Psychosocial Correlates of Jordanian Adolescents’ Help-Seeking Intentions for Depression: Findings From a Nationally Representative School Survey

Abstract

Little is known about help-seeking for depression among Jordanian adolescents who are a vulnerable population with high rates of depressive symptoms and few mental health services. The purpose of this study was to (1) explore Jordanian adolescents’ helpseeking intentions for depression and (2) examine whether depression stigma, depression severity, or their interaction are associated with Jordanian adolescents’ willingness to seek help for depression and the type of treatment they would seek. In collaboration with the Jordanian Ministry of Education, we conducted a nationally representative, school-based survey of adolescents aged 12–17 years (N = 2,349). One fourth of the adolescents reported they would not seek professional help for depression, and those respondents had higher average depression scores. Among those adolescents willing to seek help, the most likely sources included family member (57%), school counselor (46%), psychiatrist (43%), religious leader (39%), and general health practitioner (28%). Lower stigma scores were associated with greater likelihood to seek psychotherapy or visit a psychiatrist, while higher stigma scores were associated with increased likelihood to seek help from a school counselor or a family member. Jordanian adolescents experience significant barriers to seeking professional help for depression. However, even among adolescents with greater depression severity and depression stigma, school counselors were identified as a key resource for help. These findings suggest that school-based interventions may fill a critical service need for adolescents with depression and other mental health problems. School nurses should be leveraged along with counselors to address mental health issues in this vulnerable population.

Keywords

adolescent depression Arab depression stigma Jordan help-seeking school nurse

Early detection and treatment of adolescent depression is vital to prevent its many immediate and long-term individual, interpersonal, family, and societal costs (Koplewicz & Klass, 2016; Neufeld, Dunn, Jones, Croudace, & Goodyer, 2017; Stockings et al., 2016). Unfortunately, depression in adolescence is widely underdiagnosed and undertreated, as adolescents often avoid reporting symptoms of depression and have poor utilization of mental health services (Arbanas, 2008; Sheffield, Fiorenza, & Sofronoff, 2004; Williams & Pow, 2007). Research has shown that factors like personal characteristics, inadequate knowledge, false beliefs, and stigmatizing attitudes toward mental illness can substantially influence depressed adolescents’ (a) willingness to seek help and (b) views of best treatment (Arbanas, 2008; Calear, Griffiths, & Christensen, 2011; Sheffield et al., 2004; Slade, 2002). Therefore, these factors need to be carefully considered when designing depression education, early intervention, and treatment programs. It is also important to realize that these factors are often embedded in their sociocultural context, varying widely from person to person and from culture to culture (Dardas & Simmons, 2015).

Jordanians share a set of Arabic values, beliefs, and traditions that are largely different from those of Westerners, and these cultural mores can be decisive in shaping their perception and management of mental illnesses as well as their selection, engagement, and utilization of mental health services (Dardas & Simmons, 2015; Fakhr El-Islam, 2008). Our first nationally representative survey of adolescent depressive symptoms in Jordan revealed a critically high prevalence reaching up to 34% for moderate-to-severe symptoms (Dardas, Silva, Smoski, Noonan, & Simmons, 2017). Further, the vast majority of these adolescents reported high stigmatizing attitudes toward depression and endorsed several false beliefs and misconceptions (Dardas, Silva, Smoski, Noonan, & Simmons, 2017). With the substantial lack of mental health resources, little is known about help-seeking for depression among this vulnerable population. It is also not clear how Jordanian adolescents’ characteristics, depression levels, and attitudes toward depression may affect their willingness to seek psychological help (Dardas, Bailey, & Simmons, 2016). Addressing this significant gap in knowledge can guide intervention programs to increase treatment utilization and maximize health outcomes for Jordanian adolescents at risk for or diagnosed with depression.

The Role of the School Nurse in Addressing Adolescent Depression in Jordan

According to the most recent schools report released by the JMOE (2014), there are 4,686 schools that include a total of 749,134 adolescents aged 12–17 years, accounting for nearly 93% of all Jordanian adolescents aged 12–17 years (Jordanian Department of Statistics, 2016). The school setting is considered a critical environment for promoting adolescents’ mental and emotional well-being as well as for identifying those at risk for or experiencing mental health problems (Jané-Llopis, Barry, Hosman, & Patel, 2005; Wyn, Cahill, Holdsworth, Rowling, & Carson, 2000). Thus, utilizing the school setting for depression education and intervention programs has the potential to reach large numbers of Jordanian adolescents with undiagnosed and undertreated depression. This is critically important, given the substantial lack of mental health services in Jordan and the high stigma associated with accessing professional services. The World Health Organization (WHO) mental health assessment report (2011) revealed that mental health services in Jordan are confined to mental hospitals and few psychiatric units, while primary services, like those provided in school settings, are critically underdeveloped and even entirely absent in the vast majority of Jordanian schools. In fact, schools may provide a nonstigmatizing framework within which badly needed mental health services can be provided. However, to date, the only mental health services available in the schools come from counselors whose primary job is to address academic, career, and disciplinary issues as opposed to mental health concerns.

In Jordan, school nurses may be uniquely situated to address the growing numbers of adolescents experiencing depression. While many schools started to hire nurses, they are not being used to their full scope. Studies of school nurses in Western countries have shown that they are vital to the health and academic performance of school adolescents (Carnevale, 2011). In fact, the National Association of School Nurses [NASN] declared mental health assessment within the scope of practice for school nurses, as they are prepared to identify, treat, and likely prevent worsening of symptoms (NASN, 2012). However, no evidence is available on whether these Western standards are readily applicable in Jordan. It is also unknown whether Jordanian adolescents are willing to seek school services for psychological support.

Additionally, no data are available on what sources of help depressed Jordanian adolescents tend to seek. Therefore, the aims of this study were to (1) examine Jordanian adolescents’ help-seeking intentions for depression and (2) determine whether stigmatizing attitudes toward depression, depression severity, or their interaction are associated with Jordanian adolescents’ willingness to seek help for depression and the type of treatment they would seek. The overarching goal of this work is to provide the data necessary to advocate for school nurses being available in all Jordanian schools and working to their full scope, so that the schools can be a frontline defense for the significant problem of adolescent depression.

Method

Design

The procedures for this study have been described in detail elsewhere (Dardas et al., 2017). In brief, we conducted a nationwide school survey in collaboration with the JMOE. A representative sample of adolescents aged 12–17 years was obtained by applying a stratified random sampling procedure to randomly select from Jordanian public and private schools. Data were collected from a total of 48 schools located in all regions of the country with proportions reflecting population density. Our anonymous survey included measures on the adolescents’ sociodemographic and health characteristics, depression symptoms, depression stigma, and help-seeking intentions for depression, as described below. The study received institutional review board approvals from both Duke University and the University of Jordan.

Participants

The sample included 2,349 Jordanian adolescents aged 12–17 years, with a mean age of 15.0 years (SD = 1.5). The majority of the sample was female (59%), living in the central urban region (43%), and with a grade point average between very good and excellent (58%). Among the adolescents, 15% reported having a mental health problem, 8% reported they had received a psychiatric diagnosis, and 22% reported they sought a psychological help at some point in the past. However, the vast majority of participants (65%) reported that they sought such help from a family member or a friend, while only 4–8% of the sample reported seeking help from a school counselor, a psychiatrist, or a general health practitioner.

Measures

Adolescent characteristics

Research from the Arab literature revealed that individuals’ characteristics like age, gender, socioeconomic status, region of residence, and mental health history might affect Arabs’ willingness to seek psychological help. However, these relationships have not been examined among Arab adolescents. Thus, we collected data on these variables to be included in our subsequent analyses.

Depression severity

A validated Arabic version of the Beck Depression Inventory–II (BDI-II; Beck, Steer, & Brown, 1996) was used to assess the severity of depression symptoms among the adolescents. The BDI-II, a self-reported questionnaire assessing 21 depression symptoms, has been validated with good sensitivity in differentiating depressed from nondepressed individuals. The BDI-II total score has a possible range of 0–63, with higher total scores representing greater severity of depression. A total score of 20–28 indicates moderate depression, while a score of 29 or higher reflects severe depression (Beck et al., 1996). In this study, the Cronbach’s α for the scale was .89.

Depression stigma

The Depression Stigma Scale (DSS; Griffiths, Christensen, & Jorm, 2008) was used to assess the stigma associated with depression. The scale is an 18-item measure that assesses the following major themes: depression as an illness, personal control of depression, depression as a character flaw, dangerousness and unpredictability of someone with depression, shame of depression, and avoidance and discrimination of those with depression. Each item is scored on a Likert-type scale (0 = strongly disagree to 4 = strongly agree), with a higher score indicative of greater stigma. In this study, the Cronbach’s α for the scale was .80.

Depression help-seeking intentions

Participants’ likelihood to seek help for depression was assessed using the Depression Treatment Seeking Scale (Barney, Griffiths, Jorm, & Christensen, 2006). The scale consists of 9 items rated on a 5-point Likert-type scale (1 = not at all likely to 5 = very likely). Example items include If I had depression I would seek help from a counselor, psychiatrist, general health practitioner, clergy/Shaikh, or others; I would not seek treatment from a professional; I would be willing to take medication; and I would be willing to seek therapy. The scale has shown good internal reliability and validity (Barney et al., 2006; Wadian, 2013). In this study, the Cronbach’s α for the scale was .78.

No Arabic versions were available for the DSS and help-seeking intentions scales, and thus two bilingual professional language editors were hired to conduct a systematic translation–back translation procedure. An expert panel was then used to ensure linguistic and conceptual equivalence of the original measures. The translated measures were piloted with a sample of 88 Jordanian adolescents, and exploratory and confirmatory factor analyses confirmed the psychometric properties of the translated measures (Dardas, Silva, Noonan, & Simmons, 2016, 2017).

Analysis Plan

All data were analyzed using SAS 9.4 software (SAS Institute, Cary, NC). Descriptive statistics were used to detail the sample characteristics and study measures. Nondirectional statistical tests were conducted with the level of significance set at 0.05 for each test. Regression analyses were performed to examine whether depression stigma, depression severity, or their interaction are associated with Jordanian adolescents’ willingness to seek help for depression and the type of treatment they would seek, after adjusting for adolescent characteristics (Table 1). Adolescent characteristics were sex, region of residence, history of mental health problem, and psychological help-seeking. First, bivariate regression analyses were conducted to examine the simple relationship between each candidate predictor and each outcome. For each outcome, only those adolescent characteristics significant at the .10 level were retained as covariates for the multiple regression analysis. The initial multiple regression model for each outcome included depression severity, depression stigma, their interaction, and the retained covariates. Multicollinearity among the main effects of the predictor and covariates in each model was assessed using the tolerance score. Next, a manual backward elimination method was used to reduce the initial multiple regression model to final model that included depression severity and depression stigma regardless of statistical significance and other terms (interaction or covariates) significant at the .05 level. Adjusted R ² values were used to address effect size and clinical significance of the final reduced model. In line with Wadian (2013), a separate model was built for each outcome on the depression help-seeking scale.

Table 1.

Descriptive Statistics for Study Predictors and Outcomes.

Measures	Total Sample
Key predictors: Depression stigma and severity
BDI-II depression severity total score	16.3 ± 11.2
DSS depression stigma total score	35.9 ± 10.8
Covariates: adolescent characteristics
Female	1,389 (59%)
Region of residence–Central (urban)	1,018 (43%)
Region of residence–Southern (rural)	545 (23%)
Mental health problem	353 (15%)
Ever sought a psychological help	521 (22%)
Outcomes: help-seeking intentions
I would seek help from a counselor	3.0 ± 0.3
I would seek help from a psychiatrist	3.1 ± 1.4
I would seek help from a general health practitioner	2.6 ± 1.3
I would seek help from a religious leader	2.9 ± 1.4
I would seek help from a family member	3.4 ± 1.4
I would be willing to take medication	3.3 ± 1.5
I would be willing to seek a therapy	3.2 ± 1.4
I would NOT seek treatment from a professional	2.4 ± 1.4

Note. N = 2,349. BDI-II = Beck Depression Inventory-II; DSS = Depression Stigma Scale; Mean ± SD for continuous measures; n (%) for categorical measures.

Results

Depression Severity and Associated Stigma

The mean BDI-II total score was 16.3 (SD = 11.2, 95% confidence interval [CI] = [15.8, 16.7]), with scores ranging from 0 to 55. Using the severity cutoff scores provided by Beck, Steer, and Brown (1996), 34% of the adolescents reported moderate-to-severe depression (19% moderate and 15% severe). The mean DSS total score was 35.9 (SD = 10.8, 95% CI = [30, 43]). Of the 2,349 participants, 12% reported low stigma (scores ranging from 0–23), 77% moderate stigma (scores ranging from 24 to 48), and 11% high stigma (scores ranging from 49 to 72). Adolescents agreed the most to the item “people with depression could snap out of it if they wanted” (67%). On the other hand, adolescents agreed least on the following items: “I would not employ someone if I knew they had been depressed” (26%) and “people with depression are dangerous” (27%). Further details on these findings are provided elsewhere (Dardas et al., 2017a, b and c).

Help-Seeking Intentions for Depression

Table 2 presents the descriptive statistics for items of the Depression Treatment Seeking Scale. The adolescents rated each help-seeking intention using a 5-point scale. Based on likely to very likely responses, adolescents were more likely to seek help for depression from a family member (57%), followed by a school counselor (46%), psychiatrist (43%), religious leader (39%), or general health practitioner (28%). In addition, 53% of the adolescents reported they would be willing to take medications for depression, while 50% expressed willingness to seek a therapy. Finally, 25% of the adolescents reported they would not be willing to seek professional help for depression. Nearly half (48%) of the participants reported they would seek help from “other sources” and identified these sources in an open-ended field. However, an analysis of these open-ended responses showed that all of the sources identified had been previously assessed in other items on the scale. Thus, the item “other sources” was not included in the regression analysis.

Table 2.

Help-Seeking Intentions for Depression.

Help-Seeking Intentions	n	(1) Not at All Likely (%)	(2) Unlikely (%)	(3) Neutral (%)	(4) Likely (%)	(5) Very Likely (%)
I would seek help from a counselor	2,191	26	15	13	27	19
I would seek help from a psychiatrist	2,184	21	19	15	25	20
I would seek help from a general health practitioner/family doctor	2,180	28	24	20	18	10
I would seek help from a religious leader	2,166	25	17	19	24	15
I would seek help from a family member	2,140	17	11	15	29	28
I would seek help from other sources	1,967	24	13	15	26	22
I would be willing to take medication for my depression	2,167	19	12	16	25	28
I would be willing to seek therapy	2,157	18	15	17	26	24
I would NOT seek treatment from a professional	2,164	41	17	17	13	12

Factors Associated With Adolescents’ Help-Seeking Intentions for Depression

The bivariate regression results indicated that depression severity significantly predicted the following outcomes at the .05 level: seeking help from a counselor (p < .0001), a psychiatrist (p < .0001), a general health practitioner (p = .0039), a religious leader (p = .0015); a family member (p < .0001); seeking treatment from a professional (p = .0041); or not willing to seek therapy (p = .0038). Depression stigma was significantly related at the .05 level to seeking help from a counselor, a psychiatrist, a general health practitioner, a religious leader, a family member; seeking treatment from a professional; willingness to take a medication; and not willing to seek a therapy (all p < .0001). Furthermore, each of the adolescent characteristics (sex, region, history of mental health problem, and help-seeking) significantly influenced all eight help-seeking intentions outcome at the .10 level, and thus, all were retained as covariates for the initial multiple regression models.

The initial multiple regression model for each outcome included depression severity, depression stigma, and their interaction along with adolescent characteristics as covariates. Each multiple regression model was then reduced to a final model with depression severity and depression stigma regardless of statistical significant. To be included in the reduced model, the depression severity-by-stigma interaction and/or a covariate had to be significant at the .05 level. Multicollinearity was not an issue in any of the final models, as indicated by tolerance scores of 0.83 or greater for the predictors.

Table 3 presents the final reduced model after applying the manual backward elimination variable selection method. Increased depression stigma was associated with a decreased likelihood to visit a psychiatrist (p < .0001) but associated with greater likelihood to seek help from a school counselor, or a family member, or to seek some therapy (all p ≤ .05). In addition, Jordanian adolescents with higher depression scores were less likely to endorse willingness to seek help for depression from all investigated sources (all p ≤ .05).

Table 3.

Final Reduced Multiple Regression Model Results.

Multiple Regression Model	N	B	SE	t Value	p Value	β	Adjusted R ²
Seek help from a school counselor	2,095						.13
Depression severity		.0083	.0095	0.88	.3801	.0615
Depression stigma		.0250	.0049	5.04	<.0001	.1809
Depression severity-by-stigma		−.0005	.0002	−2.11	.0347	−.1593
Female		.2245	.0665	3.37	.0008	.0739
Mental health problem		.2143	.0995	2.16	.0313	.0507
Seek help from a psychiatrist	2,092						.13
Depression severity		−.0109	.0031	−3.50	.0005	−.0837
Depression stigma		.0152	.0029	5.26	<.0001	.1137
Female		.1575	.0645	2.44	.0147	.0537
Mental health problem		.2189	.0963	2.27	.0231	.0537
Seek help from a general practitioner	2,089						.13
Depression severity		.0138	.0084	1.65	.0989	.1159
Depression stigma		.0189	.0044	4.30	<.0001	.1544
Depression severity-by-stigma		−.0004	.0002	−2.14	.0328	−.1613
Female		−.2036	.0589	−3.46	.0006	−.0758
Central urban region		−.2379	.0574	−4.15	<.0001	−.0898
Mental health problem		.2936	.0881	3.33	.0009	.0784
Seek help from a religious leader	2,078						.15
Depression severity		.0243	.0088	2.76	.0059	.1918
Depression stigma		.0284	.0047	6.10	<.0001	.2169
Depression severity-by-stigma		−.0008	.0002	−3.25	.0012	−.2437
Female		−.4379	.0623	−7.03	<.0001	−.1529
Central urban region		−.1653	.0606	−2.72	.0065	−.0585
Mental health problem		.2539	.0932	2.72	.0065	.0637
Seek help from a family member	2,039						.16
Depression severity		.0062	.0091	0.68	.4940	.0483
Depression stigma		.0267	.0047	5.62	<.0001	.2006
Depression severity-by-stigma		−.0007	.0002	−2.99	.0028	−.2253
Mental health problem		.3575	.0960	3.72	.0002	.0889
Ever sought a psychological help		−.3535	.0789	−4.48	<.0001	−.1031
Willing to take medication	2,058						.13
BDI-II total score		.0244	.0093	2.61	.0091	.1841
DSS total score		.0298	.0049	6.02	<.0001	.2164
BDI-II total score × DSS total score		−.0008	.0002	−3.08	.0021	−.2343
Female		.1767	.0662	2.67	.0077	.0589
Central urban region		−.1363	.0641	−2.13	.0337	−.0461
Ever sought a psychological help		.2289	.0802	2.85	.0044	.0649
Willing to seek a therapy	2,071						.13
Depression severity		.0184	.0093	1.98	.0478	.1418
Depression stigma		.0265	.0048	5.51	<.0001	.1993
Depression severity-by-stigma		−.0007	.0002	−2.90	.0038	−.2235
Female		.1791	.0645	2.78	.0055	.0614
Mental health problem		.2247	.0962	2.34	.0195	.0554
Not willing to seek a professional help	2,106
Depression severity		.0070	.0028	2.52	.0117	.0548	.11
Depression stigma		.0103	.0029	3.58	.0004	.0777

Note. Depression severity, as measured by total score of Beck Depression Inventory-II (BDI-II); depression stigma, as measured by the total score of the Depression Stigma Scale (DSS). B = unstandardized regression coefficient; β = standardized regression coefficient; SE = standard error.

The results revealed a significant interaction between depression scores and stigma scores on adolescents’ willingness to seek help from a counselor, a general health practitioner, a religious leader, or a family member as well as adolescents’ willingness to take a medication or seek a therapy for depression (all p ≤ .05). To better understand these interactions, the adolescents were divided into two depression groups based on the BDI-II severity cutoff scores and two stigma groups based on the median score of 36. The two depression groups were (1) minimal to mild depression (low depression) and (2) moderate-to-severe depression (high depression), while the two stigma groups were (1) low stigma and (2) high stigma.

Figure 1 depicts the significant depression severity-by-stigma interaction by presenting the adjusted least square means of the outcome for four depression severity-stigma subgroups. Adolescents with minimal to mild depression were more likely to seek help from a counselor, a general health practitioner, a religious leader, or a family member and more willing to take a medication or seek a therapy for depression if they had high depression stigma scores. In other words, adolescents with moderate-to-severe depression were less likely to seek help from these resources regardless of their stigma scores.

The analyses also revealed sex differences in help-seeking intentions. Female adolescents were more willing to seek help from a counselor or a psychiatrist and more willing to take medication and seek therapy for depression (all p ≤ .05), while male adolescents were more likely to seek help from a general health practitioner or a religious leader (all p ≤ .05). Adolescents who reported seeking psychological help in the past were also more likely to seek help from a family member than other professional resources (p ≤ .05). Finally, adolescents residing in the southern rural regions were more likely to seek help from a general health practitioner or a religious leader and less likely to seek a therapy (p ≤ .05).

Discussion

Little research has considered the impact of depression stigma on adolescents’ willingness to seek professional psychological help for depression, and until now, no studies have addressed this issue among Arab adolescents. Given the importance of family in Arab culture, it was not surprising that family was the most commonly cited source of help. This result underscores Gilat, Ezer, and Sagee’s (2010) study, which revealed that when a family member shows symptoms of mental illness, Arabs usually turn first to other family members, and it often takes months or even years before some families accept that the person with mental illness needs professional psychiatric care. Our results also demonstrated an overall lower tendency among adolescents to seek help from professional sources, such as psychiatrists, counselors, or general health practitioners. Still, 25% of the adolescents reported that they would not seek any treatment, and these adolescents had higher depression scores. Additionally, only half of participants expressed willingness to seek psychological therapy, and 39% showed willingness to seek help from a religious leader. These findings suggest there is significant work to do regarding education around treatment-seeking for depression. This includes information on the biological basis of the illness to promote medication use and the importance of behavioral strategies to address the negative effects of depression on activities of daily life. Moreover, since Arab youth tend to view religion as a powerful anchor of their identity and their ability to navigate the future (Khoury & Lopez, 2011), religious leaders should be targets for some of these educational interventions, so that they can direct youth and their families to the proper resources. In fact, studies of mental illness in Western culture have shown similar preferences for turning to religious leaders for help, and recent efforts to provide church-based mental health services are promising (Rogers & Stanford, 2015), although more work needs to be done. Still, these models may be adapted in Arab countries, and future studies should investigate this.

Factors Influencing Jordanian Adolescents’ Willingness to Seek Help

Research in Arab countries shows that holding a positive attitude toward mental health treatment is not sufficient to seek it, since many other factors can significantly impact people’s willingness to do so (Dardas & Simmons, 2015; Fakhr El-Islam, 2008). This study found that factors like depression stigma, depression severity, and sociodemographic characteristics can affect not only Jordanian adolescents’ willingness to seek help but also the type of help they are willing to seek.

In our study, Jordanian adolescents with higher depression scores were less likely to endorse willingness to seek help for depression, which is a particularly concerning finding. Several factors might explain this relationship. It is possible that depressive symptoms like pessimism, indecisiveness, negative thinking, and/or lack of energy interfere with adolescents’ ability and motivation to seek help. However, it is important to keep in mind that there is a substantial lack of mental health services and professionals in Jordan (WHO, 2011). Even the few available services are often not well recognized or understood, and many Jordanians lack knowledge about psychiatric illnesses and treatments (Nasir & Al-Qutob, 2005).

Additionally, adolescents’ willingness to seek help from a particular treatment does not necessarily mean they believe it will be helpful. Adolescents may seek help from certain sources and avoid others due to fear of the stigma. Our findings support this hypothesis in that the likelihood to visit a psychiatrist was negatively associated with higher depression stigma scores, while higher stigma scores were associated with increased likelihood to seek help from a school counselor, a general health practitioner, or a family member. This is consistent with previous studies, which have found that the stigma of mental illnesses like depression limiting treatment-seeking from professional sources (Golberstein, Eisenberg, & Gollust, 2008; Simmons, Yang, Wu, Bush, & Crofford, 2015; Wrigley, Jackson, Judd, & Komiti, 2005). People may avoid treatment as a way to distance themselves from mental illness and avoid the negative reactions and responses from others. Interestingly, 53% of the adolescents in this study were willing to take medications for depression. While this finding may indicate increased awareness among our sample regarding the effectiveness of pharmacotherapy in treating depression, it is also possible that taking medications is viewed as easier to conceal than attending psychiatrist or psychologist clinics. Both Olfson et al. (2002) and Barney, Griffiths, Jorm, and Christensen (2006) found that taking medications was more preferred than psychosocial treatments for outpatients with depression because it is easier to conceal from others. The finding that stigma scores were significantly associated with tendency to seek help from a school counselor or general health practitioner might be promising, as it indicates that while certain sources of help might not be appealing for adolescents, they are still generally willing to seek help from some sources.

While exploring the main effects of depression and stigma severity on adolescents’ help-seeking intentions can be informative, it is important to acknowledge the significant interactions between these two factors. Adolescents with high stigma scores were more likely to seek help for depression if they had low depression. It is possible that when depression is high, negative thinking and cognitive distortions may exacerbate the stigma related to the symptoms and discourage seeking treatment (Kanter, Rusch, & Brondino, 2008).

This study also indicated that certain individual characteristics influence Jordanian adolescents’ help-seeking intentions. For example, female adolescents were more willing to seek help from a counselor or a psychiatrist and more willing to take medication and seek therapy for depression. Male adolescents, however, were more likely to seek help from a general health practitioner or a religious leader. Research has shown that Arab females are often at higher risk of experiencing public stigma and thus are less likely to be taken for treatment than their male counterparts (Al-Balhan, 2006; Dardas, Bailey, et al., 2016). Our findings show that despite the existing public stigma, female adolescents are more willing to seek professional psychological help than male adolescents, which underscores the need for gender-based interventions to promote help-seeking behaviors among this population.

Interestingly, adolescents who reported seeking psychological help in the past were more likely to seek help from a family member than other professional resources. This finding might reflect some negative experiences with accessing mental health services in Jordan. Research has revealed that adolescents often report they turn to traditional healers or social sources of support when they lose trust in professional sources of help due to the ways in which these professionals addressed their problems (Barker, 2007). If this is the case, more attention should be given to repair trust among young people in seeking professional psychological help.

Region of residence also affected adolescents’ willingness to seek help for depression and the type of treatment they are likely to seek. Overall, adolescents residing in the southern rural regions were more likely to seek help from a general health practitioner or a religious leader and less likely to be willing to seek a psychological therapy. This could be related to the stigma associated with depression, which research has found particularly concerning among rural individuals with a history of depression, making it difficult for them to seek professional psychological help (Jackson et al., 2007; Simmons et al., 2015).

Implications: The Promising Role of the School Nurse

Intervention research on adolescent depression in Western countries has documented that the most effective strategies have been school based, with the benefit of reaching large numbers of adolescents with undiagnosed and undertreated depression (Buttigieg et al., 2015; Duong, Cruz, King, Violette, & McCarty, 2016; Merry et al., 2012). However, most school-based interventions to date have been delivered by school psychologists, teachers, or counselors rather than school nurses. This is a missed opportunity because research evidence has shown that school nurses can play a significant role in promoting mental health and subsequent academic achievement among youth experiencing mental health problems (DeSocio, Stember, & Schrinsky, 2006; Puskar & Bernardo, 2007). With their academic preparation and experience, school nurses can help to recognize cognitive, somatic, and physical symptoms of depression that may be missed by other adults in the school system. As a result, school nurses can provide early interventions and recommend appropriate referral and follow-up. To fill this gap in school-based mental health services, policy makers in Jordan should ensure that school nurses are available in all schools and working to their full scope. At present, school nurses are very limited in some schools in the country and totally absent in many others. An exemplar for such promising efforts is the first School-Nurse Bachelor’s program launched in Kuwait in 2015. The program committee announced that this program meets the growing mental health needs in schools, promotes primary preventive care, and ensures appropriate referrals in schools (http://www.paaet.edu.kw).

This study revealed that even among adolescents with greater depression severity and depression stigma, school counselors were identified as a key resource for help. These findings suggest that school-based interventions may fill a critical service need for adolescents with depression and other mental health problems. School nurses can offer both preventive and intervention services to address issues associated with depression among adolescents in the school, alleviating the long-term consequences of depression on academic performance, social relationships, and emotional well-being (WHO, 2013). Increasing communication between parents, students, and school professionals is another strategy in which school nurses can engage to address adolescent depression. As with any screening, education, or treatment program, clear and frequent communication between the school nurse, school administrators, parents, and other key personnel can maximize the benefits of adolescent depression prevention and management programs (Cowell, 2013).

Routine screening of depression in the school environment can have a substantial impact on the overall emotional and physical well-being, as well as the academic success of adolescents. A recent study in Seattle, WA, demonstrated the success of screening by school nurses as being both cost effective and a useful way to identify potential at-risk students (Kuo, Vander Stoep, Herting, Grupp, & McCauley, 2013). Several depression screening tools and preventive programs are available in the Western literature specific to the school nurse (Carnevale, 2011). Future research should examine whether existing practice parameters and models used in Western countries can be translated directly to the Arab population or whether the sociocultural context might influence the experience and response to treatment, requiring adapted approaches.

Conclusion

Findings from this study provide evidence of significant differences in Jordanian adolescents’ help-seeking intentions for depression, considering depression severity, depression stigma, and sociodemographic characteristics. We recommend targeting these factors when designing interventions to promote Jordanian adolescents’ attitudes toward seeking help. However, it is important to acknowledge that our inferences might be limited by the cross-sectional nature of the study. Questions concerning temporal relationships between the investigated variables and depression can best be answered through prospective, longitudinal research with both clinical and at-risk samples. Overall, Jordanian adolescents experience significant barriers to seeking professional psychiatric help for depression. However, even among adolescents with greater depression severity and depression stigma, school counselors were identified as a key resource for help. These findings suggest that school-based interventions may fill a critical service need for adolescents with depression and other mental health problems. School nurses should be leveraged along with counselors to deliver educational and treatment services to address mental health needs in this vulnerable population.

Footnotes

Authors’ Note

All authors substantially contributed to the conception, drafting, revising, and final approval of the article. Latefa Dardas collected the data and obtained funding. Latefa Dardas and Susan Silva conducted data analyses. Leigh Ann Simmons supervised the research group.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by The Sigma Theta Tau International/The Council for Advancement of Nursing Science Grant, Duke Graduate School Dissertation Research Grant, Duke University School of Nursing Pilot Study Grant, and The University of Jordan.

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