems
which found that the choice of a confidante was impor-
tant in determining whether a mental health professional
was consulted [11]. Confiding in a family member or
friend may provide support and encouragement for self-
harming young adults to seek formal help, if required;
alternatively, young adults may have a general tendency
towards help-seeking [12].
Very few in the present study who had self-harmed
had sought help from other professional services such as
telephone counselling or crisis centres. This seemed
somewhat surprising given that services such as Lifeline
and Youthline are free and their availability brought to
the attention of potential consumers by a variety of
media. Hawton [19] commented that research on the
Samaritans in the UK had not shown a significant impact
on suicide rates, possibly because clients who contact the
Samaritans may be different from patients who attempt
suicide.
Treating substance use problems, which are known to
be strongly associated with self-harm including suicidal
behaviours [20] may be a way of preventing self-harm.
Our finding that about 10% in the intoxication group had
sought help from general practitioners, counsellors, or
psychologists, suggests that those health professionals
do get opportunities to address young adults’ substance
use problems. An Australian prospective study found
that men diagnosed with substance misuse were at high
risk for suicide, but concluded that clinicians found this
particular group difficult to engage in treatment [13].
A limitation of the present study was that even with
965 participants, there were too few reporting ICD-self-
harm in the previous year for barriers to help-seeking
to be analyzed separately for them. For the combined
self-harm group (ICD-self-harm or other self-harmful
behaviours), just over half had not sought help, with the
commonest reason being that it was not considered
necessary. This may have been appropriate, particularly
for those engaging in lesser forms of self-harm such as
self-battery. Recent findings from the National Comor-
bidity Survey [21] indicated that most people with less
severe or impairing psychopathology did not perceive a
need to seek help, perhaps because they recognized the
self-limiting nature of their problems. This could well
have been true for some who reported self-harm in the
present study. Nevertheless, one-third reported attitudi-
nal barriers to help-seeking, and it is likely that some
who were in need of help did not seek help, largely
because of these attitudinal barriers rather than practical
ones.
Conclusion
We agree with Pirkis et al. [22] who commented that
more research is required on the patterns of help-seeking
by those who engage in self-harm (including suicidal
behaviour) to determine if their patterns are unusual and
whether they have particular risk factors. Many in this
representative sample of young adults who self-harmed
did not seek help from professional or other sources. To
encourage help-seeking, it may be necessary to address
attitudinal barriers, raise awareness and recognition of
mental health problems and promote appropriate health
service use early in the life course.
Acknowledgements
We are grateful to the study members and their fami-
lies for their support. The self-harm study was funded by
Project Grant 98/148 from the Health Research Council
of New Zealand (HRC) to the Injury Prevention Research
Unit (IPRU) and a Community Trust of Otago Research
Fellowship. We thank Paula Sowerby, John Langley,
Richie Poulton, Phil Silva and DMHDS staff. The IPRU
is supported by the HRC and the Accident Compen-
sation Corporation.
References
1. Coggan C. Suicide and attempted suicide in New Zealand:
a growing problem for young males. The New Zealand Public
Health Report 1997; 4:49–51.
2. Wright CS, Langley JD, Allnatt DM. Trends in non-fatal injury:
injury fact sheet number 18. Dunedin: University of Otago,
2000.
3. Hatcher S. A survey of deliberate self harm services in New
Zealand: shouldn’t we be doing better? New Zealand Medical
Journal 1997; 110:74–75.
4. Appleby L, Warner R. Parasuicide: features of repetition and the
implications for intervention. Psychological Medicine 1993;
23:13–16.
5. Haw C, Hawton K, Houston K, Townsend E. Psychiatric and
personality disorders in deliberate self-harm patients. British
Journal of Psychiatry 2001; 178:48–54.
6. Beautrais AL, Joyce PR, Mulder RT, Fergusson DM,
Deavoll BJ, Nightingale SK. Prevalence and comorbidity of
mental disorders in serious suicide attempts: a case control study.
American Journal of Psychiatry 1996; 153:1009–1114.
 S. NADA-RAJA, D. MORRISON, K. SKEGG
7. Andrews JA, Lewinsohn PM. Suicidal attempts among older
adolescents: prevalence and co-occurrence with psychiatric
disorders. Journal of the American Academy of Child and
Adolescent Psychiatry 1992; 31:655–662.
8. Patton GC, Harris R, Carlin JB et al. Adolescent suicidal
behaviours: a population-based study of risk. Psychological
Medicine 1997; 27:715–724.
9. Hornblow AR, Bushnell JA, Wells JE, Joyce PR,
Oakley-Browne MA. Christchurch psychiatric epidemiology
study: use of mental health services. The New Zealand Medical
Journal 1990; 103:415–417.
10. Lin E, Goering P, Offord DR, Campbell D, Boyle MH. The use
of mental health services in Ontario: epidemiologic findings.
Canadian Journal of Psychiatry – Revue Canadienne de
Psychiatrie 1996; 41:572–577.
11. Gasquet I, Ledoux S, Chavance M, Choquet M. Consultations of
mental health professionals by French adolescents with probable
psychiatric problems. Acta Psychiatrica Scandinavica 1999;
99:126–134.
12. Howard KI, Cornille TA, Lyons JS, Vessey JT, Lueger RJ,
Saunders SM. Patterns of mental health service utilization.
Archives of General Psychiatry 1996; 53:696–703.
13. De Moore GM, Robertson AR. Suicide in the 18 years after
deliberate self-harm: a prospective study. British Journal of
Psychiatry 1996; 169:489–494.
14. Feehan M, Stanton W, McGee R, Silva PA. Parental
help-seeking for behavioural and emotional problems in
childhood and adolescence. Community Health Studies 1990;
14:303–309.
605
15. Leaf PJ, Alegria M, Cohen P et al. Mental health service use in
the community and schools: results from the four-community
MECA Study. Methods for the Epidemiology of Child and
Adolescent Mental Disorders Study. Journal of the American
Academy of Child and Adolescent Psychiatry 1996; 35:889–897.
16. Silva PA, Stanton WR, eds. From child to adult. Oxford: Oxford
University Press, 1996.
17. Reeder AI, Feehan M, Chalmers DJ, Silva PA. Some
socioeconomic characteristics of a much-studied cohort. The
Dunedin Multidisciplinary Health and Development Study.
New Zealand Journal of Educational Studies 1994; 29:209–213.
18. Nada-Raja S, Skegg KM, Langley JD, Morrison DN,
Sowerby PJ. Self-harm behaviours in a population-based sample
of young adults. Suicide and Life Threatening Behaviour 2003
(In submission).
19. Hawton K. Suicide. In: Paykel ES, Jenkins R, Gaskell eds.
Prevention in psychiatry. London: Royal College of
Psychiatrists, 1994; 67–79.
20. Blenkiron P, House A, Milnes D. The timing of acts of deliberate
self-harm. is there any relation with suicidal intent, mental
disorder or psychiatric management? Journal of Psychosomatic
Research 2000; 49:3–6.
21. Mojtabai R, Olfson M, Mechanic D. Perceived need and
help-seeking in adults with mood, anxiety, or substance use
disorders. Archives of General Psychiatry 2002; 59:77–84.
22. Pirkis J, Burgess P. Suicide and recency of health care contacts.
British Journal of Psychiatry 1998; 173:462–474.