Received: 1 August 2018 Revised: 21 March 2019 Accepted: 21 March 2019 DOI: 10.1002/mpr.1782 SPECIAL ISSUE Barriers of mental health treatment utilization among first‐year college students: First cross‐national results from the WHO World Mental Health International College Student Initiative David Daniel Ebert1 | Philippe Mortier2 | Fanny Kaehlke1 | Ronny Bruffaerts2 | Harald Baumeister3 | Randy P. Auerbach4 | Jordi Alonso5,6 | Gemma Vilagut5,6 | Kalina U. Martínez7 | Christine Lochner8 | Pim Cuijpers9 | Ann‐Marie Kuechler3 | Jennifer Green10 | Penelope Hasking11 | Coral Lapsley12 | Nancy A. Sampson13 | Ronald C. Kessler13 | On behalf of the WHO World Mental Health—International College Student Initiative collaborators 1 Clinical Psychology and Psychotherapy, Department of Psychology, Friedrich‐Alexander‐University Erlangen‐Nürnberg, Erlangen, Germany 2 Universitair Psychiatrisch Centrum—Katholieke Universiteit Leuven (UPC‐KUL), Campus Gasthuisberg, Leuven, Belgium 3 Clinical Psychology and Psychotherapy, University of Ulm, Ulm, Germany 4 Department of Psychiatry, Columbia University, New York City, New York 5 Health Services Research Unit, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain 6 CIBER en Epidemiología y Salud Pública (CIBERESP), Madrid, Spain 7 Department of Psychology, Universidad Autónoma de Aguascalientes, Aguascalientes City, Mexico 8 MRC Unit on Anxiety & Stress Disorders, Department of Psychiatry, University of Stellenbosch, Stellenbosch, South Africa 9 Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health research institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands 10 School of Education, Boston University, Boston, Massachusetts 11 School of Psychology and Speech Pathology, Curtin University, Perth, Western Australia, Australia 12 Department of Medical Sciences, Ulster University, Derry‐Londonderry, UK 13 Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts Correspondence David Daniel Ebert, Clinical Psychology and Abstract Psychotherapy, Department of Psychology, Background: Although mental disorders and suicidal thoughts‐behaviors (suicidal Friedrich‐Alexander‐University Erlangen‐ Nürnberg, Nägelsbachstr. 25a, 91052 thoughts and behaviors) are common among university students, the majority of Erlangen, Germany. students with these problems remain untreated. It is unclear what the barriers are Email: david.ebert@fau.de to these students seeking treatment. Funding information Aims: The aim of this study is to examine the barriers to future help‐seeking and Fondo de Investigación Sanitaria, Instituto de Salud Carlos III—FEDER, Grant/Award Num- the associations of clinical characteristics with these barriers in a cross‐national bers: PI13/00343 and PI13/00506; Instituto sample of first‐year college students. de Salud Carlos III, Grant/Award Numbers: CD12/00440 and CM14/00125; Northern -------------------------------------------------------------------------------------------------------------------------------- This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. © 2019 The Authors International Journal of Methods in Psychiatric Research Published by John Wiley & Sons Ltd Int J Methods Psychiatr Res. 2019;28:e1782. wileyonlinelibrary.com/journal/mpr 1 of 14 https://doi.org/10.1002/mpr.1782 2 of 14 EBERT ET AL. Ireland Public Health Agency; Bristol‐Myers Squibb; GlaxoSmithKline; Ortho‐McNeil Phar- Method: As part of the World Mental Health International College Student (WMH‐ maceutical; Pan American Health Organization; ICS) initiative, web‐based self‐report surveys were obtained from 13,984 first‐year Fogarty International Center, Grant/Award Number: FIRCA R03‐TW006481; US Public students in eight countries across the world. Clinical characteristics examined Health Service, Grant/Award Numbers: R01 included screens for common mental disorders and reports about suicidal thoughts DA016558, R01‐MH069864 and R13‐ MH066849; Pfizer Foundation; John D. and and behaviors. Multivariate regression models adjusted for socio‐demographic, Catherine T. MacArthur Foundation; Consejo college‐, and treatment‐related variables were used to examine correlates of Nacional de Ciencia y Tecnología (CONACyT), Grant/Award Number: CB‐2016‐01‐285548; help‐seeking intention and barriers to seeking treatment. Ulster University; Northern Ireland Public Results: Only 24.6% of students reported that they would definitely seek treat- Health Agency (HSC R&D); European Union Regional Development Fund (ERDF) EU Sus- ment if they had a future emotional problem. The most commonly reported reasons tainable Competitiveness Programme for not to seek treatment among students who failed to report that they would definitely Northern Ireland; FPU, Grant/Award Number: FPU15/05728; DIUE Generalitat de Catalunya, seek help were the preference to handle the problem alone (56.4%) and wanting to Grant/Award Number: 2017 SGR 452; talk with friends or relatives instead (48.0%). Preference to handle the problem alone Ministerio de Sanidad, Servicios Sociales e Igualdad, PNSD, Grant/Award Number: and feeling too embarrassed were also associated with significantly reduced odds of 2015I015; ISCIII, Grant/Award Numbers: having at least some intention to seek help among students who failed to report that CD12/00440 and CM14/00125; Ithemba Foundation; South African Medical Research they would definitely seek help. Having 12‐month major depression, alcohol use dis- Council; Protestants Fonds voor de Geestelijke order, and suicidal thoughts and behaviors were also associated with significantly Volksgezondheid; ZonMw, Grant/Award Number: 636110005; BARMER; Eli Lilly and reduced reported odds of the latter outcome. Company, Grant/Award Number: IIT‐H6U‐BX‐ Conclusions: The majority of first‐year college students in the WMH‐ICS surveys I002; King Baudouin Foundation United States, Grant/Award Number: 2014‐ report that they would be hesitant to seek help in case of future emotional problems. J2140150‐102905; Belgian Fund for Scientific Attitudinal barriers and not structural barriers were found to be the most important Research, Grant/Award Numbers: 1114717N, 11N0514N and 11N0516N; National Institute reported reasons for this hesitation. Experimental research is needed to determine of Mental Health (NIMH), Grant/Award Num- whether intention to seek help and, more importantly, actual help‐seeking behavior bers: R56MH109566 and R01MH070884 could be increased with the extent to which intervention strategies need to be tai- lored to particular student characteristics. Given that the preference to handle prob- lems alone and stigma and appear to be critical, there could be value in determining if internet‐based psychological treatments, which can be accessed privately and are often build as self‐help approaches, would be more acceptable than other types of treatments to student who report hesitation about seeking treatment. K E Y W OR D S epidemiology, public mental health, service utilization, student, treatment gap 1 | I N T RO D U CT I O N remain untreated even in high income countries (Auerbach et al., 2016; Blanco et al., 2008; Demyttenaere et al., 2004; Eisenberg Mental disorders and suicidal thoughts and behaviors are highly et al., 2009; Larisch et al., 2013; Mortier et al., 2018). Cross‐national prevalent among college students (Auerbach et al., 2016, 2018; Mortier data suggest that less than one in four students with any 12‐month et al., 2018) and are associated with substantial current role impair- mental disorder or suicidal thoughts and behaviors (STB) receives ments (Alonso et al., 2018) as well as with diverse negative long‐term any kind of treatment (Bruffaerts et al., 2019), with 12‐month consequences such as lower academic achievement (Bruffaerts et al., disorder‐specific treatment rates ranging from 19.8% for alcohol use 2018; Eisenberg, Golberstein, & Hunt, 2009; Hysenbegasi, Hass, & disorder to 42% for panic disorder. Rowland, 2005; Mortier et al., 2015), higher risk for dropout (Ishii Structural supply shortfalls doubtlessly are at least partially respon- et al., 2018; Kessler, Foster, Saunders, & Stang, 1995), and worse func- sible for these low treatment rates. However, recent studies suggest tioning in later life (Goldman‐Mellor et al., 2014; Niederkrotenthaler that a large number of affected students do not make use of treatments et al., 2014). even when they are available (Bruffaerts et al., 2019). Known barriers to Despite the wide availability and efficacy of clinical interventions treatment include the perception that treatment is not needed, lack of (Cuijpers et al., 2013), the vast majority of college students with clini- time, perceived stigma, and preference for self‐management cally significant mental disorders and suicidal thoughts and behaviors (Eisenberg, Hunt, & Speer, 2012, Vidourek, King, Nabors, & Merianos, EBERT ET AL. 3 of 14 2014). These findings are in line with results from a systematic review employer or employer sponsored health insurance rather than through of reported barriers to mental health treatment in adolescent general their college. In addition, preliminary analyses reported below showed population samples that identified stigma, embarrassment, problems that the majority of the 50 remaining students who identified either as recognizing symptoms, and a preference for self‐reliance as the most transgender or “other” rather than as male or female endorsed a num- important barriers (Gulliver, Griffiths, & Christensen, 2010). ber of mental disorders and experienced considerable impairment, To the best of our knowledge, no cross‐national data exist on bar- leading us to focus on them in a separate report. riers to mental health help‐seeking among college students, as most All first‐year students in the colleges were invited to participate in published studies on that topic have been based on cohorts in the a web‐based self‐report health survey. While the core set of survey United States (Csyz et al., 2013; Eisenberg et al., 2012; Vidourek questions was identical across all countries, the initial mode of contact et al., 2014, Eisenberg et al., 2014). The aim of the current study is varied across colleges. In all cases other than in Mexico, we attempted to present preliminary information about these barriers based on data to recruit 100% of first‐year students either as part of a health collected in the World Mental Health International College Student evaluation, the registration process, or in a stand‐alone web survey (WMH‐ICS) surveys. We focus on reported willingness of first‐year delivered to students via their university email addresses. Students college students from eight countries worldwide to use mental health in Mexico were invited to fill out the survey in conjunction with man- services, reported barriers to such help‐seeking and the correlates of datory activities (e.g., student health evaluations and tutoring ses- reported these barriers. sions). Other than in Mexico, where no attempts were made to recruit initial nonrespondents, attempts to complete the survey with initial nonrespondents were made through a series of personalized 2 | METHODS reminder emails. Financial incentives were used in the final stages of recruitment in 10 of these colleges. Spain applied an “end‐game” 2.1 | Sample and procedures strategy, in which a random sample of nonrespondents received a financial incentive for one last chance at participation, with those As reported in prior papers in this issue, the first phase of survey data responding in this final phase given a weight equal to the inverse of collection in the WMH‐ICS designed to obtain basic cross‐national their probability of selection to adjust for the undersampling of these information on the prevalence, incidence, and correlates of mental, hard‐to‐recruit students. substance, and behavioral disorders among college students world- wide; to describe patterns of service use, barriers to treatment, and 2.2 | Measures unmet need for treatment; to investigate the associations of these disorders with role function in academic and other life domains; 2.2.1 | Intention to use mental health services to evaluate the effects of a wide range of preventive and clinical interventions on student mental health, functioning, and academic Intention to use mental health services in case of a future emotional performance; and to develop precision medicine clinical decision problem was assessed by asking participants “If during this coming support tools to help select the right interventions for the right school year, you developed an emotional problem that caused you a students (Cuijpers et al., 2019). lot of distress and interfered with your school work, how likely would Web‐based self‐report questionnaires were administered to you be to go to the student Counseling Center for help?” “How likely representative samples of first‐year students in 19 colleges and uni- would you be to go somewhere else for help, like to your doctor, a versities (seven private, 12 public; henceforth referred to as “colleges”) mental health professional, or religious advisor?” (definitely would go in eight countries (Australia, Belgium, Germany, Mexico, Northern [4]; probably would go [3]; might or might not go [2]; probably would Ireland, South Africa, Spain, and the United States). Each collaborating not go [1]; definitely would not go [0]; Ursano, 2012). A dichotomy college obtained ethical approval to participate in the project and all was created by collapsing the highest two values in response to participants provided informed consent. This initial round of WMH‐ either of these two questions into a positive value and others into a ICS surveys was conducted between October 2014 and February negative value. 2017. The sample size ranged from 633 in Australia to 4,590 in Belgium, with a total of 14.371 students across countries and a 2.2.2 | Barriers of treatment weighted mean response rate across all surveys of 45.5%. For the present analysis, we restricted the sample to full‐time students that If participants did not indicate that they “definitely would go” to seek self‐identified as male or female (n = 13,984) and excluded those with help in case of a future emotional problem, they were asked about missing information on gender or full‐time status (n = 35) or who did potential reasons: “If you decided not to seek help if you developed not identify as male or female (n = 50) or who reported part‐time such a problem, how important do you think each of these would be status (n = 302). as reasons for not seeking help?”. Reasons listed were: “You are not Most of these students came from the Australian sample and were sure available treatments are very effective”; “You would want to older, full‐time employed people who would normally be expected to handle the problem on your own”; “You would be too embarrassed”; access mental health services, if they were needed, through their “You would talk to friends or relatives instead”; “You think it costs 4 of 14 EBERT ET AL. too much money”; “You are unsure of where to go or who to see”; 2.2.6 | Socio‐demographics “You anticipate problems with time, transportation, or scheduling”; “You are afraid it might harm your school or professional career”; Gender was assessed by asking respondents whether they identified “You are afraid of different treatment from others”; and “Other rea- as being male, female, transgender (male‐to‐female/female‐to‐male), sons” (1 = very important; 2 = important; 3 = moderately important; or “other.” Respondent age was categorized into three categories 4 = somewhat important; 5 = unimportant; Hoge et al., 2004; Kessler (18 years/19 years/20 or more years old). Parental educational level et al., 2008). was assessed for father and mother separately and was categorized into high (university graduate or more), medium (some postsecondary 2.2.3 | Mental disorders education), and low (secondary school or less) based on the higher‐of‐ both parents' educational levels. Parental marital status was As described in more detail elsewhere in this issue (Auerbach et al., dichotomized into “parents married and both alive” versus all others. 2018) 12‐month major depression, generalized anxiety disorder, panic Respondents were asked about the urbanicity of the place they were disorder, broad mania, and drug use disorder were assessed using the raised (small city/large city/town or village/suburbs/rural area) and validated self‐report screening scales of the widely used Composite their religious background (categorized into Christian/Other International Diagnostic Interview (Kessler, Calabrese, et al., 2013; religion/No religion). Sexual orientation was classified into the catego- Kessler & Üstün, 2004). These scales correlate highly with blinded clin- ries heterosexual: gay or lesbian, bisexual, asexual, not sure, and other. ical diagnoses based on the Structured Clinical Interview for DMS‐IV Additional questions were asked about the extent to which respon- (First, Spitzer, Gibbon, & Williams, 1994), with area under the curve dents reported being attracted to men and women and the gender(s) (AUC) in the range 0.70–0.78 (Kessler, Calabrese, et al., 2013; Kessler, of people they had sex with (if any) in the past 5 years. Responses Santiago, et al., 2013). Alcohol use disorder was assessed using the were used to categorize each student as either heterosexual with no Alcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, same‐sex attraction, heterosexual with some same‐sex attraction, Babor, De la Fuente, & Grant, 1993), with either a total score of 8+ nonheterosexual without same‐sex sexual intercourse, and nonhetero- or a score of 4+ on the AUDIT dependence questions as a definition sexual with same‐sex sexual intercourse. for alcohol use disorder (Babor, Higgins‐Biddle, Saunders, & Monteiro, 2001). The concordance of the AUDIT with clinical diagnoses is in the range AUC = 0.78–0.91 (Reinert & Allen, 2002). 2.2.7 | College‐related predictors 2.2.4 | Suicidal thoughts and behaviors Respondents were asked where they ranked academically compared Lifetime and 12 months suicidal thoughts and behaviors were with other students at the time of their high school graduation (from assessed using a modified version of the Columbia Suicidal Severity top 5% to bottom 10%; categorized into quartiles) and what their most Rating Scale (Posner et al., 2011). The key questions were: “Did you important reason was for going to college. Based on the results of a ever wish you were dead or would go to sleep and never wake up?” tetrachoric factor analysis (details available on request), responses and “Did you ever in your life have thoughts of killing yourself?” were categorized into either extrinsic reasons (i.e., “family wanted (suicidal ideation); “Did you ever think about how you might kill your- me to,” “my friends were going,” “teachers advised me to,” and “I did self (e.g., taking pills, shooting yourself) or work out a plan of how to not want to get a job right away”) or intrinsic reasons (“to achieve a kill yourself?” (suicide plans); and “Have you ever made a suicide degree,” “I enjoy learning and studying,” “to study a subject that really attempt (i.e., purposefully hurt yourself with at least some intent to interests me,” “to improve job prospects generally,” and “to train for die)?” (suicide attempts). specific type of job”). Respondents were also asked where they were living during the first semester of the academic year (parents', other 2.2.5 | Stages of change scale relative's, or own home/university or college hall of residence/shared house, apartment, or flat/private hall of residence/other) and if they All respondents were presented with an adapted version of the Stages expect to work in a student job. of Change scale that asked How would you rate your readiness or willingness to change any emotional or substance use problems you are 2.2.8 | Treatment utilization experiencing at this time (check one of the following): I do not have a problem that I need to change; I have a Past year use of mental health treatment for any emotional or problem, but I am not yet sure I want to take action to substance use problem was assessed by asking participants whether change it; I have a problem and I intend to address it; they ever got psychological counseling or medication for an emotional I have a problem and I already am working actively to or substance problem along with ages of first and last times they change it; I had a problem but I have addressed it and received medication or counseling (Kessler & Üstün, 2004; Ursano, things are better now. 2012; Hoge et al., 2004). EBERT ET AL. 5 of 14 2.3 | Analysis suicidal thoughts and behaviors. As in early steps in the analysis, models included all possible combinations of predictor blocks and All analyses were conducted with SAS version 9.4. Data were adjusted for the same covariates as in Step 2. Although only the weighted using poststratification weights (Groves & Couper, 2012) best‐fitting models are reported below, results of all other models to adjust for differences between survey respondents and nonrespon- are available on request. We exponentiated the regression coefficients dents based on socio‐demographic and college‐related characteristics and their multiple imputation‐based standard errors to obtain odds that were made available by institutional officials. Multiple imputation ratios (ORs) and associated 95% confidence intervals. Statistical signif- by chained equations (Van Buurens, 2012) was used to adjust for icance was set in all analyses at level α < .05 using two‐sided tests. within‐survey item nonresponse, random internal subsampling of survey sections, and missing data due to skip logic errors that occurred in some of the surveys. All analyses were conducted in the subsample 3 | RESULTS that excluded the 24.6% of students who said they would definitely seek treatment in case of a future emotional problem (n = 9,939; 3.1 | Sample description and willingness to seek help 75.4% of the total sample). In the first step, we estimated the distribu- in the overall sample tion of the eight reported barriers to seeking treatment in this subsample. To obtain pooled estimates of prevalence across countries, Only 24.6% of the 13,984 students in the total sample indicated that each country was given an equal sum of weights. they would definitely seek help in case of a future emotional problem, Second, we estimated the associations between both a total score whereas 32% said they probably would seek help, 24.9% might or might for overall number of barriers for seeking treatment obtained by sum- not, 13.3% probably would not, and 5.2% definitely would not. Subse- ming all eight barrier items (on the one hand) and type of 12‐month quent analyses focused on the 75.4% (n = 9,939) of students exclusive mental disorder, number of 12‐month mental disorders, and 12‐month of those who reported that they definitely would seek help. More than suicidal thoughts and behaviors (on the other hand). Ordinary least one fourth (28.6%) of the students who would not definitely seek treat- squares regression was used. We estimated bivariate associations ment fulfilled the criteria for at least one of the 12‐month mental disor- adjusting only for country of survey followed by multivariate models der assessed in the survey. The most prevalent 12‐month disorders including all possible combinations of predictor blocks, that is, (a) six were major depressive episode (18.6%) and generalized anxiety disor- types of 12‐month mental disorders, coded as six dummy variables; der (16.1%), with 17.9% of the focal sample meeting criteria for exact (b) number of 12‐month mental disorders, coded as a continuous one, 8.9% exact two, and 4.7% three or more of the mental disorders predictor (ranging from zero to six); (c) number of 12‐month mental assessed in the survey. Twelve‐month suicide ideation was reported disorders, coded as series of dummy variables indicating exactly one, by 8.8% of the respondents who would not definitely seek treatment, exactly two, and three or more disorders; and (d) 12‐month suicidal and 7.8% reported a 12‐month suicide plan. Patterns of service use thoughts and behaviors. Best‐fitting multivariate models were among these students as a function of 12‐month disorders are reported selected based on the Akaike information criterion. All multivariate elsewhere in this issue (Bruffaerts et al., 2019). models adjusted for socio‐demographic and college‐related predictors, country membership, past‐year treatment, likelihood of seeking treat- 3.2 | Barriers to mental health treatment ment in case of a future emotional problem, and scores on the stages of change scale. This enabled us to examine the associations of clinical Table 1 shows the distribution of barriers and their relative importance characteristics with barriers over and above the socio‐demographic, among students in the focal sample. The barrier rated the most impor- college‐related, and treatment history‐related variables associated tant was the preference to handle the problem alone (rated either with the clinical characteristics. “important” or “very important” by 56.4% of respondents) followed Third, we used ordinal regression to estimate the associations of by wanting to talk with friends or relatives instead (48%) and being the eight individual reported barriers for seeking treatment with type too embarrassed to seek help (32.2%). Structural barriers such as cost number of 12‐month mental disorders and 12‐month suicidal thoughts (24.1%) and anticipating problems with time, transportation, or sched- and behaviors. We began by estimated bivariate associations uling (22.6%) were rated of lower importance than most attitudinal (adjusting for country membership only), followed by multivariate barriers. models including all possible combinations of predictor blocks. Multivariate models were adjusted for the same covariates as in Step 2, 3.3 | Clinical characteristic as correlates of barriers as well as for the total barriers score to identify unique associations to treatment between clinical characteristics and specific barriers, above and beyond the effect of the total barriers score. Table 2 shows bivariate associations of clinical characteristics Fourth, we again used ordinal regression to examine the associa- with reported barriers to treatment. Almost all investigated clinical tions of likelihood of seeking treatment in case of a future emotional characteristics were associated with increased reporting of treatment problem with the eight barriers, type of 12‐month mental barriers. The highest regression coefficients predicting the total bar- disorder, number of 12‐month mental disorders, and 12‐month riers score were associated with having three or more disorders 6 of 14 EBERT ET AL. (b = 3.23), broad mania (b = 2.44), and generalized anxiety disorders Note. All analyses were conducted in the subsample of respondents that would not definitely seek treatment in case of a future emotional problem (n = 9,939; 75.4% of the total sample). To obtain pooled esti- You are afraid it might harm your school or professional career (b = 2.30). A similar picture occurred when predicting individual bar- riers, with clinical characteristics associated with increased reporting. The exception was “wanting to talk with friends instead,” which was 33.5 (0.7) 24.6 (0.7) 19.2 (0.6) 13.7 (0.5) 9.1 (0.5) inversely associated with most clinical characteristics (significant ORs % (SE) ranging between 0.56 and 0.85). When examining multivariate associations of these clinical charac- teristics predicting the summary count of number of barriers (Table 3), problems with time, transportation, or the best‐fitting regression model, adjusted for socio‐demographic, college‐related, and treatment‐related characteristics, included type of You anticipate scheduling mental disorder as a significant predictor block within significant predic- 31.1 (0.7) 24.9 (0.7) 21.4 (0.6) 15.3 (0.6) 7.3 (0.4) tive associations for either number of disorders or suicidal thoughts and % (SE) behaviors. The individual disorders most strongly related to barriers were generalized anxiety disorder (b = 1.45), broad mania (b = 1.17), You are unsure of where to go or alcohol use disorder (b = 1.15), and major depression (b = 1.06). who to see When examining multivariate associations of clinical characteristics predicting individual barriers, a more differentiated picture occurred. 23.0 (0.7) 21.8 (0.6) 26.0 (0.7) 22.1 (0.7) 7.2 (0.4) % (SE) None of the specific barriers were predicted by all three types of clini- cal characteristics, that is, types of mental disorders, number of mental disorders, and suicidal thoughts and behaviors. After adjustment for all much money covarites (including the total barriers score), none of the three broad You think it costs too groups of clinical characteristics predicted the barriers “wanting to han- 30.7 (0.7) 23.6 (0.7) 19.6 (0.6) 15.2 (0.6) 10.9 (0.5) % (SE) dle the problem on one's own,” “being unsure available treatments are very effective,” “being unsure of where to go or who to see,” and “antic- ipating problems with time, transportation, or scheduling” in the multi- relatives instead variate model. For each of the other barriers, different combinations of You would talk to friends or clinical characteristics were significant predictors. As in the bivariate 14.7 (0.6) 15.7 (0.6) 21.7 (0.7) 27.7 (0.7) 20.3 (0.6) models, and with only two exceptions, these associations were % (SE) positive, which means that these specific barriers were significantly more likely to be reported by students with than without the clinical embarrassed characteristics, above and beyond the effect of the total barrier score. You would The first of the two exceptions to this general pattern was a neg- 21.3 (0.6) 22.8 (0.7) 23.6 (0.7) 20.2 (0.6) 12.0 (0.5) be too ative association of number of disorders with embarrassment in a % (SE) model that also included disorder types (which had significantly ele- vated ORs) as predictors. The negative associations of number with mates of prevalence, each country was given an equal sum of weights. You would want to handle the embarrassment in this model indicated that there are submultiplicative problem on Perceived barriers to seeking treatment (n = 9,939) your own interactions of comorbid disorders with this barrier. That is, odds of 7.9 (0.4) 11.4 (0.5) 24.3 (0.7) 32.4 (0.7) 24.0 (0.7) embarrassment being a barrier are elevated among students with indi- % (SE) vidual disorders (most notably major depression and generalized anxi- ety disorder), but this elevated risk is dampened among students with available treatments multiple disorders. The second exception was that several clinical are very effective characteristics were associated with significantly reduced odds of You are not sure reporting wanting to talk to friends or relatives instead of a profession as a reason for not wanting to seek professional treatment. 26.6 (0.7) 23.6 (0.6) 24.8 (0.7) 17.8 (0.6) 7.1 (0.4) % (SE) Abbreviation: SE, standard error. 3.4 | Predicting likelihood to seek treatment in case Moderately important of an emotional problem Of little importance Very important Unimportant We also examined associations of treatment barriers and 12‐month Important clinical characteristics in predicting reported intentions to seek treat- TABLE 1 ment in case of a future emotional problem, again excluding from the analysis students who reported that they would definitely seek TABLE 2 Bivariate associations of clinical characteristics predicting perceived barriers to seeking treatment (n = 9,939) EBERT Perceived barriers for seeking treatment Perceived You anticipate You are afraid it ET AL. barriers for You are not You would problems might harm your seeking sure available want to handle You would talk You think it You are unsure with time, school or Predictor treatment treatments are the problem You would be to friends or costs too of where to go transportation, professional distributiona total score very effective on your own too embarrassed relatives instead much money or who to see or scheduling career % (SE) b (SE) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Type of 12‐month mental disorder Major 18.1 (0.6) 1.83 (0.16)* 1.23 (1.14–1.34)* 1.29 (1.18–1.41)* 1.71 (1.57–1.87)* 0.72 (0.66–0.79)* 1.59 (1.47–1.72)* 1.38 (1.27–1.51)* 1.43 (1.32–1.55)* 1.50 (1.38–1.63)* depressive episode Generalized 16.1 (0.6) 2.30 (0.18)* 1.35 (1.23–1.47)* 1.21 (1.10–1.34)* 1.69 (1.54–1.86)* 0.84 (0.77–0.93)* 1.70 (1.55–1.86)* 1.42 (1.29–1.56)* 1.64 (1.50–1.80)* 1.65 (1.52–1.80)* anxiety disorder Panic disorder 4.2 (0.3) 1.91 (0.41)* 1.39 (1.12–1.73)* 1.17 (0.92–1.47) 1.36 (1.09–1.68)* 0.79 (0.62–1.00) 1.48 (1.23–1.77)* 1.32 (1.09–1.60)* 1.53 (1.24–1.88)* 1.74 (1.37–2.21)* Broad mania 3.1 (0.3) 2.44 (0.36)* 1.42 (1.18–1.72)* 1.55 (1.27–1.89)* 1.51 (1.25–1.84)* 0.73 (0.60–0.88)* 1.48 (1.23–1.76)* 1.68 (1.38–2.05)* 1.48 (1.22–1.79)* 1.72 (1.43–2.06)* Alcohol abuse 6.8 (0.4) 1.29 (0.23)* 1.17 (1.04–1.31)* 1.20 (1.06–1.37)* 1.20 (1.06–1.35)* 0.99 (0.87–1.11) 1.20 (1.06–1.36)* 1.15 (1.02–1.29)* 1.23 (1.08–1.40)* 1.35 (1.20–1.52)* or dependence Drug abuse or 3.1 (0.3) 0.78 (0.40) 1.21 (0.99–1.48) 1.31 (1.06–1.63)* 0.98 (0.80–1.20) 0.74 (0.60–0.92)* 1.34 (1.09–1.65)* 1.10 (0.89–1.35) 1.33 (1.08–1.64)* 1.14 (0.91–1.43) dependence Number of 12‐month disorders Three or more 4.7 (0.4) 3.23 (0.34)* 1.57 (1.30–1.89)* 1.41 (1.16–1.72)* 1.78 (1.47–2.15)* 0.66 (0.54–0.81)* 2.07 (1.73–2.46)* 1.67 (1.41–1.99)* 1.98 (1.64–2.39)* 2.28 (1.90–2.72)* Exactly two 8.9 (0.4) 2.35 (0.23)* 1.34 (1.19–1.50)* 1.33 (1.16–1.52)* 1.81 (1.60–2.05)* 0.76 (0.67–0.87)* 1.73 (1.55–1.94)* 1.42 (1.26–1.61)* 1.72 (1.54–1.92)* 1.70 (1.51–1.91)* Exactly one 17.9 (0.6) 1.34 (0.16)* 1.16 (1.07–1.26)* 1.22 (1.12–1.32)* 1.51 (1.39–1.64)* 0.85 (0.78–0.93)* 1.32 (1.22–1.43)* 1.26 (1.16–1.38)* 1.23 (1.13–1.33)* 1.28 (1.18–1.38)* None 68.5 (0.7) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) F (dfn,dfd)b F 3,1576 = 77.44* F 3,624 = 18.27* F 3,432 = 14.61* F 3,465 = 64.54* F 3,272 = 14.10* F 3,813 = 58.56* F 3,414 = 26.87* F 3,1085 = 51.57* F 3,616 = 58.34* 12‐month suicidal thoughts and behaviors Planned or 0.9 (0.1) 1.77 (0.75)* 1.18 (0.79–1.76) 1.17 (0.77–1.76) 1.91 (1.27–2.86)* 0.56 (0.38–0.83)* 1.81 (1.25–2.62)* 1.27 (0.86–1.88) 1.50 (1.02–2.20)* 2.09 (1.43–3.06)* unplanned attempt Plan, no 7.8 (0.4) 1.25 (0.26)* 1.29 (1.13–1.47)* 1.29 (1.11–1.49)* 1.47 (1.29–1.68)* 0.52 (0.45–0.60)* 1.63 (1.42–1.87)* 1.25 (1.10–1.42)* 1.33 (1.16–1.53)* 1.59 (1.39–1.82)* attempts Ideation only 8.8 (0.4) 0.79 (0.23)* 1.13 (1.00–1.26)* 1.17 (1.04–1.33)* 1.40 (1.25–1.58)* 0.74 (0.66–0.83)* 1.41 (1.26–1.58)* 1.24 (1.10–1.38)* 1.19 (1.06–1.34)* 1.09 (0.97–1.22) Never 82.6 (0.6) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) (ref) F (dfn,dfd)b F 3,2068 = 12.44* F 3,569 = 5.63* F 3,422 = 5.64* F 3,716 = 23.58* F 3,227 = 31.81* F 3,511 = 28.69* F 3,928 = 7.91* F 3,415 = 9.07* F 3,587 = 19.58* Note. All analyses were conducted in the subsample that would not definitely seek treatment in case of a future emotional problem (n = 9,939; 75.4% of the total sample). All models adjusted for country membership. Abbreviations: b, unstandardized regression coefficient; CI, confidence interval; OR, odds ratio; SE, standard error. a To obtain pooled estimates of prevalence, each country was given an equal sum of weights. b F test to evaluate joint significance of predictor block. dfn = numerator degrees of freedom; dfd = denominator degrees of freedom. *p < .05. 7 of 14 TABLE 3 Multivariate predictors for perceived barriers for seeking treatment (n = 9,939) 8 of 14 Perceived Barriers barriers for seeking You would talk to You are afraid it might harm Predictor treatment total You would be friends or relatives You think it costs your school or professional distributiona score too embarrassed instead too much money career % (SE) b (SE) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Type of 12‐month mental disorder Major depressive episode 18.1 (0.6) 1.06 (0.19)* 1.48 (1.30–1.69)* 0.74 (0.65–0.84)* 1.06 (0.94–1.20) 0.98 (0.86–1.12) Generalized anxiety disorder 16.1 (0.6) 1.45 (0.20)* 1.31 (1.12–1.55)* 0.86 (0.74–1.00) 1.09 (0.97–1.24) 0.98 (0.84–1.15) Panic disorder 4.2 (0.3) 0.58 (0.42) 1.04 (0.77–1.41) 0.86 (0.64–1.16) 0.89 (0.70–1.14) 1.17 (0.88–1.57) Broad mania 3.1 (0.3) 1.17 (0.37)* 1.07 (0.83–1.39) 0.74 (0.58–0.95)* 0.83 (0.67–1.03) 0.96 (0.75–1.23) Alcohol abuse or dependence 6.8 (0.4) 1.15 (0.24)* 1.05 (0.90–1.22) 0.96 (0.83–1.11) 0.88 (0.76–1.02) 1.04 (0.90–1.21) Drug abuse or dependence 3.1 (0.3) 0.22 (0.41) 0.89 (0.69–1.16) 0.91 (0.70–1.17) 1.20 (0.92–1.58) 0.75 (0.57–1.00) b F (dfn,dfd) F 6,1076 = 32.81* F 6,501 = 8.96* F 6,260 = 4.41* F 6,241 = 1.89 F 6,64 = 0.47 Number of 12‐month disorders Three or more mental disorders 4.7 (0.4) ‐ 0.56 (0.38–0.82)* 1.30 (0.90–1.87) ‐ 1.46 (1.03–2.07)* Exactly two mental disorders 8.9 (0.4) ‐ 0.79 (0.64–0.97)* 1.12 (0.91–1.39) ‐ 1.24 (0.98–1.57) Exactly one mental disorder 17.9 (0.6) ‐ (ref) (ref) ‐ (ref) None 68.5 (0.7) ‐ (ref) (ref) ‐ (ref) b F (dfn,dfd) ‐ F 2,193 = 4.67* F 2,386 = 1.39 ‐ F 2,295 = 2.48 12‐month suicidal thoughts and behaviors Planned or unplanned attempt 0.9 (0.1) ‐ 1.27 (0.81–2.00) 0.69 (0.45–1.06) 1.39 (0.89–2.16) 1.67 (1.04–2.69)* Plan, no attempts 7.8 (0.4) ‐ 1.10 (0.93–1.32) 0.61 (0.52–0.71)* 1.30 (1.10–1.54)* 1.33 (1.12–1.57)* Ideation only 8.8 (0.4) ‐ 1.17 (1.03–1.32)* 0.79 (0.70–0.90)* 1.22 (1.06–1.40)* 0.92 (0.80–1.05) Never 82.6 (0.6) ‐ (ref) (ref) (ref) (ref) F (dfn,dfd)b ‐ F 3,764 = 2.40 F 3,422 = 14.75* F 3,323 = 5.08* F 3,484 = 5.95* Note. All analyses were conducted in the subsample that would not definitely seek treatment in case of a future emotional problem (n = 9,939; 75.4% of the total sample). Models with optimal model fit (based on Akaike information criterion) are shown. For four barriers (not sure available treatments are very effective, want to handle problems on own, not sure where to go or who to see, anticipated problems with time or travel or scheduling), mental disorders, number of mental disorders, and suicidal thoughts and behaviors were not significant as predictors; those barriers are not shown in the table. Each model includes the predictors shown in the rows, and adjusts for socio‐demographic (gender, age, parental educational level, parental marital status, place raised, religion, sexual orientation, and current living situation), college‐ related predictors (expected to work on a student job, academic performance in high school, most important reason to go to university), perceived barriers for seeking treatment total score (in the models for individual barriers), country membership, past‐year treatment, likelihood of seeking treatment in case of a future emotional problem, and stages of change. Abbreviations: b, unstandardized regression coefficient; CI, confidence interval; OR, odds ratio; SE, standard error. a To obtain pooled estimates of prevalence, each country was given an equal sum of weights. b EBERT F test to evaluate joint significance of predictor block. dfn = numerator degrees of freedom; dfd = denominator degrees of freedom. *p < .05. ET AL. EBERT ET AL. 9 of 14 treatment. An inspection of bivariate associations indicated that all of treatment if they had a future emotional problem. A separate analysis the barriers were significant predictors, both that most of them were (results available on request) found, not surprisingly, that students associated with increased rather than decreased odds of seeking treat- with 12‐month mental disorders were more likely than those without ment (Table 4). Clinical characteristics, in comparison, were associated such disorders to report that they would definitely seek treatment. with significantly reduced odds of seeking treatment. It is only among students who reported at least some hesitation in this With regard to multivariate associations, the best‐fitting regression regard that presence of mental disorders was positively associated model to predict reported likelihood to seek treatment was the addi- with extent of hesitation to seek treatment. This suggests that tive model that included barriers to treatment, type of mental disorder, reported hesitation in the presence of actual need indicates and suicidal thoughts and behaviors but not number of Mental Health stronger reluctance to seek treatment than it does in the absence of Disorders (MHDs). All barriers other than “thinking it costs too much actual need. money” were significant but again with many more of them associated There was evidence in the multivariate analysis of clinical with elevated than reduced odds of seeking treatment. “Wanting to characteristics predicting reported barriers that certain barriers are handle the problem on ones' own” was associated with the lowest more common among students with some clinical characteristics than odds of reported willingness to seek treatment (OR = 0.80) and “being others. Most notably, major depression and generalized anxiety unsure of where to go or who to see” with the highest odds disorder were the disorders associated with highest odds of reporting (OR = 1.14). Clinical factors, in comparison, were consistently embarrassment as a barrier to treatment. In light of this fact, interven- associated with significantly reduced odds of seeking treatment. tions designed to increase the use of mental health services might take These associations were significant for major depression (OR = 0.81), individual clinical characteristics into consideration in tailoring strate- alcohol use disorder (OR = 0.75), 12‐month suicidal plans (OR = 0.69), gies. It is noteworthy that the few empirical studies that evaluated and 12‐month suicide ideation without a plan (OR = 0.79). acceptance‐facilitating interventions (Baumeister et al., 2014, 2015; Ebert et al., 2015; Lin, Faust, Ebert, Kramer, & Baumeister, 2018) did not take differences of this sort into consideration. 4 | DISCUSSION Two of the three most often mentioned reasons for not wanting to seek help, the wish to solve problems on one's own, and being too Only one fourth of college students stated that they would definitely embarrassed, were also the only barriers independently associated seek treatment if they developed an emotional problem. This finding with reduced intention to seek treatment after excluding students is indirectly consistent with research showing that a low proportion who reported that they definitely would seek treatment. It is plausible of college students with common mental disorders receive profes- to think in light of this finding that digital delivered self‐help sional treatment (Bruffaerts et al., 2019). Responses to our questions approaches, which do not require the patient to disclose their about barriers provided some insights into the reasons for this low problems to others (Ebert et al., 2018; Ebert, Cuijpers, Muñoz, & treatment rate. Baumeister, 2017), might be ideally suited to students reporting such The clearest pattern in the data was that attitudinal barriers are barriers, in which case offering such interventions might help increase much more common than structural barriers, with the most commonly treatment among this hard‐to‐reach segment of the student popula- reported barriers being the preference to handle the problem on one's tion. This possibility is in line with the findings of another paper in this own, the wish to talk to friends or relatives instead, and being too issue in which approximately one third of the students participating in embarrassed. Two of these three, preference to handle the problem an internet‐based treatment for social anxiety disorder indicated that on one's own and embarrassment, were the only two endorsed they would be unwilling to use face‐to face psychotherapy (Kählke barriers associated with significantly reduced odds of reporting at least et al., 2019). Future research should explore to which extend students some intention to seek treatment in the future in the face of an emo- that are not willing to seek help with traditional forms of health care tional problem. This pattern is in line both with reports about barriers can be reached using such digital approaches. to seeking treatment among adults with mental disorders in the cross‐ Results of the present study should be seen in the context of a national WMH surveys (Andrade et al., 2014) and with prior studies of range of limitations. First, as pointed out in other papers' of this issue barriers to treatment among students (Gulliver et al., 2010; Vidourek (Auerbach et al., 2018; Bruffaerts et al., 2019; Alonso, Vilagut et al., et al., 2014). This is an important pattern because these attitudinal 2018) and related recent papers (Alonso, Mortier et al., 2018), the barriers might be easier to overcome than structural barriers. response rate in the WMH‐ICS surveys was suboptimal across virtu- Most of the clinical characteristics considered here had significant ally all sites. Although all reported results are weighted using and positive associations with most of the reported barriers and neg- poststratification weights to adjust for differences between survey ative associations with intention to seek treatment. Furthermore, a respondents and nonrespondents based on socio‐demographic or positive dose–response relationship was found between the number college‐related characteristics that were made available from univer- of 12‐month mental disorders the student had and the number of sity officials, a potential selection bias regarding other variables cannot barriers the student endorsed. The sign of these associations might be excluded. Second, clinical characteristics were assessed using fully seem counterintuitive but is important to remember that the analysis structured self‐report scales rather than clinical interviews. Despite excluded students who reported that they would definitely seek evidence for good concordance between diagnoses based on these 10 of 14 EBERT ET AL. TABLE 4 Multivariate associations of perceived barriers and 12‐month clinical characteristics predicting reported likelihood of seeking treatment in case of a future emotional problem (n = 9,939) Predictor distributiona Bivariate modelsb Multivariate modelc % (SE) OR (95% CI) OR (95% CI) II. Perceived barriers to seeking treatment You are not sure available treatments are very effective ‐ 1.06 (1.02–1.09)* 1.04 (1.01–1.08)* You would want to handle the problem on your own ‐ 0.82 (0.79–0.85)* 0.80 (0.77–0.83)* You would be too embarrassed ‐ 0.94 (0.91–0.97)* 0.91 (0.88–0.94)* You would talk to friends or relatives instead ‐ 1.06 (1.03–1.09)* 1.07 (1.04–1.10)* You think it costs too much money ‐ 1.07 (1.04–1.10)* 1.03 (1.00–1.07) You are unsure of where to go or who to see ‐ 1.14 (1.10–1.17)* 1.14 (1.10–1.18)* You anticipate problems with time, transportation, or scheduling ‐ 1.11 (1.08–1.14)* 1.07 (1.03–1.11)* You are afraid it might harm your school or professional career ‐ 1.07 (1.04–1.10)* 1.05 (1.01–1.08)* F 8,222 d ‐ 38.53* IV. Type of 12‐month mental disorder Major depressive episode 18.1 (0.6) 0.76 (0.69–0.83)* 0.81 (0.71–0.91)* Generalized anxiety disorder 16.1 (0.6) 0.94 (0.84–1.04) 0.98 (0.87–1.12) Panic disorder 4.2 (0.3) 1.04 (0.77–1.40) 1.07 (0.77–1.50) Broad mania 3.1 (0.3) 0.78 (0.63–0.97)* 0.89 (0.71–1.12) Alcohol abuse or dependence 6.8 (0.4) 0.74 (0.64–0.85)* 0.75 (0.64–0.87)* Drug abuse or dependence 3.1 (0.3) 0.72 (0.57–0.91)* 0.85 (0.66–1.08) F 6,428 d ‐ 5.95* VI. 12‐month suicidal thoughts and behaviors Planned or unplanned attempt 0.9 (0.1) 0.70 (0.56–0.87)* 0.80 (0.51–1.26) Plan, no attempts 7.8 (0.4) 0.84 (0.73–0.96)* 0.69 (0.58–0.82)* Ideation only 8.8 (0.4) 0.82 (0.75–0.90)* 0.79 (0.69–0.91)* Never 82.6 (0.6) (ref) (ref) d e F 10.43* 8.17*f Note: All analyses were conducted in the subsample that would not definitely seek treatment in case of a future emotional problem (n = 9,939; 75.4% of the total sample). Abbreviations: CI, confidence interval; OR, odds ratio; SE, standard error. a To obtain pooled estimates of prevalence, each country was given an equal sum of weights. b Each row shows a separate logistic regression model with likelihood of seeking treatment in case of a future emotional problem as the outcome variable, adjusting for country membership. Only bivariate associations for predictors that were included in the final multivariate model (i.e., the last column) are shown. c The final (best‐fitting) multivariate model adjust for socio‐demographic (gender, age, parental educational level, parental marital status, place raised, reli- gion, sexual orientation, and current living situation), college‐related predictors (expected to work on a student job, academic performance in high school, most important reason to go to university), country membership, past‐year treatment, stages of change, and for predictors shown in the rows. d F test to evaluate joint significance of predictor block with numerator degrees of freedom, denominator degrees of freedom. e The degrees of freedom for this F value are dfn = 3, dfd = 1023 f The degrees of freedom for this F value are dfn = 3, dfd = 580. *p < .05. measures and those based on blinded clinical evaluations in previous (Webb & Sheeran, 2006). Therefore, we plan to use future prospective studies, no clinical reappraisal studies of these scales have as yet been WMH‐ICS data to examine the association of barriers reported in the carried out in sample of college students. As a result, we cannot baseline survey with subsequent treatment over the next year of col- exclude the possibility of bias in estimates of mental disorders. Third, lege. Fourth, the changes of stages scale assessed the readiness to we only assessed hypothetical intention to seek mental health treat- seek help in case of emotional or substance use problems in one item, ment. Although this generally viewed as a useful best proximal indica- and this item did also not differentiate between different types of tor, it does not always translate directly to actual use of services emotional problems, for example, depression versus suicidal EBERT ET AL. 11 of 14 behaviors. We cannot exclude that responses regarding stages of United States (2014‐J2140150‐102905) (R. B.); Eli Lilly and Company change might have differed if assessed separately for different types (IIT‐H6U‐BX‐I002) (R. B. and P. M.); BARMER, a health care insurance of emotional‐ or substance‐related problems. Finally, we neither company, for project StudiCare (D. D. E.); ZonMw (Netherlands Orga- examined a broad range of potentially relevant predictors nor consid- nisation for Health Research and Development; Grant 636110005); ered relevant interactions between different student characteristics in the PFGV (Protestants Fonds voor de Geestelijke Volksgezondheid) the prediction of intention to seek treatment. Expanded investigations in support of the student survey project (P. C.); South African Medical of that sort are needed in future iterations of the WMH‐ICS survey. Research Council and the Ithemba Foundation (D. J. S.); Fondo de Within the context of these limitations, the study has a number of Investigación Sanitaria, Instituto de Salud Carlos III—FEDER (PI13/ important implications. First, we showed clearly that the majority of 00343), ISCIII (Río Hortega, CM14/00125), ISCIII (Sara Borrell, students reported at least some hesitation to seek treatment for CD12/00440), Ministerio de Sanidad, Servicios Sociales e Igualdad, emotional problem and that psychological barriers are paramount, PNSD (Exp. 2015I015); DIUE Generalitat de Catalunya (2017 SGR thereby arguing that the treatment gap that exists among college 452), FPU (FPU15/05728) (J. A.); Fondo de Investigación Sanitaria, students cannot be closed entirely by doing nothing more than Instituto de Salud Carlos III—FEDER (PI13/00506) (G. V.); European increasing access to treatment. Much existing implementation Union Regional Development Fund (ERDF) EU Sustainable Competi- research designed to increase use of existing services has been limited tiveness Programme for Northern Ireland, Northern Ireland Public to descriptive studies of barriers along the lines of those studied in this Health Agency (HSC R&D), and Ulster University (T. B.); Consejo report (Bauer, Damschroder, Hagedorn, Smith, & Kilbourne, 2015). Nacional de Ciencia y Tecnología (CONACyT) Grant CB‐2016‐01‐ Future research needs to implement controlled trials to evaluate con- 285548 (C. B.). The World Mental Health International College crete strategies to reduce barriers in an effort to increase treatment. Student (WMH‐ICS) initiative is carried out as part of the WHO World Failure to do this has resulted in criticisms of prior research on barriers Mental Health (WMH) Survey Initiative. The WMH survey is sup- to treatment lacking external validity (Pressler & Kaizar, 2013). We ported by the National Institute of Mental Health (NIMH) plan to implement such experiments in future iterations of the R01MH070884, the John D. and Catherine T. MacArthur Foundation, WMH‐ICS surveys, as these surveys give us unique access to students the Pfizer Foundation, the US Public Health Service (R13‐MH066849, with current mental disorders who have not sought treatment. Our R01‐MH069864, and R01 DA016558), the Fogarty International initial efforts along these lines are described in another paper of this Center (FIRCA R03‐TW006481), the Pan American Health issue (Ebert et al., 2018). Organization, Eli Lilly and Company, Ortho‐McNeil Pharmaceutical, GlaxoSmithKline, and Bristol‐Myers Squibb (R. C. K.). None of the funders had any role in the design, analysis, interpretation of results, DECLARATION OF INTEREST STATEMENT or preparation of this paper. We thank the staff of the WMH Data Collection and Data Analysis Dr. Ebert has served as a consultant to/on the scientific advisory boards Coordination Centres for the assistance with instrumentation, of Sanofi, Novartis, Minddistrict, Lantern, Ideamed, Schoen Kliniken, fieldwork, and consultation on data analysis. A complete list of all Agaplesion, and German health insurance companies (BARMER, within‐country and cross‐national WMH‐ICS publications can be Techniker Krankenkasse). He is also stakeholder of the Institute for found at http://www.hcp.med.harvard.edu/wmh/. health training online (GET.ON), which aims to implement scientific findings related to digital health interventions into routine care. In the past 3 years, Dr. Kessler received support for his epidemiological studies from Sanofi Aventis; was a consultant for Johnson & Johnson Wellness WHO WMH‐ ICS Collaborators and Prevention, Sage Pharmaceuticals, Shire, Takeda; and served on an Australia: Mark Boyes, PhD, School of Psychology, Curtin University; advisory board for the Johnson & Johnson Services Inc. Lake Nona Life Glenn Kiekens, MSc, School of Psychology, Curtin University and RG Project. Kessler is a co‐owner of DataStat, Inc., a market research Adult Psychiatry KU Leuven, Belgium; Germany: Harald Baumeister, firm that carries out healthcare research. Drs. Mortier, Auerbach, PhD, University of Ulm; Fanny Kaehlke, MSc, Matthias Berking, PhD, Alonso, Bantjes, Benjet, Cuijpers, Greif Green, Hasking, Nock, O'Neill, Friedrich‐Alexander University Erlangen Nuremberg; Mexico: Adrián Pinder‐Amaker, Vilagut, Zaslavsky, Bruffaerts, and Ms. Sampson report Abrego Ramírez, PhD, Universidad Politécnica de Aguascalientes; no biomedical financial interests or potential conflicts of interest. Guilherme Borges, PhD, Instituto Nacional de Psiquiatría Ramón de la Fuente; Anabell Covarrubias Díaz, PhD, Universidad La Salle ACKNOWLEDGMENTS Noroeste; Ma. Socorro Durán, MPsych, Universidad De La Salle Bajío; Funding to support this initiative was received from the National Rogaciano González González, PhD, Universidad De La Salle Bajío, Institute of Mental Health (NIMH) R56MH109566 (R. P. A.), and the campus Salamanca; Raúl A. Gutiérrez‐García, PhD, Universidad De content is solely the responsibility of the authors and does not neces- La Salle Bajío, campus Salamanca; Alicia Edith Hermosillo de la Torre, sarily represent the official views of the National Institutes of Health or PhD, Universidad Autónoma de Aguascalientes; Kalina Isela NIMH; the Belgian Fund for Scientific Research (11N0514N, Martinez Martínez, PhD, Universidad Autónoma de Aguascalientes, 11N0516N, and 1114717N) (P. M.); the King Baudouin Foundation Departamento de Psicología, Centro Ciencias Sociales y Humanidades; 12 of 14 EBERT ET AL. María Elena Medina‐Mora, PhD, Instituto Nacional de Psiquiatría Andrade, L. H., Alonso, J., Mneimneh, Z., Wells, J. E., Al‐Hamzawi, A., Borges, Ramón de la Fuente; Humberto Mejía Zarazúa, PhD, Universidad La G., … Kessler, R. C. (2014). Barriers to mental health treatment: Results from the WHO World Mental Health surveys. 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