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\begin{document}

\title{Young People's Pathways to a Specialist Suicide Prevention Service and
the Influence of Caregiver prior Suicidality and Mental Health Treatment}



\author[1]{Anna Sidis}%
\author[1]{Zozan Onay}%
\author[1]{Frank Deane}%
\author[1]{Laura Robinson}%
\affil[1]{University of Wollongong School of Psychology}%


\vspace{-1em}



  
  \date{June 18, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
\textbf{Aim}. Timely help-seeking and pathways to care (PtC) have been
linked to positive outcomes in suicidal adolescents. While the
importance of formal contacts is recognised, caregivers also play a
significant role in these pathways. Caregiver's familiarity with mental
health issues may influence an adolescent's PtC. This study explores the
relationship between a caregiver's prior suicidality and mental health
treatment on their children's pathways to entering a specialist suicide
prevention treatment program. \textbf{Method.} Caregivers ( \emph{n} =
118, 35 males and 83 females) of young individuals (12-25 years) who
were admitted into an outpatient suicide prevention service, completed a
self-report questionnaire describing their child's onset of symptoms,
help-seeking, PtC and the caregiver's prior suicidality and mental
health treatment. \textbf{Results.} Parents were the source most likely
to recognise the onset of suicidality, with general practitioners and
psychologists the most common first contacts. Significant delays were
identified for onset duration averaging 48.0 weeks, and it was observed
that shorter delays in treatment were related to fewer number of
contacts. Caregiver prior suicidality was associated with longer delays
in treatment but had no relationship with onset duration.
\textbf{Conclusion.} Caregivers and professional contacts are vital
agents in improving the PtC of suicidal adolescents. Results highlight
the significant delays in treatment and the added complexity of a
caregiver's prior experience of suicidality to these pathways. These
complexities warrant further exploration to minimise obstacles that
hinder help-seeking and lengthen PtC, as this may improve interventions
and outcomes for suicidal adolescents and their caregivers.
\textbf{Keywords.} Pathways to care; delay in treatment; caregiver
familiarity; suicide; adolescent.%
\end{abstract}%



\sloppy


\par\null

\textbf{Title:} Young People's Pathways to a Specialist Suicide
Prevention Service and the Influence of Caregiver prior Suicidality and
Mental Health Treatment

\textbf{Authors:}

Zozan Onay, Frank P. Deane, Anna Sidis, and Laura Robinson

\textsuperscript{All authors have no conflicts of interest to disclose
in relation to this manuscript.}

\textbf{Affiliations:}

School of Psychology, University of Wollongong

\textbf{Correspondence to:}

Dr. Anna Sidis

School of Psychology

University of Wollongong, Northfields Avenue,

Wollongong, NSW, 2522, Australia

Email: asidis@uow.edu.au



\textbf{Abstract}

\textbf{Aim} . Timely help-seeking and pathways to care (PtC) have been
linked to positive outcomes in suicidal adolescents. While the
importance of formal contacts is recognised, caregivers also play a
significant role in these pathways. Caregiver's familiarity with mental
health issues may influence an adolescent's PtC. This study explores the
relationship between a caregiver's prior suicidality and mental health
treatment on their children's pathways to entering a specialist suicide
prevention treatment program.

\textbf{Method.} Caregivers (\emph{n} = 118, 35 males and 83 females) of
young individuals (12-25 years) who were admitted into an outpatient
suicide prevention service, completed a self-report questionnaire
describing their child's onset of symptoms, help-seeking, PtC and the
caregiver's prior suicidality and mental health treatment.

\textbf{Results.} Parents were the source most likely to recognise the
onset of suicidality, with general practitioners and psychologists the
most common first contacts. Significant delays were identified for onset
duration averaging 48.0 weeks, and it was observed that shorter delays
in treatment were related to fewer number of contacts. Caregiver prior
suicidality was associated with longer delays in treatment but had no
relationship with onset duration.

\textbf{Conclusion.} Caregivers and professional contacts are vital
agents in improving the PtC of suicidal adolescents. Results highlight
the significant delays in treatment and the added complexity of a
caregiver's prior experience of suicidality to these pathways. These
complexities warrant further exploration to minimise obstacles that
hinder help-seeking and lengthen PtC, as this may improve interventions
and outcomes for suicidal adolescents and their
caregivers.\textbf{Keywords.} Pathways to care; delay in treatment;
caregiver familiarity; suicide; adolescent.



\textbf{Introduction}

Adolescence is characterised by major developmental and psychological
shifts, often coinciding with increased suicidal ideation and behaviour
(Bridge, Goldstein, \& Brent, 2006; Husler, Blakeney, \& Werlen, 2005).
Globally, it is estimated that one person dies from suicide every 40
seconds, with suicide the second leading cause of death among those aged
15 to 29 years (WHO, 2016). Among Australians aged 15 to 24 years,
suicide is the leading cause of death and accounts for over one third of
deaths (36\%). These statistics are alarming and highlight the high
prevalence of suicide in young Australians.

Although suicidal thoughts and comorbid problems should serve as an
internal signal to seek help, suicidal adolescents frequently withhold
their distress from adults or professional services (McCarty, et al.,
2011; Pisani, Schmeelk-Cone, Gunzler, \& Petrova, 2012). As a result,
less than a third of suicidal adolescents receive treatment at the time
of their death/attempt, despite 80\% to 90\% presenting with a
diagnosable psychological disorder (Gould, et al., 2003; Sheppard,
Deane, \& Ciarrochi, 2018; Wu, Liu, Fan, \& Fuller, 2010). For
adolescents at risk of suicide, communicating their distress and
suicidal ideation with others may lead to life saving interventions
(Pisani et al., 2012).

Despite the prevalence of mental illness among young people, many remain
untreated or experience multiple help-seeking contacts before receiving
appropriate care (MacDonald, Falnman-Adelman, Anderson, \& Iyer, 2018).
Appropriate help-seeking and pathways to care (PtC) are essential for
prevention and early intervention in suicidal adolescents . However,
research on the PtC for adolescents with suicide ideation is limited.
Most research on PtC has focused on help-seeking in response to
hypothetical suicide ideation , or first-episode psychosis .

Appropriate PtC for suicidal adolescents can reduce the impact of mental
health problems and the incidence of relapse or recurrence (Allen \&
McKenzie, 2015). In two Australian studies, one with university students
(Deane, Wilson, \& Ciarrochi, 2001) and another with high school
students (Wilson, Deane, \& Ciarrochi, 2005a), it was found that an
increase in suicidal ideation significantly predicted lower intentions
to seek help from formal (e.g. mental health professional, general
practitioner, helpline) and informal (e.g. friends, family, parents)
contacts in both clinical and non-clinical samples. This phenomenon has
been referred to as ``help-negation'' and this along with low rates of
help-seeking in suicidal individuals, highlights the need to better
understand the processes involved in help seeking. One rarely explored
opportunity is to expand knowledge about PtC for those who are
successful in seeking help. Greater insights into PtC would allow
suicide prevention services to better identify strategies (e.g., health
literacy, referral strategies etc) to target appropriate links in the
pathways to care.

Although the importance of formal contacts has been recognised in the
help seeking process, often families, friends and caregivers play a
significant role in the pathways to professional services, and act as
primary contacts on the PtC for adolescents (Fridgen, et al., 2013;
McGorry, 2007; Rickwood, et al., 2007). Families have been found to be
highly involved in the PtC of adolescents and have been identified as
the most common first contact for help (Del Vechhio, et al., 2015;
Fridgen, et al., 2013). They also recommend further help-seeking
contacts (Chadda, Agarwal, Singh, \& Raheja, 2001), or directly initiate
contact with help sources (Ehmann, et al., 2014; Giasuddin, et al.,
2012).

An adult caregiver's familiarity with mental health issues, particularly
personal experience of mental health problems and psychological
treatment, may influence the nature of an adolescent's PtC and increase
their likelihood of seeking help (Lutgens, Malla, Joober, \& Iyer, 2015;
Schmeelk-Cone, Pisani, Petrova, \& Wyman, 2012; Sullivan, Marshall, \&
Schonert-Reichl, 2002). However, research on caregiver's familiarity
with mental illness and PtC for their children has been mostly limited
to first-episode psychosis and with conflicting findings. For example,
Chen et al. (2005) found caregiver experience of mental illness was
associated with shorter delays to treatment, whereas Norman et al.
(2007) reported the reverse relationship and Lutgens et al. (2015)
reported that caregiver familiarity did not affect the delay in
treatment of psychosis. The disparity in findings has been attributed to
different service contexts and sample characteristics.

In the context of suicide, it is possible that family members with a
personal history of suicide or mental health problems may have; a higher
sensitivity to symptoms of suicidality, more positive attitudes towards
help seeking, and be more familiar with appropriate contacts. It has
been suggested that familiarity through personal experience may offer
caregivers greater sensitivity to and preparedness to navigate these
complexities, the ability to better recognise early signs of
psychological distress, and encourage more effective help-seeking (Chen,
et al. 2005; Lutgens, et al., 2015; Sullivan, et al., 2002). However,
these potential benefits have not yet been empirically tested. Even when
caregivers recognise the need for help, some report that it is often
difficult to access support (Stewart, et al., 2018). Thus, an
understanding of the relationship between caregiver's personal
experiences of suicidality and prior mental health treatment and how
these might be related to their young person's PtC in the context of
seeking help for suicidal behaviours is needed.

More specifically, we explore the relationship of these caregiver
variables and delay in the young person's help seeking journey from
initial identification of a problem through to attending a specialist
suicide prevention service. This study aims to describe the: (i)
duration between the onset of presenting problem and seeking
professional help for suicidal youth, (ii) duration between the onset of
presenting problem and accessing a SP service for suicidal youth, (iii)
number of steps in pathways to accessing a SP service for suicidal
youth, (iv) primary contacts and initial contacts involved in the PtC
for suicidal youth, and determine (v) whether caregiver's personal
experience of suicidality and mental health treatment is associated with
PtC for suicidal youth.

\textbf{Method}

\textbf{Participants}

This study accessed data from the Suicide Prevention Research Databank
held by Grand Pacific Health. Grand Pacific Health is an Australian
primary healthcare organisation that operates a specialist youth SP
service that provides intensive psychological treatment for youth at
risk of suicide, including those who have engaged in self-harm or who
are experiencing suicidal thoughts. Individuals admitted into this
program were between the ages of 12 and 25 years.

Participants of this study included parents/caregivers (\emph{n} = 118,
35 males and 83 females) of young individuals (30 male and 88 female)
admitted into the SP service. The average age of the young people was
15.47 (SD=2.17) years.

Ethical review and approval were obtained from the University of
Wollongong Human Research Ethics Committee and the Grand Pacific Health
(HE 2016/090).

\textbf{Procedure}

As a part of admission procedures caregivers of patients were invited to
attend a single group information session aimed at describing what the
SP program involves, practical ways of improving communication with
their child and sources of support for caregivers experiencing mental
health difficulties themselves. During these information sessions
caregivers were also invited to complete a questionnaire which asked
them to describe their child's onset of symptoms, help-seeking and PtC,
and the level of familiarity and experience that the caregiver had with
treatments for psychological problems, suicidal ideation and suicidal
behaviour.

\textbf{Measures}

\textbf{Onset duration.} The length of time (in weeks) between the onset
of the presenting problem and data collection at entry to SP service was
provided by caregivers and assessed using the following item:

\emph{``How long ago was the first time you thought your child was at
risk of suicide or self-harm?''.}

\textbf{Help-seeking delay.} Caregivers also provided the length of time
(in weeks) between the onset of the presenting problem and seeking
professional help using the following item: \emph{``How long was the
period from when you first noticed there was a problem until you began
to seek professional help?''}

\textbf{Treatment delay.} Treatment delay was determined by calculating
the duration between help-seeking to accessing the SP service. Figure 1
shows a diagrammatic representation of these intervals.

\textbf{A} \textbf{B}

First noticed First started seeking Entry into Suicide

suicidality professional help Prevention service

Figure 1. Representation of intervals.

Note. A+B = Onset to entry to suicide prevention service ``\emph{Onset
duration} ''; A = Problem identification to professional help seeking
initiation ``\emph{Help seeking delay''} ; B = Professional help seeking
initiation to SP service entry, \emph{``Treatment delay''}

\textbf{Contacts.} The sequence and types of contacts involved in the
individual participants' PtC was obtained using the following
item;\emph{``Please write in order who first alerted you to the problem,
who you first contacted for help, and the other people you had seen
prior to your child accessing the suicide prevention service.''} Parents
responded using the following sequenced trajectory item;

\emph{\_\_\_\_\_\_\_\textgreater{} \_\_\_\_\_\_\_\textgreater{}
\_\_\_\_\_\_\_\textgreater{} \_\_\_\_\_\_\_\textgreater{}
\_\_\_\_\_\_\_\textgreater{} \_\_\_\_\_\_\_\textgreater{} SP service.}

\textbf{Caregiver Familiarity} \emph{.} This was assessed using two
factors: i) \emph{caregiver's experience of prior mental health
treatment} ; and ii) \emph{caregiver's experience of prior suicidality}
.

\emph{Caregiver's experience of prior mental health treatment.} This was
assessed by two items: 1) \emph{``Have you ever received psychological
treatment in the past?''} 2) \emph{``Have you ever been prescribed
medication for a psychological problem in the past?''}(both Yes/No
responses). Respondents who responded yes to either item were coded
1(yes) and all others 0 (no).

\emph{Caregiver's experience of prior suicidality} . This was assessed
by three items: 1) \emph{``Do you have a history of suicidal
ideation/behaviour?''} 2) \emph{``Do you have a history of deliberate
self-harm ideation/behaviour?''} (Yes/No responses), 3) ``\emph{How many
times have you made a suicide attempt (with intent to die)?''}Responses
for the last item were provided using a Likert scale (`0 = none', `1 =
one', `2 = two', `3 = three', `4 = four or more'). Finally, all items
were summed to form one score with higher scores indicating greater
parental familiarity. Cronbach's alpha was .74.

\textbf{Analysis}

Descriptive statistics were conducted on all measures with frequencies
used to examine the most frequent contact, pathway chain, and the
frequencies of each contact along the pathway. All variables were
assessed for normality, linearity and homoscedasticity. Overall delay in
treatment and number of contacts were significantly skewed, and
non-parametric statistics were employed. Spearman's correlations were
conducted to examine the relationship between the number of pathway
contacts and overall delay in weeks.

Additionally, three multiple regression analyses were conducted in SPSS
(IBM Corp., 2022) one for each dependent variable: 1) onset duration; 2)
treatment delay duration; and 3) help-seeking delay. For all regressions
the following variables were included: caregiver familiarity (Caregiver
MH treatment and Caregiver suicidality), the age of young person, young
person's gender and caregiver gender. Next moderation was conducted for
each moderator separately (age and gender) for each of the dependent
variables using PROCESS for SPSS (Hayes, 2013).

Prior to interpreting the results of the regression, several assumptions
were evaluated, and results indicated that normality, linearity,
homoscedasticity of residuals, multicollinearity and assessment for
multivariate outliers supported assumptions of the analyses. Descriptive
analysis (Table 2) revealed outliers. Therefore, a sensitivity analysis
was conducted to determine whether results were affected by including,
excluding or adjusting the highest time durations (outlier) in the
regression findings. The results showed similar patterns of predictors
and statistical significance irrespective of inclusion or exclusion of
outliers for the time duration variables. Thus, we report the results of
the regression with all duration scores as reported and unchanged (i.e.,
including outliers).

\textbf{Results}

\textbf{Descriptive Data}

The mean number of steps in the pathway to the specialist suicide
service was 2.90 contacts (\emph{SD} = 1.33). The most frequent sequence
of contacts for the first three pathway steps was young person
\textgreater{} doctor/GP \textgreater{} psychologist (9\% of sample had
this sequence). When the young person contact was not included, the most
frequent sequence of contacts for the first three pathway steps was
parent \textgreater{} doctor/GP \textgreater{} emergency
services/psychiatrist (8\% had this sequence). The most frequent initial
contact was the young person, followed by the parent. The most common
professional contact was with a GP/Doctor followed by Psychologist. The
mean number of weeks between the onset of presenting problem to seeking
professional help (help-seeking delay) was 16.5 weeks (SD=1.5, range 1
to 208). Treatment delay, that is the time between seeking professional
help to accessing the SP service, averaged 37.7 weeks (SD=11.0; range 1
to 512). The duration between onset of presenting problems to accessing
SP, that is onset duration had a mean of 48.0 weeks (SD=16.0, range 1 to
512). Further descriptive statistics of the frequency of each contact
along the pathway are shown in Table 1.

Table 1 \emph{Frequencies and percentages of contacts within each steps
of pathway to care.}\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
\textbf{Type of Contact} & \textbf{Steps on Pathway} & \textbf{Steps on
Pathway} & \textbf{Steps on Pathway} & \textbf{Steps on Pathway} &
\textbf{Steps on Pathway} & \textbf{Steps on Pathway} & \textbf{Steps on
Pathway}\tabularnewline
\midrule
\endhead
& Contact 1 (\emph{N} = 118) \emph{\% (n)} & Contact 2 (\emph{N} = 103)
\emph{\% (n)} & Contact 3 (\emph{N} = 67) \emph{\% (n)} & Contact 4
(\emph{N} = 35) \emph{\% (n)} & Contact 5 (\emph{N} = 14) \emph{\% (n)}
& Contact 6 (\emph{N} = 4) \emph{\% (n)} & Contact 7 (\emph{N} = 2)
\emph{\% (n)}\tabularnewline
Young person & Young person & 24.6 (29) & 1.9 (2) & 1.5 (1) & 0 (0) & 0
(0) & 0 (0)\tabularnewline
Family & Family & 5.9 (7) & 1.9 (2) & 1.5 (1) & 2.9 (1) & 0 (0) & 25.0
(1)\tabularnewline
Parent & Parent & 23.7 (28) & 8.7 (9) & 1.5 (1) & 0 (0) & 7.1 (1) & 0
(0)\tabularnewline
School & School & 11.9 (14) & 3.9 (4) & 0 (0) & 5.7 (2) & 0 (0) & 0
(0)\tabularnewline
GP/Doctor & GP/Doctor & 10.2 (12) & 37.9 (39) & 29.9 (20) & 22.9 (8) &
28.6 (4) & 0 (0)\tabularnewline
Friend & Friend & 4.2 (5) & 4.9 (5) & 7.5 (5) & 5.7 (2) & 0 (0) & 0
(0)\tabularnewline
School Counsellor & School Counsellor & 9.3 (11) & 10.7 (11) & 9.0 (6) &
5.7 (2) & 0 (0) & 0 (0)\tabularnewline
Psychologist & Psychologist & 5.9 (7) & 20.4 (21) & 35.8 (24) & 48.6
(17) & 57.1 (8) & 50.0 (2)\tabularnewline
Emergency Service & Emergency Service & 4.2 (5) & 7.8 (8) & 7.5 (5) &
2.9 (1) & 0 (0) & 0 (0)\tabularnewline
Other & Other & 0 (0) & 1.9 (2) & 6.0 (4) & 5.7 (2) & 7.1 (1) & 25.0
(1)\tabularnewline
\bottomrule
\end{longtable}

\textbf{Correlations between Number of Contacts, Time Durations and
Caregiver variables}

As shown in Table 2 Spearman's correlation showed a small significant
positive relationship between the number of contacts and delay in
treatment (\emph{r\textsubscript{s}} = .19, \emph{p} \textless{} .05).
No significant relationships were found between the number of contacts
with onset duration or help seeking delay. A small significant negative
relationship was found between number of contacts and caregiver prior
mental health treatment (\emph{r\textsubscript{s}} = -.22), such that
higher caregiver prior mental health treatment was associated with lower
numbers of contacts. Help-seeking delay and onset duration had a
positive correlation (\emph{r\textsubscript{s}} = .69
\emph{p}\textless{} .05).

Table 2\emph{. Correlations between number of contacts, time durations
and caregiver familiarity variables}\selectlanguage{english}
\begin{longtable}[]{@{}lllllllll@{}}
\toprule
\begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\emph{1}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\emph{2}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\emph{3}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\emph{4}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\emph{5}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\emph{6}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\emph{7}\strut
\end{minipage} & \begin{minipage}[b]{0.08\columnwidth}\raggedright\strut
\emph{8}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\emph{Gender}\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\emph{Caregiver's gender}\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.00\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\emph{Age}\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
-.38**\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.01\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\emph{Number of contacts}\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.04\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.05\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
-.11\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\emph{Treatment delay}\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.03\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.02\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.18\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.19*\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\emph{Onset duration}\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.04\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.03\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.15\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.16\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.69**\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\emph{7. Help seeking delay}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
.04\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
.05\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
.14\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-.09\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-.05\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
.40**\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
\emph{8. Caregiver prior Suicidality}\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
.08\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-.01\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-.11\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
.08\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
.18\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
.12\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
-.01\strut
\end{minipage} & \begin{minipage}[t]{0.08\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
\emph{Caregiver prior MH treatment}\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.02\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
-.10\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.02\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
-.22*\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
-.14\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
-.10\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.04\strut
\end{minipage} & \begin{minipage}[t]{0.11\columnwidth}\raggedright\strut
.34**\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\emph{**p} \textless{}.01, *\emph{p} \textless{}.05. For gender 1=male,
2=female

\textbf{Predictors of Time Durations.}

Table 3 provides the results from the three regressions with each of the
three-time duration variables as dependent variables.

\textbf{Onset duration} . Results show a significant positive
relationship between the number of contacts and onset duration (Table
3). There was also a significant positive association between caregiver
prior suicidality and onset duration, as well as between age and onset
duration. Finally, there was a significant relationship between gender
and onset duration, with onset duration being significantly longer in
females (M= 52.42, SE = 7.54) compared to males (M=21.89, SE=12.10).

\textbf{Help-seeking delay} . There were no significant associations
between the number of contacts, caregiver suicidality or caregiver prior
treatment and help-seeking delay. There were no other significant
relationships with help-seeking delay.

\textbf{Treatment delay} . Number of contacts, caregiver MH treatment,
caregiver suicidality were significantly positively associated with
treatment delay (Table 3). There was also a significant positive
relationship between age and treatment delay and a significantly
negative relationship between gender and treatment delay. Overall delay
in treatment was significantly longer for females (M=46.75, SE=7.33)
than for males (M=8.17, SE=11.58).

Table 3. \emph{Regression coefficients for parent familiarity and number
of contacts for each type of time delay}\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{Onset Duration}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{Onset Duration}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{Help seeking delay}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{Help seeking delay}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{Treatment Delay}\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\textbf{Treatment Delay}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\emph{B(SE)}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\emph{CI {[}LL,UL{]}}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\emph{B(SE)}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\emph{CI {[}LL,UL{]}}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\emph{B(SE)}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\emph{CI {[}LL,UL{]}}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Gender Male Female\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-30.53 (14.07)* 0\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
{[}-57.41, -1.64{]}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
7.76 (7.31) 0\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
{[}-6.74, 22.25{]}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-37.20 (13.56)** 0\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
{[}-64.10, 10.29{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Parent gender Male Female\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-12.88 (13.22) 0\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
{[}-39.09, 13.34{]}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-6.38 (7.09) 0\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
{[}-20.46, 7.77{]}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
-14.28 (12.79) 0\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
{[}-39.68, 1.11{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Age\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
21.26 (2.91)***\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}15.49, 27.03{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.94 (1.54)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}-1.12, 5.00{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
20.33 (2.74)***\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}14.90, 25.77{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Number of contacts\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11.63 (4.62)**\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}2.46, 20.80{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
-1.60 (2.48)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}-6.51, 3.31{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
13.13 (4.50)**\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}4.19, 22.07{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Caregiver prior MH treatment Yes No\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9.82 (13.27) 0\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
{[}-16.46, 36.12{]}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4.99 (6.97) 0\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
{[}-8.84, 18.82{]}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5.45 (12.95) 0\textsuperscript{a}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
{[}-20.25, 31.16{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Caregiver prior suicidality\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
10.22 (4.80)*\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}.69, 19.74{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
-.46 (2.43)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}-5.29, 4.36{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11.59 (4.57)*\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}2.52, 20.67{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Number of contacts x gender\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
22.02 (9.76)*\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}2.67, 41.37{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
.07 (5.19)0\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}-10.22, 10.36{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
18.88 (9.30)*\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}.41, 37.35{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Number of contacts x age\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6.16 (1.60)**\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}3.00, 9.32{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
-.40 (.92)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}-2.23, 1.41{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6.00 (1.48)***\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}3.06, 8.93{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Caregiver suicidality x gender\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
9.10 (12.40)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}-15.49, 33.69{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
-2.18 (6.27)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}-14.63, 10.27{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
16.32 (11.54)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}-6.61, 39.26{]}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Caregiver suicidality x age\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5.46 (2.63)*\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}.244, 10.68{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
-.36 (1.37)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}-3.08, 2.36{]}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
7.81 (2.50)*\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
{[}2.84, 12.79{]}\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Note. 0\textsuperscript{a} = This parameter is set to zero because it is
redundant.***\emph{p} \textless{}.001; **\emph{p}
\textless{}.01\textsuperscript{*} \emph{p \textless{}} .05\emph{.}

\textbf{Post-hoc moderation analyses}

In an effort to better understand the effects of number of contacts and
caregiver prior suicidality on treatment delay and onset duration we
conducted exploratory moderation analyses with gender and age.

There was a significant interaction effect of gender on the relationship
between number of contacts and onset duration (Table 3). Conditional
effects showed that this relationship was significant and positive for
females (b=10.09, SE=5.37, \emph{p} =.001) but not significant for males
(b=-3.93, SE=8.25, \emph{p} =.64). Thus, for females the greater number
of contacts was related to longer onset duration. There was also a
significant interaction effect of age on the relationship between number
of contacts and duration. Conditional effects showed that that this
relationship was only significant for older young people (that is, one
standard deviation above the mean = 17 years; b=17.41, SE=4.60,\emph{p}
=.002) compared to the mean age of 15 years and the younger age of 13
years. Thus, the relationship between number of contacts and onset
duration was strongest for females and older youth. The same pattern of
results was found for the relationship between number of contacts and
delay in treatment.

Gender also moderated the relationship between number of contacts and
delay in treatment. Conditional effects shows that this positive
relationship was significant for females (b=19.02, SE=5.30,\emph{p}
\textless{}.001) and not for males. Age also moderated the relationship
between number of contacts and delay in treatment. Conditional effects
showed that this positive relationship was only significant for older
young people (that is, one standard deviation above the mean = 17 years;
b=18.63, 4.39, \emph{p} \textless{}.001) compared to the mean age of 15
years and the younger age of 13 years.

The moderating effect of age on the relationship between caregiver prior
suicidality and onset duration was significant. Conditional effects
showed that this relationship was significant and positive at the mean
age (15 years; b=16.35, SE=5.58, \emph{p} =.004) and at one standard
deviation above the mean age (17 years; b=27.28, SE=27.28,\emph{p}
=.005), however it was not significant at one standard deviation below
the mean age (16 years). Gender did not moderate the relationship
between caregiver prior suicidality and onset duration.

The moderating effect of age on the relationship between caregiver prior
suicidality and treatment delay was significant. Conditional effects
showed a significant positive relationship at the mean age (15 years;
b=21.16, SE=5.34, \emph{p} \textless{}.001) and at one standard
deviation above the mean age (17 years; b=36.78, 9.18, \emph{p}
\textless{}.001). There was no significant relationship between
caregiver suicidality and delay in treatment for younger participants
(13 years). Gender did not moderate the relationship between caregiver
prior suicidality and treatment delay.

\textbf{Discussion}

This study investigated the PtC for suicidal adolescents entering a
tertiary suicide prevention service, and the impact of caregiver prior
suicidality and mental health treatment on onset duration and treatment
delay. Consistent with previous research (e.g., Hodgekins et al., 2017),
participants experienced significant delays averaging 48.0 weeks from
the onset of problem to obtaining suicide prevention treatment. Results
revealed that most commonly there were three contacts in the PtC, with
parents and the individual young people themselves most likely to
recognise the onset of suicidality. The findings suggested that with
regard to professional sources, the majority of young people seek help
from their general practitioner, followed by psychologists and emergency
services, indicating the important roles health services play in
providing suicidal adolescents with treatment and/or onward referral.
Additionally, longer treatment delays in reaching the suicide prevention
service were related to higher numbers of contacts in the PtC. This
suggests that attempts at addressing the young person's difficulties
through other sources may delay the overall time it takes to reach the
specialist SP service. The current study cannot clarify whether these
earlier contacts were appropriate or efficient, in that they promptly
referred the young person to the next level of care if they were beyond
the expertise of the contact or not making progress. Further, the
current study does not account for those young people who were
successfully supported by earlier sources of help before requiring
referral to the specialist suicide prevention program. The current study
only reveals information about those who needed further treatment.

Bivariate correlations indicated that young people whose caregivers had
prior mental health treatment had lower numbers of contacts. This would
be consistent with a situation where caregivers' knowledge of the
service system as a function of having navigated and utilised it
themselves might mean that a more direct route to specialist suicide
prevention program results. However, the multiple regressions indicated
that the hypothesis that caregiver prior mental health treatment would
be associated with shorter onset duration or delays in treatment was not
supported. This may be due to the number of contacts being only weakly
related to treatment delays. Instead, caregiver prior suicidality
appeared to have a negative impact on the treatment delay, such that
adolescents whose caregivers reported prior suicidality were more likely
to experience longer treatment delays in reaching the SP service. It is
unclear why this might be the case and in an effort to better understand
these relationships we explored potential interactions with age and
gender.

The current study found that the relationships between caregiver prior
suicidality and both onset duration and treatment delays were moderated
by age of the young person. In short, higher prior caregiver suicidality
was related to higher delays but only for older age groups. It is
possible that greater parental involvement with younger adolescents who
have suicidality evokes greater urgency amongst parents which speeds the
referral process.

Prior research has found that as a young person progresses through
adolescence, their parents become less prominent and there is a greater
need for autonomy and to handle their problems independently (Gould, et
al., 2004; Wilson, Deane, \& Ciarrochi, 2005a). Reduced parental
involvement and greater independence may explain the longer delays in
treatment for older adolescents but we can only speculate as to why
caregiver prior suicidality is associated with higher treatment delay.
It may be that older adolescents are more aware of their caregivers
prior suicidality and they may perceive that prior professional help
seeking was not helpful for them, so they delay their own treatment.
Alternatively, older adolescents may have poorer communication with
caregivers who have experienced suicidality which reduces any influence
caregivers might have in the help seeking process. There is a need for
future research to explore the potential dynamics that may be at play
that determines why caregiver prior suicidality might be associated with
longer treatment delays in older age groups. In the meantime, general
strategies such as increasing young peoples' mental health literacy
including that treatment can be helpful may facilitate help-seeking
behaviour (Logan \& King, 2001; Rickwood, Deane, Wilson, \& Ciarrochi,
2005).

Our results suggested that suicidal adolescents whose caregiver has a
prior experience of suicidality or self-harm will experience longer
durations between contact with other professionals and reaching a
specialist suicide prevention service. A similar result was found in a
population with psychosis (Norman et al., 2007), where a history of
psychotic disorder in family relatives was associated with longer delays
in treatment, despite the relative being more likely to recognise the
need for help for the unwell individual. In contrast, Chen et al. (2005)
looked at family relatives who had received psychiatric treatment, and
found that previous family experience of treatment was related to
reduced delays in Hong Kong adolescents accessing treatment for
psychosis. This disparity may in part be due to the prominent role that
families play in the lives of adolescents, even older adolescents in
Hong Kong. Given our findings suggest that prior caregiver suicidality
may have a negative role on the PtC of suicidal adolescents, future
research is needed to clarify why prior experience of suicidality is
related to longer delays. It may be that prior experiences are
predominantly perceived as being negative or unhelpful which then
increases the reluctance of parents to pursue professional services.
Studies have found that the perceived helpfulness of prior help-seeking
is related to future help-seeking intentions (e.g., Cusack et al.,
2006,\emph{r} = .32) and attitudes towards help-seeking .

Our results revealed that gender was significantly associated with onset
duration and treatment delays with females having significantly longer
delays than males. Moderation analyses also showed that relationship
between number of contacts and treatment delays was significant for
females but not males. Thus, the number of contacts appeared to increase
delays for females. It is possible that the range of informal supports
(e.g., friends/family) that females are willing or able to access is
higher than for young males and this contributes to higher numbers of
contacts and subsequent delays. In general, women and girls have more
positive help seeking attitudes and are more like to seek help, it is
possible that for young men they do not reveal their suicidality as
early and wait to initiate help seeking only at the point where their
suicidality is high and acute. This may result in higher perceived risk
and a more direct route to tertiary suicide prevention programs.

Interestingly, caregivers with a prior experience of treatment did not
have a significant impact on treatment delay, help-seeking delay or
onset duration. We expected that greater familiarity with mental health
service systems may be related to shorter delays in getting a young
person to help. There are several possibilities for this lack of
relationship. As noted above, it may be that prior help seeking was
viewed as unhelpful. For example, Ten Have et al. (2010) found that 32\%
of a large European sample who had previously used mental health
services perceived seeking professional help for serious mental health
as worse than or equivalent to no help. Perceptions of treatment being
unhelpful may nullify any effects of caregiver familiarity on
help-seeking behaviour (Velasco, Santa Cruz, Billings, Jimenez, \& Rowe,
2020). Future research should seek to assess the perceived helpfulness
of prior help-seeking and professional service use, in order to
determine the efficacy of treatments applied in the professional sector
and to encourage providers to learn from patient's experiences of care.

The results also identified a delay in treatment of over 9 months once
engaged within professional/formal contacts. It could be argued that the
greatest delay in the pathway to care for suicidal adolescents exists
once they have engaged professional contacts. This delay may be a result
of multiple processes, such as the lack of clarity professionals may
have about the adolescent's problem and what is required. Professional
contacts attempting to treat the problem before recognising the need for
tertiary referral to a specialist service may contribute to delays in
treatment. As adolescents develop mental health problems, it is possible
that emerging symptoms are interpreted as typical teenage behaviour,
leading to inappropriate services or lack of onward referral . The role
of professional services, particularly general practitioners, is well
recognised and increased training and knowledge is vital to improve
recognition and response to psychological distress (Pfaff, Acres, \&
McKelvey, 2001; Wilson, Deane, Marshall, \& Dalley, 2010). Some initial
contacts may also be more desirable to adolescents as they utilise lower
intensity treatments. Professionals, such as school counsellors, may
help many adolescents resolve the problems that underlie their
suicidality, but there may also be a proportion where problems worsen
such that suicide risk remains. Under these circumstances there are
likely to be longer delays getting to specialist services.

\textbf{Limitations}

While this study was novel in looking at the PtC in suicidality
specifically, there were some limitations. The data in this study was
collected retrospectively, therefore the PtC and durations were based on
caregivers' self-report and recall accuracy. The reliability of our
self-report questionnaire has not been specifically assessed, however
the PtC measure has been used in a previous study . Another weakness is
the moderate sample size which may limit statistical power. Given the
importance of reducing the delays in help seeking and treatment in
suicidal adolescents, further research into the PtC and role of
caregiver familiarity for this population is warranted with larger
sample sizes. Finally, this study was conducted on participants who were
referred to a specialised SP service. Thus, not all findings can be
directly compared with results from other mental health care systems
across countries.

\textbf{Conclusion}

Parents and primary caregivers play a vital role as an initial contact
and often set in motion the help-seeking process to accessing
professional services (Rickwood et al., 2007). It is recognised that
adolescents in their early to mid-teens still depend on their parents to
help them identify the presence of mental health problems and facilitate
appropriate help-seeking behaviour . This study highlights the
significant delays in treatment experienced by adolescents with suicidal
ideation or behaviour, and how their caregiver's prior experience of
suicidality is associated with these pathways and delays. Future
research should clarify whether caregiver perceived helpfulness of their
prior mental health treatment helps explain why prior caregiver
suicidality is related to longer treatment delays. .

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\verb`Table 2.docx`  available at \url{https://authorea.com/users/671058/articles/670754-young-people-s-pathways-to-a-specialist-suicide-prevention-service-and-the-influence-of-caregiver-prior-suicidality-and-mental-health-treatment}

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\verb`Table 3.docx`  available at \url{https://authorea.com/users/671058/articles/670754-young-people-s-pathways-to-a-specialist-suicide-prevention-service-and-the-influence-of-caregiver-prior-suicidality-and-mental-health-treatment}

\textbf{Hosted file}

\verb`table1.docx`  available at \url{https://authorea.com/users/671058/articles/670754-young-people-s-pathways-to-a-specialist-suicide-prevention-service-and-the-influence-of-caregiver-prior-suicidality-and-mental-health-treatment}

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