Many teenagers depend on multiple sources of health care, and school personnel are important sources of health-related information [1]. The expansion of school-based health services since the early 1970s is a specific response to meet the medical needs of youth [2]. Adolescents are often vulnerable to particular health risks and face multiple barriers to accessing health care. School-based clinics represent an alternative model of health care that responds to the unique health issues of adolescents by offering preventive, comprehensive services, including mental health and other sensitive services [3].

According to Parker and Roy, the chances of becoming depressed in adolescence increased in the latter part of the 20th century and the onset of depression is observed at a younger age than before [4]. They added that adolescent depression is manifested either as melancholic symptoms or as irritability and anger.

The association between adolescents’ use of health services and their mental health status is controversial. Pastore et al. found that the average users, frequent users and non-users of a school-based health centre did not differ in the mental health problems measured in their study [5], whereas others have found that depressive symptoms were associated with increased service utilization [6].

The aim of this study was to assess the patterns of use of different health services by secondary school adolescents aged 14–19 years in Alexandria, Egypt, and to examine the association between utilization and adolescents’ most common mental health problems, namely depressive and aggressive symptoms.

In a cross-sectional school-based study in 1996, 1577 students of both sexes were selected by systematic stratified random sampling from 12 secondary schools representing the 6 districts of Alexandria, Egypt.

A self-report questionnaire was designed by the researcher to be completed by secondary school students. It included demographic and personal data such as age, sex, birth order, number of friends, number of family members, degree of family coherence, satisfaction with school, history of dropping a class and history of organic illness in the year prior to the study. Respondents were asked how many times they had visited primary care centres, school health clinics, mental health services or other health services (e.g. private clinics, general or military hospitals) in the previous year. The questionnaire also included a question on cigarette smoking (never-, ever-, ex- or current smoker). The Arabic Social Class Scale [7] was applied to participants’ responses. This uses the degree of parents’ education, occupation and crowding index (number of family members divided by number of closed rooms in the accommodation).

To obtain a history of emotional disturbance in the previous year, students were asked if they had had any emotional or psychological problems that made them consult a doctor in the year before the survey. Two further tools were used to assess adolescent depression, which usually manifests either as melancholic symptoms or as irritability and hostility [4]:

It took around 40 minutes for the students to complete the questionnaire and other scales during a class session.

Data coding, entry and management was made using the Epi-Info statistical program [10], followed by data analysis using SPSS, version 6 for Windows [11].

To preserve confidentiality, no direct or indirect identification of respondents was used. The adolescent respondents gave their verbal consent to participate in the study. Pre-testing of the questionnaire was conducted on 100 students of both sexes before running the study.

From the 12 secondary schools in Alexandria, 1577 adolescent students (49.8% male) competed the questionnaires and self-report scales. Their ages ranged from 14 to 19 years with a mean of 15.8 years (SD 1.3).

The respondents’ scores on the depression scale ranged from 1 to 43, with a mean of 13.2 (SD 6.17). After applying the cut-off score of 24, 69 (4.4%) of the sample were considered to have depressive symptoms. The adolescents’ scores on the aggression scale ranged from 0 to 26, with a mean of 11 (SD 4.4). Applying the cut-off score of 18, 78 (4.9%) of the sample were considered to have aggressive symptoms.

Adolescents who reported frequent use of primary health centres or school health clinics were more likely to have aggressive and depressive symptoms than infrequent users. The correlation coefficient between number of visits to health facilities and depression and aggression scores respectively were 0.14 and 0.139 (P < 0.001). The coefficient correlation between depression and aggression scores was 0.428 (P < 0.001) (data not shown in tables).

The association between adolescents’ psychiatric symptoms and the pattern of utilization of health services has to our knowledge never been studied before in Alexandria. However, the study relied only on self-report questionnaires that, despite being easy to apply, might yield inaccurate responses. The study should therefore be viewed as preliminary.

The results of the current study noted under-utilization of mental health services by adolescents. Cohen and Hesselbart mentioned that the under-use of services of middle income and rural children might reasonably be ascribed to access problems [12]. Kulka et al. indicated that people of lower socioeconomic status have a lower rate of mental health service utilization [13]. This is inconsistent with our findings, which showed no significant association between utilization of all types of health facility and the social class of the study sample. We also showed that there was no significant association between frequency of utilization of health facilities and the adolescents’ sex, which is similar to what Thompson et al. found in their study [14]. Adolescents’ age also had no association with utilization. Ryan et al. mentioned that age and sex were more important in predicting use of illness-related care than routine use of medical care [15].

The under-utilization of mental health services could be a resort to avoid the stigma of being mentally ill, lack of confidentiality on visiting the crowded general hospitals or because health insurance for adolescents is not extended to private clinics. Ziv et al. found that adolescents under-utilized physician offices and they were more likely to be uninsured than other age groups [16]. Ryan et al. concluded that having a regular source of care and health insurance were strong predictors of using medical care [15].

School health clinics were the most highly utilized facility in the current study. Only 2.9% of the sample did not use this facility in the year before the study because all school students in Alexandria, Egypt, are medically insured within the school health clinics, school health polyclinics and school health hospitals. That was in comparison with 6.3% who had not used primary health centres, 83.2% not using mental health services, or 86.4% not using other health services. School-based clinics staffed by an interdisciplinary team of health care professionals are among the pioneering efforts that address both health and education of adolescents [17]. School health clinics can also increase students’ health knowledge and access to health- related services [18].

Adolescents who reported more frequent use of primary health centres or school health clinics were more likely to have aggressive and depressive symptoms than others. Consistent evidence has shown that a substantial proportion of people with emotional problems and mental disorders are treated in the physical health sectors [19,20]. Alegria et al. found that subjects with high scores for psychiatric symptoms were also found to make more use of general health services [21]. Johnson et al. found that major depression and depressive symptoms were associated with increased service utilization [6]. Hansson et al. also concluded that patients in contact with psychiatric services were more frequent users of other medical services [22]. In contrast, Katerndahl and Realini concluded that subjects with panic symptoms reported higher rates of health care utilization despite having less insurance coverage and experiencing barriers to access [23]. The high utilization pattern of general health facilities by adolescents with depressive or aggressive symptoms in the current study could be explained if adolescents increased their utilization of general heath services when psychiatric services utilization was reduced. It could also be assumed that somatization occurs in response to stress for the predisposed personality, which in turn would increase utilization of the general health services.

Depressive or aggressive symptoms were associated with increased utilization of school health clinics and primary health centre facilities. To achieve the goal of mental health care for all Africans, psychiatry should be included in the primary health care programme. Physicians actually provide services to more patients with depressive symptoms than to patients with formally defined conditions of depressive disorders. For those working with adolescents, it is important to take into account all aspects of the individual’s world. Cumulative life stress, friendship networks and self-esteem should be considered when working with non-clinical as well as clinical populations.

We recommend further study using standardized personal interviews to establish a psychiatric diagnosis for adolescents in addition to reviewing utilization patterns from health facility records instead of self-reported use of health services.

23. Katerndahl DA, Realini JP. Use of health care services by persons with panic symptoms. Psychiatric services, 1997, 48(8):1027–32.