“You Have the Choice of Whether You’re Going to Get Help or Attempt Suicide”: Exploring the Process and Impact of Mental Health Help-Seeking with Young People (16–25 Years)

Reviewer 1 comments

Responses

Abstract

• Change the following sentence: “Young people are encouraged to seek help with mental distress but help-seeking in this demographic are low.” to “Young people with mental distress are encouraged to seek help, but help-seeking in this demographic is low.”

Thank you for spotting this, it is now been rectified.

• I would suggest using the term “mental health problem” throughout as this is distinguishable from “mental health distress”.

We have changed to the use of the broader term ‘mental health problem’ throughout to avoid any conflation with ‘mental health distress’, a concept in psychology that is often measured. We have now changed these throughout and they are highlighted in green.

• suggest omitting “young people” as you have already indicated the demographic in the other key word “youth suicide”
• suggest instead of “lived experience” (as this infers phenomenological inquiry), including “grounded theory”

Thank you for this comment, we have reflected on this and would prefer to keep in the term ‘young people’ for search engine purposes to include those searching for young people and mental health but not necessarily suicide. We have replaced “lived experience” with “healthcare experiences” as this is central to the study, but less suggestive of a purely phenomenological approach.

Introduction/Review of the Literature:

• Page 2 Line 42 – Goodwin et al should be listed before Gulliver et al
• Page 2 Line 43 – Burlaka et al should be listed before Loureiro et al
• Page 2 Line 62 – Breslin et al should be listed before Cornally & McCarthy
• There are several mistakes, beyond those mentioned, regarding alphabetical order of in-text citations throughout the manuscript.

Thank you for noting these, the referencing system has been changed to Chicago style in line with the journal requirements.

• Page 2 Line 65 – Please adjust the following sentence as it does not make sense: “Their mental health help-seeking and young people literature base…”
• Page 2 Line 79-83 – Please adjust the following sentence: “As further research is needed to develop youth specific help-seeking models…”. I would separate this sentence into two sentences to strengthen your point, first that further research is needed, and second that inquiry can deepen understanding of the processes and experiences of young people seeking help which will support theory development…

This first comment has now been reviewed and corrected for clarification and we have also reviewed line 79-83 and improved this section for clarity, on pg.4, both highlighted in green

• The review of the relevant literature needs to be strengthened. I was surprised the authors did not specifically discuss mental health literacy among young people, as help-seeking is a key feature of mental health literacy.

Thank you for this comment, we have reflected further on this. We absolutely agree that the concept of mental health literacy is a central concept within help seeking and we have written about this concept more specifically in other publications. The focus of this article was to highlight the theoretical development of help-seeking in relation to educational and healthcare definitions/models/approaches, rather than explore the factors involved (personal, social and service factors). However, on reflection it is also clear that the lack of discussion on mental health literacy (among other topics) creates an obvious absence. To resolve this, we have added in a short paragraph on this context and signposted to important research on these factors in the introduction (and linked briefly in the discussion), keeping in mind the topics to be prioritised within the word count. This now strengthens the introduction.

• I appreciate the inclusion of how we might understand the help-seeking relationship in learning contexts as applied to decision making processes for youth experiencing mental health problems.

Thank you for this positive feedback!

• Page 2 Line 74 – Once again, the authors reference “lived experience”. Given that the aim of grounded theory research is to develop theory, this makes me question the choice of methodology.
• Page 2 Line 93 – Again, the authors mention “lived experience”. As this is a grounded theory study, the focus should be on exploring the process of young people deciding to ask for help…. in order to develop theory of young people’s help-seeking.

We do appreciate your comments throughout this article on our use of “lived experience” and how it has been prioritised over “process” in places. To address this, we have reviewed our use throughout and ensured that “process of help-seeking” has been brought back into focus, and references to “lived experience” are used in a manner that is appropriate for a CGT study but does not evoke expectations of phenomenological inquiry, while not losing the experience content. We believe this resolves the issue and avoids confusion, and actually strengthens the reporting. Just a note - we used Constructivist Grounded Theory, which are wholly appropriate for research that includes lived experiences as data for understanding processes and/or theory development. While the concept of lived experience has strong associations with, and is central to phenomenological traditions/inquiry, they are also used across a range of methods and approaches in research. We’ve included some more information in the methods on how lived experience research is well aligned and regularly used with CGT, with emphasis on co-constructed meaning and grounded, experience-based theory development (pg.5 highlighted in green).

·       The aims of the research are clearly stated, yet once again I would suggest clarity regarding “mental health distress” or “mental health problem” is needed. The states seems to be conflated throughout.

Thank you for this comment, we agree and have corrected this throughout as per the previous comment.

Methods:

• I believe the argument or rationale for use of grounded theory, and specifically constructivist grounded theory, could be explained further.

Thank you for noting this, we have considered this and now presented a more detailed case for our methods.

• Please explain the terms “attempted, exited early or completed a help-seeking episode.” What are the parameters around each of these?

We have now clarified these terms in green highlighter on p.6

• In presenting qualitative research, it is expected that there would be a researcher’s positionality statement with respect to their relationship to the research topic. I do not believe the statement on Page 5 Line 203 is sufficient to meet this expectation.

We agree, and an updated positionality/reflexivity statement has been included on pg. 9 highlighted in green, before the presentation of the findings.

• Recruitment – it is not clear how participants were informed of the research.

The methods section has now been updated with information on recruitment of young people, with the introduction of a figure that we did not initially include, but think it is now relevant (Figure 1.) This is in green highlighter on pg. 8

• Page 4 Line 126 – Please clarify what “early stages of receiving mental health support or experiencing crisis” means. What are the parameters of these?

This has been clarified on page 7 in green highlighter. This comment has been addressed in line with Reviewer 3’s comment.

• Page 4 Line 154 – “These option” should read “The option”

Thank you, this error has been corrected.

• Please provide more information regarding how you safeguarded participants’ confidentiality during data collection.

Thank you for the comment, we have now updated safeguarding information in the Methods in green highlighter on pg. 9 under Ethical Considerations.

Findings:

• Overall, it is clear that there is rich, interesting and detailed data that the researchers had to work with.

Thank you very much for this feedback, it is appreciated.

• When presenting findings, I’m not sure it is overly helpful to state “some” or “most” or “many” participants without providing exact numbers of participants who indicated this. This is more of an issue of presentation style.

We appreciate this perspective and there are many different opinions on this matter. This approach helps the reader understand how perspectives/experiences can cluster but without quantifying experiences or undermining with qualitative methodologies. We are going to continue with this style, however, the findings have been reorganised and reviewed, and this comment was considered during this process.

• I have some questions about the labelling of the core category and 4 sub-categories. The choice of labels are conveying a sequential process, rather than actual descriptors of ‘what is happening here.’ The core category (Personal Journey of Help-Seeking), for example, does not adequately offer any insight into what the help-seeking process IS for young people. Typically, in grounded theory we would see the use of gerunds to label categories to emphasize process. For example, the sub-category “The search for help” could be re-framed in a way that captures the complex process of alerting significant others, not knowing what help was out there or who to access, etc. I’m not sure that “The search for help” captures the layers of complexity here.

We can appreciate this comment, and on reflection agree that the findings section needs further consideration. We have reviewed the category/subcategory/concept names and modified them to address the valid issues raised. We are satisfied we have both followed the CGT approach and addressed the comment, which has now strengthened the findings section. The entire section has now been reorganised, and content made more concise to account for word count were possible. No new content has been added. Changes in this section are also connected with the comment below, and are throughout pages 12-20.

• I would prefer to see a comprehensive description for each sub-category first, then moving into presenting the different features of that category supported by participants’ quotations. There are long sections of paragraphs without sub-headings. The features of each category could be offered as a sub-heading.

This perspective is appreciated, given the richness of the data and the length of this article we have included introductory and conclusionary statements to the sub-categories to improve the organisation, while being mindful of word count. Changes in this section are connected with the comment above and are throughout pages 12-20.

Discussion:

• Figure II presents a diagram of the help-seeking process. I appreciate the use of a visual to depict this complex process. I would suggest that perhaps there are ways to edit the diagram to capture the fluidity of decision-making the authors describe young people taking.

The presentation of the diagram in a circle and with rotating arrows was the attempt to visually communicate the fluidity of these decisions (non-linear). We appreciate that this did not capture that for you as a reader and so we have considered some modifications to better communicate the fluidity of the process (Fig 2).

·       The discussion is excellent in positioning the findings in relation to multiple bodies of literature.

Thank you for this feedback, we really appreciate it as this was a difficult task.

·       This work offers interesting insights into the skillset needed for help-seeking decision making, and further, how skilled help-seeking occurs within a larger context of available, accessible resources. 

We are appreciative that this important finding has been received and understood as it was intended.

·       This could be clearly linked to Michael Ungar’s work on youth resilience as being contextually located, not located within individuals.

We are familiar with Michael Ungar's work on youth resilience and agree on your observation that this could be included here, and we have signposted this in the introduction section and we have briefly connected this work on pg.25

·       Further, it was again noted that there was little integration of mental health literacy into the discussion. 

This links back with our discussion in the introduction, and we prioritise the help-seeking theory aspects but have added a reference to how this research can link with the mental health literacy field, and on how young people conceptualise mental health as a broader concept, for understanding help-seeking on pg. 22, and is highlighted in green.

• It was interesting that all participants were impacted directly by suicide and how this experience, in particular, was factored into their decision.

This was an important part of the participants experiences and links with the title of the paper and the cultural impact of suicide on the island of Ireland. We have added additional content to clarify this in relation to reviewer 3’s comment on the title and this content is on pg. 3, and on pg. 24, highlighted in blue.

• Page 14 Line 657 – please explain term “Gardai”.

This term has been clarified and is highlighted in green, on pg. 25

• I appreciate the novel insight into how we may think about help-seeking for mental health and for academic/educational purposes, and the developmental implications on help-seeking.

Thank you for taking the time to review this article, your feedback has been very helpful and has indeed strengthened this article. We are delighted to hear that the core messages of this article which come directly from young people and their experiences has been communicated in the way it was intended and can contribute to the wider conversations on these important topics globally.

Reviewer 2 comments

Responses

Methods:

·       Researcher positionality: I applaud the authors on their detailed methods section. Would it be feasible and/or appropriate to also include a positionality statement describing the lens the research team brought to the research?

Thank you for the positive feedback and we agree that a positionality statement would be appropriate here and we have now included it on pg. 9 highlighted in green, before the presentation of the findings.

• Study participants, page 3, Table 1: Could you please define your gender abbreviations (M, F, Tm) in the table note. Additionally, the methods state that Table 1 protects participant anonymity. Assuming Tm stands for transmasculine/trans man, might this potentially lead readers to assume this participant is the young person described as discussing a desire to transition in findings (and thus be able to link quotes with demographic data). Does the value of reporting information about individuals, outweigh the protection of reducing the amount of individual-level data by reporting aggregate demographics?

Thank you for noticing this absence, we have now clarified the abbreviations.

These are important conversations to have. We have considered this at length, and believe we achieved the right balance between inclusion and identity protection. For example, more demographic information was collected for all participants, that provided further context to their contributions, but to include would raise the risk of being identified. Documenting age, ethnicity and area was important to show readers the inclusive approach and broad range of perspectives. The researcher (who did the data collection and analysis) consulted, during original write up, with a local LGBTI+ advocacy worker about reporting of the LGBTI+ identifying participants data, which was also discussed with the project team. The main issue raised was through removal of ‘m’ from Tm (man from ‘trans man’), which was initially just proposed to be just T to protect identity by not being specific. It was advised not to do this as it would mean Tm become invisible, and they couldn’t be labelled “them”, which is a common approach used for anonymity, but in this context could infer non-binary, which they did not identify as. As research with trans men is underrepresented, the visibility was communicated to us as important and so a pseudonym was used, their ethnic background broadened, and the demographic context was minimised as far as possible without losing important context for reading the analysis. We are satisfied that the individual cannot be identified externally, but your comment does flag an identifiability risk internal to the dataset as there is only Tm participant. We will preserve minimal demographics information in the table, the relevant demographic data, keep the original advocacy consultation guidance, but to now reduce this identified risk, we will disconnect the pseudonym used from the quote directly describing transitioning, this way only one quote can be deducted as coming from that participant, but their contributions cannot be pieced together by readers across the data. The quote doesn’t reveal any information other than they experienced difficulty with transitioning, and the demographics mentions that one participant was Tm, but now the reader won’t know which one it is by name. This is on pg.25 under “Matching Needs to Services” and is highlighted in green.

 These are really important conversations, and we thank you for raising it and helping us reflect further on all the steps taken to protect participants and the relevancy of demographic data.

• Participant selection, page 4, lines 126-128: Young people experiencing crisis or in the early stages of help seeking are described as being excluded due to "ethical reasons". Could more specific information please be provided about the reasoning for excluding these individuals.

This has been clarified on page 7 in green highlighter. This comment has been addressed in line with Reviewer 1 & 3’s comment.

• Ethical considerations, page 4, line 157: To improve clarity for readers in different disciplines or countries, could disclosure pleased be defined? Disclosure of what? (e.g., in my context that could mean disclosure of suicidal ideation/plan or disclosure of potential child abuse/neglect).

Thank you for this comment, we absolutely want to ensure that our research is globally understood and so we have clarified this term on pg. 9, and it is highlighted in blue.

Findings:

• Participant labels: Could a statement be included in the methods to describe how participants have been labelled? Are the names provided actual names or pseudonyms? Are all participants named or did some elect not to be labelled (e.g., the participant who describes the death of a close friend by suicide on page 9 does not appear to be named).

All participants consented to the use of pseudonyms in publishing. The removal of that participant’s pseudonym was a participant anonymity check made by the research team as there was a concern that with the pseudonym, and the detailed narrative, that someone could link together the data internally. This has also been discussed on p. 9, and is highlighted in green.

• Quote formatting: Quotes are inconsistently formatted in places (e.g., italics on page 8, lack of italics or quotation marks at the top of page 9), I recommend proof-reading this section and resolving inconsistencies

Thank you for your observations, these have been amended.

Discussion:

• Figure 2, page 11: Text is cut-off in several of the text boxes in this figure.

We have updated the figure on pg. 21 (in line with Reviewer 1’s comments), and all content has been made visible

• Figure 3, page 13: It is unclear where the information in this figure, and the related discussion in-text, has been drawn from. Could relevant citations or clearer links to primary data please be provided?

Thank you for highlighting this, this has now been clarified for both figure 2 and 3, and these additions are highlighted in green.

• Length: The discussion section is quite long and feels like it is often repeating information from the results, rather than discussing that information in the context of evidence from the literature. I suggest considering reducing repetitive descriptions of findings in the discussion, and increasing the clarity with which other sources of evidence are introduced and discussed in relation to the findings.

Thank you for this feedback, his section has now been reviewed for length, and repetition, and we have removed 300 words and reorganised content, with an additional heading to improve the clarity of this section. We have also increased the clarity around how our findings are discussed with the literature. The authors are satisfied that the content is now relevant and has integrated some new aspects, as suggested by peer reviewers.

• Limitations: Given parental consent was identified as a key barrier to service access, is it possible that the requirement for parental consent to participate in research for young people under 19 years of age presented a barrier to participation for this age group?

That is a good observation, this has now been added to the limitations.

Reviewer 3

• Line 54  Citation of Wood, Burner and Ross- Per APA, all citations of 3+ can be cited in text as first author, et al., date

Thank you for noting these, the referencing system has been changed to Chicago style in line with the journal requirements.

• Line 61- additional information needed describing the Theory of Planned Behavior.

This information has now been added.

• Line 65- sentence begins with There. Do you mean The?

Thank you for noticing this, this has been corrected.

• Line 96- Terms

Thank you for noticing this, this has been corrected.

• Line 97- Very good justification of your age range as this can be a gray area.

Thank you very much for the positive feedback.

• Line 135- remove highlight
• Line 141- same feedback as line 54, apply to citation Ghaljaie
• Line 154- The option
• Line 171- use & not and
• Line 183 Charmaz

Thank you for noticing this, this has been corrected. The referencing system has been changed to Chicago style in line with the journal requirements.

• Please note if your participants have been given pseudonyms. If they have not, please do so.  As it currently stands your participants appear to be identifiable

This is on page. 9, and has been clarified further and highlighted in green. This comment has been addressed in line with Reviewer 1 & 3’s comment.

·       Line 296 (Liam),

• Line 336- error with italics
• 361- bold font
• Line 374- quotation is not needed and detracts from the message of this paragraph.

Thank you for noticing this, this has been corrected.

The bold font is for noting when a participant was being emphatic.

This paragraph has now been restructured to improve the clarity of the finding, with the quote better used, on pg. 17 and is in blue highlighter.

• Provide a better description of what constitutes inappropriate treatment. Is it an improper level of care such as outpatient when inpatient is called for? Is it peer support when formal therapy is needed? There is a difference between what clients want and what is therapeutically appropriate. Please provide more details.

We have indicated what this means and provided some participant examples on pg. 16 in purple highlighter. Experiences were individual, and difficult to list specifically, and could risk identifying individuals. We have included some more context and improved reporting, which now links better with the discussion on negative impacts on pg.29.

• Line 513- again, this line needs a definition and description of the Theory of Planned Behavior in order to make sense.

Thank you, we have reworked this section to clarify how ToPLB fits in with the findings and are satisfied this has improved the discussion, on pg. 21 in blue highlighter

• Line 598 now, not how
• The citation list needs to be check for APA errors, namely several instances lacking italics

Thank you for noting these, the referencing system has been changed to Chicago style in line with the journal requirements.

• Overall this is a timely study that lends well to the existing literature and makes another call for exploring the needs of youth seeking assistance with mental health.

We appreciate this positive feedback!

• The use of the quote in the title needs removal as it is very misleading. This is not an article solely examining suicide but the title takes readers in that direction. Likewise it is never used in the text leaving me as a reader wondering why.

We appreciate the comment and have reflected on the title. This quote is used on pg. 12, early on in the findings. We don’t think it is misleading, but we do agree that we have likely not communicated enough on the impact of suicide on the island of Ireland, specifically youth suicide. We have added some context to the background on p. 3 and on p.24, in blue highlighter. On a cultural level, suicide and help-seeking for mental health are very linked and most people living on the island have been impacted (NOSP, 2024) – all in this study reported that they were. Suicide is a relevant topic throughout, and the title reflects how young people in Ireland can reflect on suicide when they are making help-seeking decisions, and how suicidality can be an indicator of a need to ask for help. We will keep the use of the quote as it indicates that young people in Ireland are often feeling quite severe when they decide to seek help, which links well with many aspects of the article and the qualitative nature.

• This article is in need of a lot of grammatical changes as evidenced by the above notations.

We appreciate the time that you have taken to contribute to identifying these typographical errors. We have thoroughly reviewed the article after making changes for or you can turn it off grammar and typography errors.

• Additionally readers will be assisted in understanding challenges of your study participants by knowing in advance the location (Ireland) of this work. This might simply be fixed once the Ethics section is identified, but readers can better understand findings around system issues and population demographics once we understand the location of the study.  

We agree that this article did not have enough context, we hope the additional context in the introduction, methods and the discussion have supported the positioning of this study and enhanced the readers’ understanding of the study.