Background There is much debate over when it is appropriate to intervene medically for psychological distress, and limited evidence on patients' perspectives about a broad range of possible treatment options. It is currently unclear whether preferences may differ for those patients with milder symptoms compared to those experiencing more severe distress. Aim To determine patient preferences for professional, informal, and alternative help for psychological distress in primary care, and the impact of their current mental state on these. Design of study Cross-sectional survey in seven general practices across suburban/urban London. Method Participants were 1357 consecutive general practice attenders aged 18 years and over. The main outcome measure was the General Health Questionnaire 12-item version and a questionnaire on help-seeking preferences. Results Overall, only 47% of participants reported wanting 'some help' if feeling stressed, worried, or low and it was affecting their daily life. Those currently experiencing mild-to-moderate distress preferred informal sources of help such as friends/family support, relaxation/yoga, exercise/sport, or massage along with general advice from their GP and talking therapies. Self-help (books/leaflets or computer/internet) was not popular at any level of distress, and less favoured by those with mild-to-moderate distress (odds ratio [OR] = 0.50; 95% confidence interval [Cl] = 0.35 to 0.70). Those experiencing severe distress were much more likely to want talking therapies (OR = 3.43, 95% Cl = 2.85 to 4.14), tablets (OR = 3.07, 95% Cl = 2.00 to 4.71), and support groups (OR = 3.07, 95% Cl = 1.72 to 5.47). Conclusion People with mild-to-moderate distress appear to prefer informal sources of help and those involving human contact, compared to medication or self-help. This has implications for the implementation of potential interventions for psychological distress in primary care.