Australian Journal of Psychology 2018; 70: 41–47

doi: 10.1111/ajpy.12160

Exploring poor sleep, mental health, and help-seeking intention

in university students

Marina L. Zochil and Einar B. Thorsteinsson

Department of Psychology, University of New England, Armidale, New South Wales, Australia

Abstract

Objective: University students experience common mental health problems such as depression, anxiety, and stress along with
poor-sleep quality. This study explores the relationships between these concepts and help-seeking intention in a general
Australian university student population. The primary aim was to examine the moderating effects of sleep quality on help-
seeking intention for common mental health problems. The secondary aim was to examine sex differences in help-seeking beha-
viour. Method: University students, between 18 and 55 years of age (M = 30.18, SD = 11.37, N = 117) of which 98 were female,
completed an on-line survey assessing help-seeking intentions, common mental health problems, and sleep quality. Results:
High levels of depression, anxiety, and stress were significantly associated with decreased sleep quality or decreased help-
seeking intention. A multiple regression analysis predicted that students were more likely to report intention to seek help if
they had lower scores of depression, but higher scores of stress. Help-seeking intention levels were lower for males than
females. Poor-sleep quality was not found to be a moderator of help-seeking intention. Conclusion: Although the proposed
moderation effect of poor-sleep quality on the relationship between common mental health problems and help-seeking inten-
tion was not supported, the study advanced our knowledge of university students’ low intention to seek help, despite high
scores of poor-sleep quality. Implications for on-campus interventions and raising awareness among students about these issues
are discussed.

Key words: anxiety, depression, help-seeking intention, poor sleep, stress, university/college students

What is already known about this topic?
• University students experience common mental
health problems such as depression, anxiety, and
stress.
• Some students do not seek help as symptoms
increase.
• Poor-sleep quality is often comorbid to mental health
problems.
Mental health problems and poor-sleep quality are preva-
lent amongst the general university student population
(Zochil, 2013). Although the comorbid relationship of these
problems has been established in the literature (Atalay,
2011), people often seek help for poor-sleep quality only,
unaware of potential comorbid problems impacting their
treatment and recovery (Malhi et al., 2014). As universities
Correspondence: Dr Einar B. Thorsteinsson, Department of
Psychology, University of New England, Armidale, NSW 2351,
Australia. Email: ethorste@une.edu.au
Received 07 April 2016. Accepted for publication 16
February 2017.
© 2017 The Australian Psychological Society
What this topic adds?
• Increased levels of depression and anxiety reflect
decreased sleep quality and decreased help-seeking
intention.
• Help-seeking intention levels were lower for males
than females.
• Shows the importance of investing in mental health
literacy campaigns on campuses aimed at increasing
students’ insight and decreasing negative perceptions
of mental health problems.
aim to enhance services for students (Vogel, Wester, Lar-
son, & Wade, 2006), it is beneficial to understand the asso-
ciation between poor-sleep quality, mental health, and
university students’ intention to seek help (referred to as
help-seeking intention) in order to inform preventative and
treatment services on campus.
A high percentage of university students suffer from
mental health problems. Previous research indicates mental
health problems in Australian university students are higher
than that of the general population: 67.4% (Stallman,
2010) versus 25.5% (Ryan, Shochet, & Stallman, 2010).
Research into the mental health problems of university
42 M.L. Zochil and E.B. Thorsteinsson
students in Australia, and how sleep quality and help-
seeking behaviour relate to such problems contributes to an
emerging research field (e.g., O’Keeffe, 2013; Simpson &
Ferguson, 2012; Vivekananda, Telley, & Trethowan, 2011).
Similar to the general population, when university stu-
dents present to counselling services, they frequently report
symptoms consistent with depression, anxiety, and/or asso-
ciated stress (Andrews & Chung, 2011), collectively referred
to as common mental health problems. Depression, anxiety,
and stress can present separately, but often occur together,
greatly impairing an individual’s quality of life (Collins,
Westra, Dozois, & Burns, 2004). These common mental
health problems are often comorbid with poor-sleep quality
(Savard, Savard, & Morin, 2010) that can further impact
students’ functioning (Brown, Buboltz, & Soper, 2002;
Cheng et al., 2012).
Poor-sleep quality is defined as difficulty initiating, main-
taining, and/or achieving restful sleep (Atalay, 2011). It has
been estimated that between 16% and 23% of young adults
have symptoms of poor-sleep quality (Taylor et al., 2011).
This is particularly prevalent amongst university students
compared to other young people (Brown et al., 2002;
Cheng et al., 2012). Students often experience poor-sleep
quality as they attempt to balance their competing priorities
including academic demands, employment, and social life
(Andrews & Chung, 2011; Brown et al., 2002). Although
some students who suffer from poor-sleep quality and com-
mon mental health problems may recover independently,
many students will likely need to seek help in order to suc-
cessfully overcome these problems (Collins et al., 2004).
An individual’s reported future commitment to seek help
for a given problem is known as help-seeking intention
(Rickwood, Deane, Wilson, & Ciarrochi, 2005). Generally,
young people report a preference for seeking non-
professional (e.g., partner, friends, and/or family members)
over professional (e.g., psychologists, counsellors, and/or
general practitioners) help for mental health problems and
the same appears true when examining their intention to
seek help (Wilson, Deane, Ciarrochi, & Rickwood, 2007).
Not all students that need help will seek it (Ryan et al.,
2010); thus, it is imperative to understand who is likely to
seek help and for what problem in order to target those less
likely to seek help of their own accord.
However, seeking help relies on an awareness that there
is a problem that warrants intervention (Jorm et al., 1997).
A potential lack of awareness of mental health problems
(Gibbons, Thorsteinsson, & Loi, 2015; Thorsteinsson, Loi, &
Moulynox, 2014) can lead to a need for treatment being
unmet (Hess & Tracey, 2013). In support of this, Czyz, Hor-
witz, Eisenberg, Kramer, and King (2013) found that 66%
of university students with mental health problems
(e.g., depression, alcohol abuse, suicidal ideation, and/or
past history of suicide attempt) reported not engaging in
help-seeking as they did not perceive their symptoms war-
ranted intervention. Additionally, the literature suggests
that university students’ help-seeking intention tends to
decrease as symptoms increase (Ryan et al., 2010) and so
they are at an increased risk for developing common mental
health problems (Orsal, Orsal, Unsal, & Ozalp, 2013; Stall-
man, 2010). Investigating if help-seeking intention can be
predicted using scores of common mental health problems
and sleep quality may assist in clarifying how sleep affects
help-seeking intention in university students with common
mental health problems.
Common mental health problems and related comorbid
conditions, such as poor-sleep quality, seem to elicit differ-
ent help-seeking behaviours (Malhi et al., 2014). Students
may seek help for poor-sleep quality (Reinhold, 1973), but
are less likely to seek help for common mental health pro-
blems (Ryan et al., 2010), especially those who suffer from
comorbid conditions (Malhi et al., 2014). Past literature sug-
gests that individuals experiencing poor-sleep quality tend
to have more severe psychiatric symptoms (e.g., anhedonia)
than individuals who do not (Leblanc et al., 2007) and the
relationship between sleep and mental health is complicated
(Atalay, 2011). Sleep may influence the strength of the rela-
tionship between common mental health problems and
help-seeking intention. However, the underlying mechan-
isms involved in the relationship between common mental
health problems and help seeking appears unclear and to
the authors knowledge no studies have explored poor sleep,
mental health, and help-seeking intention together. Thus,
an exploration of how poor-sleep quality may interact in
the relationship between mental health problems and help-
seeking intention is warranted.
Additionally, there is a need to investigate differences
between males and females. According to BeyondBlue
(2015), there is a common myth that males should not seek
help by sharing their emotions. A systematic review sug-
gests that being young and male are significant barriers to
seeking help for mental health problems (Clement et al.,
2015). Rickwood et al. (2005) surveyed 2,721 young people
in Australia between 14 and 24 years of age, which indi-
cated that males were less likely to report help-seeking
intention for mental health problems as compared with
females of the same age. Reavley, McCann, and Jorm
(2012) suggest that these sex differences may be caused by
higher perceptions of stigma associated with seeking profes-
sional help for mental health treatment in males than
females.
To the authors’ knowledge, to date, no studies have
explored poor sleep, mental health, and help-seeking inten-
tion simultaneously in a university student population; nor
has any study investigated if poor-sleep quality moderates
the relationship between mental health and help-seeking
intention. As such, this study will focus on students with
© 2017 The Australian Psychological Society
 Poor sleep, mental health, and help seeking 43

mental health ranging from ‘normal’ to ‘extremely severe’
for depression, anxiety, and stress. The study aims to exam-
ine the (1) associations between mental health problems
(i.e., depression, anxiety, and stress), poor-sleep quality,
and students’ help-seeking intention; (2) predictors of stu-
dents’ help-seeking intention; (3) moderating effects of
poor-sleep quality on the relationship between students’
common mental health problems and help-seeking inten-
tion; and (4) differences between male and female students’
help-seeking intention.
METHOD
Participants
In total, 143 university students from multiple universities
volunteered to participate in the study. However, data from
26 participants was removed due to incomplete data. There-
fore, the final sample consisted of 117 students ranging in
age from 18 to 55 years (M = 30.18, SD = 11.37), of which
98 were female (one participant identified as ‘other’).
Table 1 shows the key demographic characteristics of the
participants.
Materials
Help-seeking intention
they would be to seek help from a variety of supportive
individuals (e.g., ‘partner’ or ‘mental health professional’)
on a 7-point-Likert scale from 1 (extremely unlikely) to
7 (extremely likely). The final four items of the GHSQ were
used to assess participants’ previous professional help-
seeking behaviour (How many visits did you have with the
mental health professional?) and experience (How helpful
was the visit to the mental health professional?; Rickwood
et al., 2005). This scale demonstrated high internal reliabil-
ity (α = .83) with a non-clinical sample (n = 218) of young
people (Wilson et al., 2007). Although there is no agreed
upon measure of help seeking in the literature to date (Li,
Dorstyn, & Denson, 2014), the GHSQ has been recom-
mended and employed in a number of studies with a stu-
dent population (Ryan et al., 2010; Smith & Shochet, 2011;
Wilson et al., 2007).
The GHSQ was adapted to be more applicable to
Australian university students with ‘school’, ‘teacher’, and
‘classroom teacher’ changed to ‘university/college’, ‘lec-
turer’, and ‘classroom tutor’, respectively. The tense was
changed for one question to ask about future intentions
replacing ‘please describe who this was’ with ‘please
describe who this would be’. Alpha levels for measures in
this study are reported in Table 2.
Common mental health problems

The General Help-Seeking Questionnaire (GHSQ; Rickwood The Depression Anxiety Stress Scales 21-items (DASS21; Psy-
et al., 2005) was used to measure students’ reported help- chology Foundation of Australia, 2014), a shortened version
seeking behaviour. The initial 10 items measured help- of the original DASS42 (Lovibond & Lovibond, 1995), is
seeking intention over the next 4 weeks for personal or commonly used to measure university students’ mental
emotional problems, if warranted. Students rated how likely health problems (Simpson & Ferguson, 2012; Zochil, 2013).
The DASS21 is a set of three scales: depression, anxiety, and
Table 1 Summary of participant demographics (N = 117) stress, with seven items for each scale. Students rated each
Participants Percentage item (e.g., ‘I found it hard to wind down’) on a 4-point-
Characteristic (n) (%) Likert scale of 0 (did not apply to me at all) to 3 (applied to me
Education very much) on how they felt over the past week. Each score
High school certificate (year 12) 50 42.7 is doubled with each scale ranging from 0 to 42 (extremely
Bachelor degree 28 23.9
TAFE certificate or diploma 8 6.9 Table 2 Descriptive statistics and correlation matrix for key
Postgraduate diploma 19 16.2 variables (N = 117)
Master’s degree 9 7.7
Doctoral degree 3 2.6 Variable 1 2 3 4 5
Current course/degree of 1. Depression .66** .63** .47** −.30**
enrolment 2. Anxiety .72** .55** −.27**
Undergraduate 83 70.9 3. Stress .56** −.12
Postgraduate 34 29.1 4. Poor-sleep −.21*
Enrolment status quality
Full-time 63 53.8 5. Help-
Part-time 54 46.2 seeking
Student status intention
Local 106 90.6 M 6.61 8.22 14.53 8.51 3.43
International 11 9.4 SD 10.74 10.11 9.67 3.91 0.99
Previously saw a mental health α .94 .92 .89 .69 .72
professional Possible range 0–42 0–42 0–42 0–21 1–7
Yes 84 70.9 Actual range 0–40 0–40 0–42 0–17 1.33–5.56
No 33 28.1
*p < .05. **p < .01 (two-tailed).

© 2017 The Australian Psychological Society

44 M.L. Zochil and E.B. Thorsteinsson
severe). The DASS21 has high specificity, clinical and
research utility, and discriminates well among the three
conditions (Dozois & Dobson, 2010). All scales have high
internal consistency: depression (α = .88), anxiety (α = .82),
and stress (α = .90; Henry & Crawford, 2005).
Poor-sleep quality
The Pittsburgh Sleep Quality Index (PSQI) is a measure of
sleep quality and disturbance over a 1-month period
(Buysse, Reynolds, Monk, Berman, & Kupfer, 1989). Stu-
dents rated statements (e.g., ‘Cannot get to sleep within
30 min’) on a 4-point-Likert scale from 0 (not during the past
month) to 3 (three or more times a week). Nineteen items are
scored to provide a global PSQI score, ranging from 0 to
21 with a cut-off score of 5 or above to indicate poor-sleep
quality (Buysse et al., 1989). The participant’s bed partner,
if applicable, rated an additional five items about the partici-
pant’s potential sleep disturbances (e.g., ‘loud snoring’) over
the past month. The PSQI is a well-established measure
with demonstrated reliability and validity (see systematic
review by Mollayeva et al., 2016) showing α from .70
to .83.
Procedure
The University’s Human Research Ethics Committee
granted ethics approval (HE15-030). Potential participants
had access to a flyer with a brief explanation of the study
and a URL link. The link allowed access to the participant
information sheet and a confidential on-line survey via
Qualtrics’ secure site (www.qualtrics.com). Three main por-
tals were used to recruit participants. First, potential partici-
pants were emailed an invitation to complete the survey
and were encouraged to forward the email to other students
in their social network. Second, the flyer was made availa-
ble on social network sites (e.g., www.facebook.com) and
the University’s e-learning platform. Third, participants
were recruited via coordinators of teaching units at other
universities who agreed to participate.
Participants gave consent after reading a study informa-
tion sheet and consent form by clicking a ‘proceed’ button
thus starting the on-line survey. The survey commenced
with demographic questions followed by the three previ-
ously described questionnaires, which were presented in
random order to reduce potential priming and order effects.
At the conclusion of the survey, participants were thanked
for their participation and could opt to enter a prize draw to
win one of three $50 vouchers.
Statistical analysis
All analyses were carried out using SPSS version 23 and
PROCESS version 2.13.2, model 1 (Hayes, 2015). Effect size
was reported and a significance level criterion of .05 was
employed. The interpretation of results focuses on the mag-
nitude of effect sizes (e.g., r and g) while also considering
statistical significance. The model for predicting help-
seeking intention included depression, anxiety, stress, and
poor-sleep quality as predictors; no confounders were
adjusted for in the model. Moderators were tested using
Model 1 in PROCESS using 5,000 bootstrap samples.
RESULTS
Eighteen students (15.4%) in the sample reported good
sleep quality and 99 (84.6%) reported poor-sleep quality.
The severity range for depression, anxiety, and stress is
shown in Table 3. The findings suggest that 18.0%, 20.5%,
and 14.6% of students suffered severe or extremely severe
depression, anxiety, or stress, respectively. Table 2 shows
the associations between the key outcome measures.
Help-seeking intention was significantly associated with
depression (r = −.30) and anxiety (r = −.27). Contrary to
expectation, help-seeking was not positively associated with
poor-sleep quality (r = −.21). Poorer sleep quality was associ-
ated with poorer mental health (rs > .46, ps < .01 two-tailed).
Help-seeking intention was predicted by mental health
problems and poor-sleep quality with 13% of the variance
explained, see Table 4. Examining the beta coefficient
depression and stress seem the strongest predictors in the
given model.
Three separate moderator analyses were conducted to
examine if the relationship between each common mental
health problem (i.e., depression, anxiety, and stress) and
help-seeking intention was moderated by poor-sleep qual-
ity. No significant interactions were found (sr2 < .02).
Help-seeking intention was lower for males (M = 2.99,
SD = 0.97) than females (M = 3.51, SD = 0.98), t
(114) = 2.06, p = .021 (one-tailed), g = 0.53 [0.02, 1.04].
DISCUSSION
Overall, the results of this study are consistent with the lit-
erature. Thus students who reported experiencing more
severe symptoms of common mental health problems were
less likely to report help-seeking intention (Ryan et al.,
2010). Further, poor-sleep quality was more prevalent in
students with higher scores of depression, anxiety, and/or
Table 3 Frequency (and percentages) severity range for the
Depression, Anxiety, and Stress Scales (21-items)
Severity range Depression Anxiety Stress
Normal 73 (62.4) 75 (64.1) 72 (61.5)
Mild 15 (12.8) 6 (5.1) 13 (11.1)
Moderate 8 (6.8) 12 (10.3) 15 (12.8)
Severe 7 (6.0) 7 (6.0) 10 (8.6)
Extremely severe 14 (12.0) 17 (14.5) 7 (6.0)
© 2017 The Australian Psychological Society

Table 4 Predicting help-seeking intention from depression,
anxiety, stress, and poor-sleep quality
CI95% for b
Predictor b Lower Upper β r
Depression −0.03 −0.05 −0.00 −0.27 −.30
Anxiety −0.02 −0.05 0.00 −0.23 −.27
Stress 0.03 0.00 0.06 0.28 −.12
Poor-sleep −0.03 −0.08 0.03 −0.11 −.21
quality
Note. Fit for model R2 = .13, adjusted R2 = .10, F(4, 112) = 4.30,
p = .003. CI = Confidence interval.
stress (Taylor et al., 2011). Low levels of depression, but
high levels of stress, predicted greater likelihood to report
help-seeking intention, further suggesting that students are
more likely to seek help for minor issues, but less likely to
seek help as mental health symptoms worsen (Ryan et al.,
2010). Furthermore, male university students were less
likely than females to report help-seeking intention
(Ciarrochi, Wilson, Deane, & Rickwood, 2003). The differ-
ence between males and females for help-seeking may be
due to perceived stigma associated with seeking help. Reav-
ley et al. (2012) found that male students and students with
severe mental health symptoms reported experiencing more
stigma associated with help seeking for mental health pro-
blems compared with female students and/or students with
less severe symptoms. Thus stigma may play a significant
role as a barrier in preventing students from seeking help
(Eisenberg, Golberstein, & Gollust, 2007). One way to
address mental health-related stigma is by investing in men-
tal health literacy campaigns on campuses aimed at increas-
ing university students’ insight and decreasing negative
perceptions of mental health problems (Smith & Sho-
chet, 2011).
In this study, students who reported poor-sleep quality
were less likely to report help-seeking intention (Malhi
et al., 2014; Reinhold, 1973). Additionally, poor-sleep qual-
ity was not found to moderate the relationship between stu-
dents’ common mental health problems and help-seeking
intention. Examining potential moderating models of the
mental health effects on help-seeking intentions indicated
only small effects. Future studies need to investigate further
these significant aspects of sleep quality, for example, help-
seeking behaviours in relation to sleep disturbance.
Overall, the results of this study suggest that students do
not have high intention to seek help despite experiencing
poor-sleep quality or low to moderate mental health symp-
toms. It is unclear what the specific reasons are for not
seeking help (Ryan et al., 2010). Previous research has
shown that lack of insight is a barrier to help seeking (Czyz
et al., 2013) as a person needs to be aware there is a prob-
lem that requires intervention in order to make the decision
to seek help (Jorm et al., 1997). Awareness campaigns
© 2017 The Australian Psychological Society
Poor sleep, mental health, and help seeking 45
aimed at improving insight to accurately identify common
mental health problems (Yap, Reavley, & Jorm, 2014) as
well as poor-sleep quality (Brown et al., 2002) are recom-
sr2 mended. Such campaigns promote effective therapeutic
.04 strategies on campus, improve awareness amongst students,
.02 and time to receive treatment (Barney, Griffiths, Jorm, &
.03 Christensen, 2006; Blumenthal & Endicott, 1996; Lauber,
.00 Nordt, Falcato, & Rössler, 2003; Reavley et al., 2012;
Smith & Shochet, 2011).
Limitations of this study include sample size and over-
representation of females thus limiting the generalisability
of the results. Future research could expand on this study
by including a larger sample size; include a better represen-
tation of males; focussing on students with mental health
problems; and by directly assessing help seeking for sleep.
Further, as university students are a part of the on-line gen-
eration (Hinsch & Sheldon, 2013), they may be more likely
to turn to this modality for their problems (Ryan et al.,
2010). On-line therapy is a growing field gaining increasing
attention in the literature of university student intervention
provision (Zochil, 2015). Therefore, future research could
investigate on-line platforms for seeking help.
The present cross-sectional design limits conclusions on
causality and directionality among the variables (Meltzoff,
2011) and causal modelling (Maxwell & Cole, 2007). Addi-
tionally, as increasing symptoms of common mental health
problems (Stallman, 2010) and poor-sleep quality
(Lamberti, 2012) are experienced towards the end of semes-
ter as students’ academic demands increase, a longitudinal
approach could assist in further explaining the temporal
relations between the variables.
In conclusion, this study attempted to expand on previous
mental health and help-seeking research by examining
these simultaneously with sleep and exploring how poor-
sleep quality may impact the relationship between depres-
sion, anxiety, and stress with help-seeking intention within
a university student population. Although the moderation
effect was not supported, it advanced our knowledge of uni-
versity student low intention to seek help for common
mental health problems despite high scores of poor-sleep
quality. The negative relationship between students’ inten-
tion to seek help and mental health should be seriously
considered in future mental health literacy campaigns and
on campus mental health interventions.
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