Journal of American College Health

ISSN: 0744-8481 (Print) 1940-3208 (Online) Journal homepage: www.tandfonline.com/journals/vach20

Perceived need for care and mental health service

utilization among college students with suicidal
ideation

Boyoung Nam, Holly C. Wilcox, Matthew Hilimire & Jordan E. DeVylder

To cite this article: Boyoung Nam, Holly C. Wilcox, Matthew Hilimire & Jordan E. DeVylder
(2018) Perceived need for care and mental health service utilization among college
students with suicidal ideation, Journal of American College Health, 66:8, 713-719, DOI:
10.1080/07448481.2018.1434779

To link to this article: https://doi.org/10.1080/07448481.2018.1434779

Published online: 30 Mar 2018.

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JOURNAL OF AMERICAN COLLEGE HEALTH
2018, VOL. 66, NO. 8, 713–719
https://doi.org/10.1080/07448481.2018.1434779

MAJOR ARTICLE

Perceived need for care and mental health service utilization among college
students with suicidal ideation
Boyoung Nam, MSWa , Holly C. Wilcox, PhDb, Matthew Hilimire, PhDc, and Jordan E. DeVylder, PhDa,d
a
School of Social Work, University of Maryland, Baltimore, Maryland, USA; bDepartment of Mental Health, Johns Hopkins Schools of
Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA; cDepartment of Psychology, The
College of William & Mary, Williamsburg, Virginia, USA; dGraduate School of Social Service, Fordham University, New York, New York, USA

ABSTRACT ARTICLE HISTORY

Objective: This study aimed to identify correlates of service utilization and perceived need for Received 17 May 2017
care among college students with suicidal ideation. Participants: Respondents were recruited Revised 9 December 2017
from introductory psychology courses at an undergraduate college during the Fall 2014 semester. Accepted 28 January 2018
Methods: Independent correlates of (1) mental health service utilization, (2) self-perceived need,
KEYWORDS
and (3) other-perceived need for mental health services among college students (N ¼ 190) with Gatekeepers; mental health
suicidal ideation were identified. Results: Service utilization was associated with need for care as services; need for care;
perceived by others. Perceived need for care by others was associated with suicidal ideation inten- social support; suicide;
sity and suicide attempt history. Perceived need by the respondents themselves was correlated young adult
with depression severity, sex, and race but was not independently associated with actual service
utilization. Conclusions: Perceived need by others was the sole significant correlate of service util-
ization, suggesting it is an important target for public health interventions aimed at facilitating
pathways into mental health treatment.

Introduction white nonimmigrant populations.10–12 Health beliefs and

Suicide is a leading cause of preventable death in the United
States, and the second leading cause of death for Americans
aged between 15 and 24 in 2015.1 Suicide attempts peak
during adolescence and young adulthood2 and approxi-
mately 10% of college students seriously consider suicide
each year.3,4 However, it is an ongoing challenge to connect
individuals at increased risk for suicide with appropriate
mental health care services.5 According to the 2014 National
Survey on Drug Use and Health,6 more than 50% of adults
with suicidal ideation, plans, or attempts did not receive any
mental health services, and 38.7% of them even felt that
there was no need for seeking help. To facilitate help-seek-
ing behaviors among youth with suicide risk, we need to
better understand factors that could either promote or deter
help-seeking behaviors.
Andersen’s Behavioral Model of Health Service Use7 pro-
vides a framework that explains factors associated with indi-
viduals’ decision to use health services, which may inform
suicide prevention efforts. According to this theory, service
utilization is determined by 3 factors: predisposing charac-
teristics; enabling or impeding factors; and need for care.
Predisposing factors include demographic factors, social
structure, and health beliefs. For example, women are gener-
ally more likely to recognize the need for mental health
services8 and receive help,9 and ethnic minority or immi-
grant populations typically show lower service use rates than
stigma also impact service use among college students.13–16
For example, Czyz and colleagues17 found that college stu-
dents with suicide risk (defined as endorsing at least 2 sui-
cide risk factors: current suicidal ideation, suicide attempt
history, current depression, current alcohol abuse) did not
initiate mental health services because of concerns about
stigma related to mental health problems and discomfort
related to discussing problems with mental health
professionals.
Enabling factors include personal and community resour-
ces that enable health service utilization. Personal or family
status in income, health insurance, and travel and waiting
times can either enable or impede service use.18 Although
college students typically have health insurance and access
to campus-based health care services, many students per-
ceive financial constraints as impeding factors for mental
health service use,19,20 and about 40% of college and gradu-
ate students with suicidal ideation reported financial reasons
as a main barrier for using mental health services.11,21
Perceived need for care is also relevant to service utiliza-
tion. Among college students who were at elevated suicide
risk such as having current suicidal ideation or attempt his-
tory but did not receive any treatment over the past 2
months, 66% reported that they did not recognize any need
for professional treatment and their symptoms were minor
or transient.17 Moreover, a lack of perceived need and bene-
fit of treatment has been found to prevent college students

CONTACT Jordan E. DeVylder jdevylder@fordham.edu Graduate School of Social Service, Fordham University, 113 W 60th St, New York, NY 10023, USA
ß 2018 Taylor & Francis Group, LLC
714 B. NAM ET AL.
from seeking mental health care.22 In addition to this, some
studies found that college students with higher suicidal idea-
tion had lower intentions to seek professional23 or informal
help.24 This phenomenon has been conceptualized as “help
negation,” which means that greater hopelessness, pessim-
ism, and maladaptive coping within individuals with suicidal
ideation make it difficult to seek help.25 Because many indi-
viduals with suicidal risk may not seek treatment on their
own, it is important for family, friends, and other concerned
individuals to help facilitate linkage to mental health serv-
ices.26 However, impact of perceived need by others on
help-seeking behaviors has been rarely examined in the pre-
vious research. In addition to this, Cauce and colleagues27
suggested that help-seeking is on a pathway, such that help-
seeking behaviors cannot be initiated without problem rec-
ognition. Therefore, it is important to understand how peo-
ple become aware of their problem and need in order to
comprehensively understand help-seeking behaviors among
college students at suicide risk.
The present study examines factors associated with ser-
vice utilization and perceived need for care among college
students with suicidal ideation. Potential predisposing fac-
tors were identified based on the Andersen’s Model of
Health Behavior,7 and included predisposing factors (i.e.,
sex, race/ethnicity, sexual orientation, and mental health
stigma), need factors (i.e., depression, distress related to
psychotic experiences, suicidal ideation severity, intensity,
and suicide attempt history, and perceived need), and an
enabling factor (i.e., family income). We first aimed to iden-
tify constructs associated with perceived need by individuals
with suicidal ideation themselves and their friends, partners,
family members to better understand why college students
with suicidal ideation feel the need for treatment, and why
this need is perceived by others. We also aimed to assess
which aspects of perceived need as well as predisposing and
enabling factors are independently associated with mental
health service utilization.
Method
Procedure and participants
Respondents were recruited from introductory psychology
courses at an undergraduate college during the Fall 2014
semester. The college is a research university located in
Virginia and provides more than 40 undergraduate pro-
grams and 20 graduate and professional degree programs.
There were over 6,200 undergraduate and 2,300 graduate
students enrolled in the institution. The institution consists
of predominantly whites (approximately over 55%) and
slightly more female students (about 58%). Participation was
voluntary in return for course credit; 2 options were given
to students in the introductory psychology courses: complet-
ing the survey or writing a paper. Students who decided to
participate in this study (N ¼ 799) provided informed con-
sent and completed an online survey through Qualtrics soft-
ware. For the present study students with suicidal ideation
(N ¼ 190) were selected from the total sample. This study
was approved by the institutional review boards of the insti-
tutions in the Mid-Atlantic region of the United States.
Measurement
Predisposing factors: Sex, race=ethnicity, sexual orienta-
tion, and mental health stigma
Self-reported sex, race=ethnicity, sexual orientation, and
mental health stigma were assessed as potential predisposing
factors for service utilization. Sex was measured as a binary
variable (ie, women and men, men were used as a reference
group). Race=ethnicity was self-reported and dichotomized
as other than white (reference group) and white due to low
frequency of non-white race=ethnicity groups. Sexual orien-
tation was assessed with a single question with responses
ranging from [1] exclusively homosexual to [7] exclusively
heterosexual, with [4] bisexual in the middle of the
responses and [8] prefer not to respond at the end. The
item was dichotomized as [1] exclusively heterosexual and
[0] others including all other answers and prefer not to
respond, due to a bimodal distribution of the original vari-
able, as in prior research with similar measures.28
Stigma, operationalized as respondents’ negative attitude
toward people with mental health problems (stereotype
awareness), was assessed using a 10-item scale based on the
well-validated perceived devaluation-discrimination scale,29
with language adaptations for this young adult age group.30
Respondents were asked to answer how strongly they agree
or disagree with the statements describing young people
with emotional problems such as “may be more dangerous,”
“have trouble taking care of themselves,” and “have them-
selves to blame.” Sum scores of 10 questions with 4-point
Likert-type scales ranges from 10 to 40 with a higher score
indicating stronger mental health stigma. Internal consist-
ency of the stigma scale was acceptable (Cronbach’s a
¼ 0.725).
Enabling factor: Family income
Family yearly income was reported in $10,000 increments:
[1] under $10,000; [2] $10,001–$20,000; [3]
$20,001–$30,000; [4] $30,001–$40,000; [5] $40,001–$50,000;
[6] $50,001–$60,000; [7] $60,001–$70,000; [8] $70,001–
$80,000; [9] $80,001–$90,000; [10] $90,001–$100,000; [11]
$100,001–$125,000; [12] $125,001–$150,000; [13] $150,001
or more; [14] not sure; and [15] prefer not to answer. For
the multiple regression, the variable was collapsed into 5
categories with $40,000 increments to avoid small cell sizes:
[1] under $40,000; [2] $40,001–$80,000; [3] more than
$80,001 [4] not sure; [5] prefer not to answer. Finally the 4
dummy variables were created and under $40,000 group was
used as reference.
Need factors: Depression, psychotic experience distress,
suicidal ideation severity and intensity, suicide attempt
history, and perceived need
Depression The Center for Epidemiologic Studies
Depression scale31 was used to measure current (past

2 weeks) depressive symptoms. Respondents answered 20
items on a 5-point Likert-type scale: [0] not at all or less
than 1 day last week; [1] 1 or 2 days last week; [2] 3 to
4 days last week; [3] 5 to 7 days last week; and [4] nearly
every day for 2 weeks. However, to avoid confounding with
suicidal ideation (ie, C-SSRS),32 1 item measuring current
suicidal thoughts (past 1 to 2 weeks) was excluded. The
potential range of sum score was between 0 and 76 with a
higher score indicating more depressive symptoms. The
internal consistency of the scale with the sample was excel-
lent (Cronbach’s a ¼ 0.916).
Psychotic Experience Distress The 21-item Prodromal
Questionnaire-Brief (PQ-B)33 was used to measure lifetime
distressing psychosis-like symptoms, which have been linked
to suicidal ideation34 and service use.35 The potential range
of sum scores of the scale are between 21 and 105, with
higher scores indicating higher level of distress associated
with psychotic experiences. The internal consistency of the
scale was good (Cronbach’s a ¼ 0.853).
Suicidal Severity, Intensity, and Suicide Attempt
Lifetime suicidal ideation severity, intensity, and suicide
attempt history were assessed with the Columbia-Suicide
Severity Rating Scale (C-SSRS).32 C-SSRS consists of 3 sub-
scales: suicidal ideation severity, suicidal ideation intensity,
and suicidal behavior. Suicidal ideation severity was meas-
ured with a 5-point ordinal scale: [1] wish to be dead; [2]
nonspecific active suicidal thoughts; [3] suicidal thoughts
with methods; [4] suicidal intent; and [5] suicidal intent
with plan. Only respondents who endorsed 1 or higher on
this severity measure were included in this study (N ¼ 190).
Suicidal ideation intensity was measured with the sum score
of 5 items assessing frequency and duration of ideation. The
internal consistency of the intensity subscale was good
(Cronbach’s a ¼ 0.848). Suicide attempt history was meas-
ured with a single item asking if respondents had made any
suicide attempt in the past (lifetime).
Perceived Need Perceived need by respondent themselves
was measured with a single question; “I felt the need for
mental health services over the past year.” Perceived need by
others was also measured with a single question; “Friends,
family members, or others close to me have told me that I
needed to seek mental health services over the past year.”
Both questions were measured with a 4-point Likert-type
scale. Possible scores range from [1] strongly disagree to [4]
strongly agree.
Service Utilization A binary variable asking if they had
an appointment with a psychiatrist, clinical psychologist, or
other mental health professional over the past year was used
to measure respondents’ service use.
Analytic plan
2
Descriptive and bivariate analyses (v and t-test) were con-
ducted to explore sample characteristics and differences
between service utilization. Two separate multiple linear
regression models were conducted to identify factors of
Andersen’s Model that were related to perceived need for
mental health service use. Multiple logistic regression was
JOURNAL OF AMERICAN COLLEGE HEALTH 715
used to test for correlates of actual service utilization,
including all indicators of predisposing characteristics, ena-
bling factors, and need for care.
Results
Characteristics of study sample
The descriptive characteristics of the sample and mean
scores on mental health measures are displayed in Table 1.
Among all respondents 23.8% reported any lifetime suicidal
ideation on the C-SSRS. Approximately 40% of respondents
reported that they had an appointment with a mental health
professional over the past year. In bivariate analyses, these
respondents reported greater suicidal ideation intensity (but
not ideation severity) and greater likelihood of both perceiv-
ing need for care themselves and having that need perceived
by others. Respondents who did and did not utilize services
did not differ in terms of sex, race, suicide attempt history,
depressive symptoms, psychotic symptoms, or stigma.
Factors associated with perceived need and mental
health service use
In a multiple regression model examining factors associated
with perceived need for help by respondents with suicidal
ideation themselves, sex (p ¼ 0.006), race (p ¼ 0.035), and
depression (p < 0.001) were statistically significant
(Table 2). Women and white respondents more strongly
endorsed the need for help. Respondents with higher depres-
sion scores were significantly more likely to perceive the
need for help. On the other hand, suicidal intensity (p ¼
0.001) and suicide attempt history (p ¼ 0.013) were the only
significant correlates of perceived need by others. When
respondents had more intense suicidal ideation and suicide
attempt history, people around the respondents were signifi-
cantly more likely to encourage them to seek help (Table 2).
In logistic regression examining factors associated with
mental health service use among respondents with suicidal
ideation, being encouraged to seek help by others was a
strong and unique factor of actual mental health service util-
ization (p < 0.001). None of other predisposing (sex, race-
=ethnicity, sexual orientation, mental health stigma),
enabling (family income), and need factors (perceived needs
by the suicidal individuals themselves, depression, psychotic-
experience distress, suicidal ideation severity, intensity, and
suicide attempt history) were associated with service utiliza-
tion (Figure 1).
Comments
The majority of clinical suicide prevention approaches rely
on identifying at risk individuals and connecting them with
mental health services as many individuals with suicidal
ideation do not seek help on their own or otherwise engage
in mental health services.6,19 The current study examined
factors associated with the use of mental health services and
perceived need for mental health services among college
716 B. NAM ET AL.

Table 1. Descriptive characteristics of the study sample and bivariate tests.

Service utilization
Variable Total sample (N ¼ 190) No (n ¼ 113) Yes (n ¼ 75) Statistics
Categorical variables N % N % N % v2
Sex
Men 60 31.6 40 66.7 20 33.3 1.582
Women 130 68.4 73 57.0 55 43.0
Race
Non-white 58 30.5 39 69.6 17 30.4 3.025
White 132 69.5 74 56.1 58 43.9
Family income
Under $40,000 26 13.7 20 76.9 6 23.1
$40,000–$80,000 96 50.5 53 55.2 43 44.8 4.506
More than $80,000 46 24.2 26 57.8 19 42.2
Not sure 13 6.8 8 66.7 4 33.3
Prefer not to answer 9 4.7 6 66.7 3 33.3
Sexual orientation
Other 84 44.7 47 56.0 37 44.0 1.093
Exclusively heterosexual 104 55.3 66 63.5 38 36.5
Suicide attempt history
No 170 89.5 104 61.9 64 38.1 2.130
Yes 20 10.5 9 45.0 11 55.0
Perceived need by others
No 120 63.2 91 75.8 29 24.2 34.221
Yes 68 35.8 22 32.4 46 67.6
Missing 2 1.0 — — — —
Perceived need by respondent
No 80 42.1 61 76.3 19 23.8 15.572
Yes 107 56.3 51 47.7 56 52.3
Missing 3 1.6 — — — —
Service utilization
No 113 59.5 — — — —
Yes 75 39.5 — — — —
Missing 2 1.0 — — — —
Continuous variables M SD M SD M SD t
Mental health stigma 19.07 3.95 20.08 3.83 19.20 4.10 1.500
CESD 18.59 12.77 17.70 11.49 19.94 14.50 1.122
PQB-distress1 14.23 13.49 12.95 12.96 16.26 14.15 1.59
Suicidal ideation severity 2.78 1.38 2.66 1.40 2.96 1.34 1.446
Suicidal ideation intensity 9.78 5.33 9.08 5.26 10.88 5.31 2.289
p < 0.05, p < 0.001.
1
Prodromal Questionnaire Brief-Distress scale.

students with suicidal ideation in order to support future
efforts to engage young adults with suicidal ideation into
treatment. The main finding of our study is that perceived
need for mental health services by family, friends, and
others was the only significant independent factor of mental
health service utilization. Individuals with suicidal ideation
were statistically significantly more likely to seek services
when their family or friends encouraged them to do so.
Appraisal from significant others may increase suicidal indi-
viduals’ perceived severity of their status. For individuals
with suicidal ideation, the ambiguity in determining need
for help may transform into certainty when someone tells
them they are in need.
While female sex, white race, and depressive symptoms
were associated with perceived need by individuals with sui-
cidal ideation, one’s own perceived need for help did not
lead them to actually seek services. In contrast, respondents
with suicidal ideation appeared to be more strongly encour-
aged to seek help by their family and friends when they
were experiencing greater intensity of suicidal ideation,
although it is not clear how these individuals perceive and
recognize this ideation intensity (or if they are responding
to more apparent general psychological distress).
Our findings suggest that friends and family of those
with suicidal ideation can be critical resources in the path-
way to care, potentially by providing more objective judg-
ment as to whether or not the individual needs to get
treatment. These findings are aligned with gatekeeper train-
ing programs that emphasize roles of gatekeepers who con-
tact individuals with suicide risk and facilitate their access
to mental health services.36,37 In addition to formal gate-
keepers such as social workers, nurses, and counselors, com-
munity members, family, and peers have gradually received
attention as informal gatekeepers because of their close rela-
tionship with those at suicide risk.38 Individuals may feel
more comfortable sharing their feelings with their family
and friends, which in turn can increase accessibility to for-
mal and informal help.36 Based on our data, educating the
general population to recognize the signs of suicidal idea-
tion and behaviors is valuable because people can detect sui-
cide related symptoms of their friends or family, make the
concern known to the individuals with suicide risk, and
facilitate linkage to mental health services, particularly on
college campuses. For example, universities can provide
information on identifying suicide risk and accessing serv-
ices on campus so that students can encourage others that
 JOURNAL OF AMERICAN COLLEGE HEALTH 717

Table 2. Multiple regressions examining factors associated with perceived need for care.
Perceived by respondent themselves1 Perceived by others2
Variable b 95% CI b 95% CI
Sex (Women) 0.186 [0.122, 0.716] 0.094 [0.099, 0.539]
Race (white) 0.146 [0.025, 0.652] 0.119 [0.049, 0.623]
Sexual orientation 0.093 [0.472, 0.078] 0.103 [0.522, 0.07]
Mental health stigma 0.087 [0.059, 0.012] 0.068 [0.057, 0.019]
Family income 40 K-80 K 0.027 [0.641, 0.805] 0.018 [0.718, 0.831]
Family more than 80 K 0.15 [0.345, 0.976] 0.198 [0.279, 1.143]
Family income-Not sure 0.137 [0.346, 1.024] 0.146 [0.361, 1.113]
Family income-Prefer not to answer 0.078 [0.499, 1.161] 0.155 [0.204, 1.582]
Depression 0.326 [0.015, 0.039] 0.122 [0.003, 0.023]
PQB-distress 0.017 [0.012, 0.01] 0.028 [0.014, 0.01]
Suicidal ideation severity 0.003 [0.138, 0.133] 0.066 [0.198, 0.094]
Suicidal ideation intensity 0.162þ [0.001, 0.065] 0.285 [0.023, 0.094]
Suicide attempt history 0.085 [0.224, 0.797] 0.199 [0.151, 1.25]
F(df1, df2) 5.258 (13,171) 4.039 (13,172)
R 0.534 0.484
R2 0.286 0.234
þ
p < 0.1, p < 0.05, p < 0.01, p < 0.001.
1
VIF < 6.069.
2
VIF < 6.103.

appear to be at risk to access available mental
health services.
On the other hand, surprisingly, other predictors sug-
gested by Andersen’s Behavioral Model such as income,
race=ethnicity, and self-reported mental health status were
not significantly associated with service utilization in the
present study. Impact of family income on mental health
service use could have been reduced as most college students
are bound to have health insurance. College students also
have relatively equal access to counseling services on cam-
pus. It is possible that different choice of study population
may have generated different results from previous studies.
There are studies that examined factors that facilitate or
deter help-seeking among college students regardless their
mental health status,22 although students with suicidal idea-
tion or depression were more likely to seek help as com-
pared to students without any mental health problems.
However, as shown in the present study of students with
suicidal ideation, just having more severe suicidal ideation
or depressive symptoms may not be sufficient for someone
to initiate mental health services. Similar to our study find-
ings, a previous study with students at suicide risk found
that about 65% of students who received treatment decided
to use the services because of the encouragement from their
families, friends, or campus staff.11 In addition, perceived
need by others has been rarely examined in the previous
research using the Andersen’s Behavioral Model whereas
perceived need by respondents themselves has been often
examined.39 Although more evidence is required, previously
supported associations between enabling, predisposing fac-
tors, and service utilization could be changed when per-
ceived need by others is included as an adjustment.
Racial=ethnic differences in service utilization may have not
been detected in the present study by combining several
racial=ethnic groups due to the low frequency of respond-
ents from individual racial=ethnic minority groups.

Figure 1. Factors associated with mental health service use. The odds ratios are plotted on a logarithmic scale. Bars indicate 95% CIs, with asterisk indicating
significance.
718 B. NAM ET AL.
Limitations
Potential limitations of this study include a cross sectional
design, making it difficult to determine causal relationships
between suicidal ideation intensity, perceived need, and
actual service use. Additionally, the lifetime suicide ideation
variable does not allow for sorting out the timing of con-
structs. We can benefit from future studies using longitu-
dinal study design in examining causality of the relationship.
Further, our single item measure of perceived need by
others did not allow us to distinguish whether respondents
are being encouraged to seek treatment by friends, family
members, or other acquaintances; the distinction may be
useful in guiding intervention efforts. Also, our study used a
measure of stigma that assessed attitudes toward mental ill-
ness itself, rather than service utilization, and therefore can-
not rule out the possibility that stigma specifically regarding
mental health service utilization may be an independent bar-
rier for treatment, as previously suggested.40,41 The study
was conducted at one undergraduate college in Virginia, so
findings from the present study may not be generalizable to
other institutions with regard to student demographics.
Study findings may be more generalizable to institutions
with more white students. In addition, samples of psych-
ology students may have limited generalizability outside of
undergraduate settings. Despite these limitations, our data
suggest that peer and family identification and intervention
provides an important pathway to service utilization for col-
lege students with suicidal ideation that may be further bol-
stered through initiatives aimed at raising community
awareness of suicide risk and available services.
Conclusions
It is an ongoing challenge in suicide prevention to connect
individuals with suicidal ideation with appropriate mental
health care services. The current study found that individu-
als with suicidal ideation were more likely to perceive need
for help when they have greater depressive symptoms,
whereas other people around the individuals with suicidal
ideation may tell them to seek care when the individuals
have intensive suicidal thoughts or suicide attempt history.
Interestingly, perceived need for help by these individuals
did not lead them to actually seek help. Instead, individuals
with suicidal ideation were more likely to seek services
when their family or friends encouraged them to do so.
Therefore, suicide prevention programs need educate people
to recognize signs of suicide and suicidal ideation, allowing
them to encourage their peers and family members to seek
proper mental health services.
Conflict of interest disclosure
The authors have no conflicts of interest to report. The authors con-
firm that the research presented in this article met the ethical guide-
lines, including adherence to the legal requirements, of the United
States and received Institutional Review Board approval from the
College of William and Mary and University of Maryland.
ORCID
Boyoung Nam http://orcid.org/0000-0001-6799-5434
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