Non-disclosing youth: a cross sectional study to understand why young people do not disclose suicidal thoughts to their mental health professional
prevalence of youth suicidal ideation is a matter of con-
cern. While the best approach to treating suicidal idea-
tion is through traditional therapeutic interventions
(e.g., dialectical behavioural therapy and cognitive-
behavioural therapy) delivered in clinical settings [7, 8],
a number of barriers exist preventing indicated popula-
tions from accessing such services.
Of the young people who do access help and disclose
their suicidal ideation, they primarily choose to do so
with parents and peer groups rather than mental health
professionals, such as psychologists, school counsel-
lors) [9–11]. Tis preference of disclosing to social sup-
port networks occurs despite many young people having
access to mental health professionals via school or other
settings (see [12]). While disclosing to close family and
friends is encouraged, members of these social networks
often report they lack the confdence and skills to appro-
priately support the young person experiencing suicidal
distress [13, 14]. As a result, this pathway can leave at risk
young persons insufciently supported [15, 16].
To date, there have been no studies which have exam-
ined the number of young persons who choose not to dis-
close their suicidal ideation, even when they have access
to a mental health professional. Teoretically, there are a
number of barriers that could feasibly prevent disclosure
of suicidal thoughts and behaviours to clinicians, includ-
ing perceived stigma [17, 18], difculties communicating
the need for help, concerns around a lack of privacy, mis-
trust of an unknown person, and beliefs that professional
help will not be efective [19, 20]. Given that non-disclo-
sure may prevent vulnerable young people from receiving
targeted support for suicidal ideation – which has been
shown elsewhere to require approaches that difer from
depression or anxiety [21, 22] - it is important to under-
stand the extent to which non-disclosure is an issue and
why it occurs.
Accordingly, the key aims of this study are to:
- Establish the prevalence of non-disclosure of sui-
cidal ideation to a mental health professional among
young people aged 16 to 25 years who are currently,
or recently been, in treatment. - Identify the key reasons why young people decide not
to disclose suicidal ideation to their mental health
practitioner.
Tis novel study is the frst the authors are aware of
to explore the experience of, and reasoning behind, a
young person’s decision to withhold disclosure of sui-
cidal thoughts from mental health professionals. Tese
insights could inform the development of policy and
practice strategies to improve clinical care for young peo-
ple with suicidal ideation.
Methods
Study design and recruitment
An online cross-sectional survey was designed and
advertised to a community-based sample of young Aus-
tralians. Ethics approval for this study was obtained
from the University of New South Wales Human
Research Ethics Committee (HC200465). STROBE
guidelines [23] were used to report this study.
Potential participants completed a short screening
survey to determine eligibility based on the following
criteria: aged 16 to 25 years, living in Australia, fuent
in English, had experienced suicidal thoughts in the
past 12 months, and had engaged with a mental health
practitioner for any reason in the past 12 months. Par-
ticipants aged 16 and 17 years were considered mature
minors that could participate without parental consent
provided they had capacity to be involved [24], which
was assessed through a Gillick Competency Task [25].
A copy of the questions and procedure to assess Gillick
competency are presented in Appendix A. Tere were
no study exclusion criteria.
Te survey was published using the online survey
platform Qualtrics on October 9th 2020, and data col-
lection remained open until the recruitment objective
was met (N=513) (12th October 2020). During this
period, the survey was promoted on social media via
targeted Facebook advertisements (target parameters:
ages 16-25, Australia, interests in National Suicide
Prevention, Lifeline, Suicide prevention, Beyondblue,
Headspace, Lifeline, R U OK Day, SANE). When a
potential participant clicked on the study advertise-
ment, they were directed to an online study portal
and asked to provide individual digital consent before
completing a fve-item screening survey to determine
eligibility. Participants who did not meet the inclu-
sion criteria (including the Gillick) were directed to a
webpage thanking them for their time and which pro-
vided relevant support contacts, such as Kids Helpline
and Lifeline phone numbers and webchat addresses.
Participants who met the study inclusion criteria were
directed to complete a 20-minute online self-report
structured questionnaire, which also included free
text options for questions relating to reasons why they
chose whether or not to disclose suicidal thoughts to
their mental health practitioner, and what would moti-
vate them to disclose to a mental health professional
in future. Participants who completed the survey were
emailed a $10 e-gift voucher as compensation for their
time. Relevant support contacts, such as Kids Helpline
and Lifeline phone numbers and webchat addresses,
were also provided on the consent form and at conclu-
sion of the survey.
Measures
Demographic characteristics were measured to describe
the sample, including age, sex, sexual orientation, rural/
remote or metropolitan location, relationship status, and
mental health status. Sexual orientation was grouped into
one of two categories for analyses: heterosexual or sexual
minority (i.e., lesbian, gay, bisexual, queer, other, not sure,
prefer not to say).
Disclosure of suicidal ideation (primary out-
come) was measured with the question, “Have you told
your mental health professional that you have suicidal
thoughts?” (‘yes’ or ‘no’). A follow-up open ended ques-
tion was asked based on the response, that is “What
factors made you choose to tell them you have suicidal
thoughts?” or “What factors made you choose not to tell
them you have suicidal thoughts?”. Open ended ques-
tions included multiple choice response options based
on common reasons observed in the literature (e.g., con-
cerns around a lack of privacy, mistrust of an unknown
person, and beliefs that professional help will not be
efective [19, 20];), as well as “other” - a free text response
option. We also asked participants, “Can you tell us what
sort of things would make you more likely to tell a mental
health professional that you have suicidal thoughts?”. To
compare the rate of disclosure to a mental health profes-
sional specifcally with the rate of disclosure in general,
we asked, “Have you ever told anyone about your suicide
thoughts or behaviours?”.
Suicidal ideation was measured using the Suicidal
Ideation Attributes Scale (SIDAS, [26]). Te SIDAS con-
sists of 5 self-reported items rated on an 11-point scale
(0 to 10). Te scale provides a total score ranging from
0 to 50, with a higher score indicating greater suicidal
ideation severity. Negatively worded items are reversed
scored and scores of 21 or greater indicate a high risk for
suicidal behaviour (attempt). Te scale has demonstrated
excellent internal consistency in the literature (α=.91,
[26]) and good internal consistency in the present sample
(α=.86).
Depressive symptoms were measured by the Patient
Health Questionnaire Depression Scale (PHQ-9, [27]).
Tis scale consists of 9 items rated on a 4-point scale,
ranging from 0 (not at all) to 3 (nearly every day). Higher
scores indicate the presence of more depressive symp-
toms, and the maximum total score is 27. Te scale has
demonstrated good internal consistency in the literature
(α>.80, [28]) and in the present sample (α=.86).
Anxiety symptoms were measured by the Gener-
alised Anxiety Disorder-7 Scale (GAD-7, [29]). Te
GAD-7 consists of 7 self-reported items rated on a
4-point scale (0 = not at all to 3 = nearly every day),
with a total score ranging from 0 to 21 and higher
scores indicating more severe anxiety symptoms. The
scale has demonstrated good internal consistency in
previous research (α>.80, [28]) and the present sample
(α=.82).
Psychological distress was measured using the Dis-
tress Questionnaire-5 (DQ5, [30]), which consists of 5
self-reported items rated on a 5-point scale (1 = never
to 5 = always). Te scale provides a total score ranging
from 5 to 25, with a higher score indicating greater psy-
chological distress. Te scale has demonstrated good
internal consistency in previous research (α=.86, [30])
and acceptable internal consistency in the present sam-
ple (α=.76).
Suicide attempt (lifetime history) was assessed with
the question “Have you ever attempted suicide?” (‘no,
never’, ‘yes, once’, or ‘yes, more than once’). For par-
ticipants who answered more than once, an additional
question asked them to specify the number of attempts.
Exposure to suicide loss was measured by asking,
“Has anyone close to you died by suicide?” ‘yes’ or ‘no’.
Tis question was a modifed from a recent study by
Maple and Sanford [31].
Personal suicide stigma was measured using the
Personal Suicide Stigma Questionnaire (PSSQ, [32]),
which consists of 16 self-reported items rated on a
5-point scale (1 = never to 5 = very often). Te scale
provides a total score ranging from 16 to 80, with a
higher score indicating suicide-related stigma experi-
ences. Te scale has demonstrated excellent internal
consistency in previous research (α=.96, [33]) and the
present sample (α=.92).
Prioritisation of mental health issues was measured
with the question, “In the following list of mental health
problems, we’d like you to rank the top 3, according to
how important these are to you when talking to your
mental health professional.”. Respondents could rank a
list of ICD-10 categories of mental health diagnoses,
and suicidal thoughts (see Appendix B), from 1 (most
important) to 3 (less important). Prioritisation of sui-
cidal ideation specifcally (ranked as top 3; ‘yes’ or ‘no’),
was used in regression analyses.
Terapeutic alliance was measured using the
Revised Helping Alliance Questionnaire (HAq-II, [34]),
which asks respondents to carefully consider their rela-
tionship with their most recent therapist and rate 19
items on 6-point scale according to how strongly they
disagree (1) to agree (6) regarding the mutual collabo-
ration and bond between client and therapist. Te scale
provides a total score ranging from 19 to 114, with a
higher score indicating greater alliance with the thera-
pist. Negatively worded items are reversed scored. Te
scale has demonstrated excellent internal consistency
in past research (α ≥.90, [35]) and the present sample
(α=.93).
Statistical Analysis
To detect non-disclosure of suicidal ideation in the
cohort (primary outcome), a total minimum sample size
of n=471 was needed. Tis estimate accounts for a youth
population-level incidence of 12-month suicide ideation
of 26% [3] and a 34% rate of suicidal ideation in a youth
population engaged with mental health services [36],
with power set at 90%, alpha set at 0.01.
Descriptive information was presented as proportions
(%) and means (with standard deviation; SD). T-tests and
chi-square (χ2) tests were conducted to establish whether
the participants who did and did not disclose suicidal
ideation difered signifcantly on demographic and clini-
cal characteristics. Signifcant variables (with a more lib-
eral cut-of of p <.10, see [37]) were chosen to be entered
into a subsequent binary logistic regression model to
examine what factors are independently associated with
disclosure of suicidal ideation to a mental health profes-
sional. In this model, disclosure (yes/no) as the depend-
ent variable was used to estimate odds ratios (ORs) with
95% confdence intervals (CIs).
Quantitative data were analysed using SPSS version
25.0, alpha was set at p < .05 for interpreting signifcant
efects. Te following guidelines were used to interpret
efect sizes: correlation coefcient (r) values of .10, .30,
.50, and .70, correspond to small, medium, large, and very
large efect sizes, respectively [38]; Phi (φ) values of .10,
.20, .30, and .40, correspond to small, medium, large, and
very large efect sizes, respectively [39]; ORs of 1.44, 2.48,
and 4.27 correspond to small, medium, and large efect
sizes, respectively [38]; raw means were calculated to
estimate Cohen’s d, with values of .20, .50, and .80 cor-
responding to small, medium, and large efect sizes,
respectively.
Responses to the three multiple-choice options "other”
allowed respondents to provide free-text responses,
which were analysed thematically using NVivo ver-
sion 12. Using an inductive approach, responses were
reviewed independently by two authors (LM and DR),
with similar responses grouped together. Groupings
were then reviewed by LM and DR together and discrep-
ancies were discussed until agreement was reached, to
form a single set of themes for each of the three free-text
questions.
Results
A missing values analysis found that less than 5% of val-
ues were missing for variables under investigation, and
that they were missing completely at random (Little’s
MCAR test: p = .125). Terefore, it was safe to list-wise
removes cases (SPSS default) and report on the ‘valid
percent’ in descriptive statistics.
Descriptive statistics
In total 513 participants completed the survey, with a
median age of 17 years. Te majority of participants
reported being diagnosed with a mental disorder (n=412,
80.3%). Other demographic characteristics are displayed
in Table 1.
Most participants reported having disclosed suicidal
thoughts to another person (n=413, 81.9%), however
when asked if they had disclosed to a mental health pro-
fessional more than one third said they had not (n=191,
39%). In ranking the importance of diferent mental
health issues when talking to a mental health profes-
sional, 304 (59.3%) participants prioritised suicidal idea-
tion as being important, but depressive (n=349, 68%) and
anxiety-related disorders (n=328, 63.9%) were prioritised
as the top two concerns. Some participants reported that
they had never disclosed suicidal thoughts to anyone at
all (n=80, 16.1%). Other clinical characteristics are dis-
played in Table 1.
Characteristics of non‑disclosure
Sample characteristics by disclosure status (disclosure,
non-disclosure) are reported in Table 1 alongside signif-
cance testing and efect sizes. Disclosure was signifcantly
associated with sexual minority status, prioritisation
of suicidal ideation, a history of suicide attempt, hav-
ing disclosed to another person in the past, greater sui-
cidal ideation severity, greater personal suicide stigma,
and greater therapeutic alliance with their most recent
therapist.
Bivariate correlations were calculated between all vari-
ables under consideration (17 variables). After making
Bonferroni corrections (p <.003), disclosure of suicidal
ideation to a mental health professional (yes) had a large
signifcant association with disclosure to anyone (r=.518,
p=.000), a medium association with prioritisation of sui-
cidal ideation (r=.326, p=.000), history of suicide attempt
(r=.305, p=.000), and small associations with greater
therapeutic alliance (r=.246, p=.000), greater personal
stigma of suicide (r=.211, p=.000), greater suicidal idea-
tion severity (r=.192, p=.000), and sexual minority status
(r=.170, p=.000).
Results from the binary logistic regression are pre-
sented in Table 2. ‘Disclosure of suicidal ideation to
anyone’ was not included in the model as an independ-
ent variable due to low cell frequency (i.e., n=5 had dis-
closed to anyone and not a mental health professional).
Te addition of eight independent variables to a model
that contained only the intercept signifcantly improved
the ft, χ2 (8) = 94.25, p < .001. Te model explained
between 22.8% (Cox and Snell R square) and 32.8%
(Nagelkerke R square) of the variance in disclosure of
suicidal ideation to a mental health professional.