Improving mental health literacy as a strategy to facilitate early intervention for mental disorders

Mental disorders often arise for the first time in adolescents or young adults. If they are recognised and treated early, this may increase the chances of a better long-term outcome.1 However, in practice, professional help is often not sought at all or only sought after a delay. Early recognition and appropriate help-seeking will only occur if young people and their “supporters” (eg, their family, teachers, and friends) know about the early changes produced by mental disorders, the best types of help available, and how to access this help. It is also important that the supporters know how to provide appropriate first aid and ongoing help. Knowledge and skills of this sort have been termed “mental health literacy”.1 Here, we review what is known about the mental health literacy of young people and their supporters, including areas where there are deficiencies, and examine ways in which mental health literacy can be improved.

We searched PubMed and PsycINFO for all studies using the phrase “mental health literacy”. The studies identified were supplemented by all studies in a recent review by Jorm and Kelly,2 studies known to us that were “in press”, and studies found by searching the reference lists of all located studies. Only studies relevant to young people and their carers were included.

Young people have similar deficits to adults in terms of mental health literacy.1,3-5 Lack of recognition of mental illnesses is a primary concern, as is the failure to recognise appropriate professional help and pharmacological treatments. Around half the young people surveyed in a number of different studies were able to identify depression from a vignette.3-5 Young adults (18–25 years) were better able to identify depression than adolescents,4 as were young women compared with young men.3-5 A vignette of psychosis was correctly identified as such by only a quarter of participants in one study,4 more by older than younger participants and more by female than male participants.

Many young people do not have positive attitudes towards medication. In one study, half the adolescents and 40% of 18–25-year-olds felt that antidepressants were helpful,4 whereas, in another study, 57% of a sample of 13–16-year-olds felt that antidepressants were helpful.3 While the debate about the appropriateness of antidepressants for adolescents continues, it is unlikely that these attitudes can be explained by any sophisticated knowledge of the evidence for efficacy. More likely, there is an overall belief that medication is undesirable. Only 40% of a sample of 12–25-year-olds considered that antipsychotics would be useful for a person described in a vignette of psychosis.

Young people have slightly more positive attitudes towards professional help in general (eg, seeing a psychologist, general practitioner or psychiatrist), although these attitudes are not reflected in their own help-seeking preferences. While professional help is strongly endorsed for young people with mental health problems, most young people prefer to speak to a friend or family member if they have a mental health problem.6

Young people are ill-equipped to provide help to peers suffering from mental illness. Around a quarter of a sample of 13–16-year-olds said they would directly engage an appropriate adult helper, and half said they would try to help their friend solely through positive social support. Similar results were found in research on responding to peers who are suicidal,7 although, when suicidal intent was described as being more overt, young people were more likely to engage adult help. A social history of suicide or suicidal behaviour predicted more active referral as well.

Less attention has been given to the knowledge that adults have about young people’s mental health. One study found that, when presented with a vignette of depression, 68% of parents (73% of mothers and 41% of fathers) were able to identify depression, but only a third of the parents approached for this study completed the questionnaire, making generalisation difficult (unpublished data). More recently, a national survey of Australian parents of young people found that the value of encouraging a young person with a mental illness to seek professional help was not universally recognised.8 Parents had a preference for informal and general sources of help, rather than specialist mental health services.9

Research on interventions to improve the mental health literacy and skills of young people has been relatively scarce and at times poorly evaluated. Nevertheless, several have been evaluated, as summarised in the Box.

Some of these interventions aimed to increase the mental health literacy of the whole community, while others specifically targeted young people. Schools have been a popular setting for intervention, because they are a convenient point to access young people. Anecdotally, many secondary schools provide some information to students about mental illness. However, there is no standardisation of mental health education in schools. Finally, there are programs that train people, including those who can support young people, in mental health first-aid skills. Despite the limitations of the evidence, it is clear that mental health literacy can be improved through planned intervention.

One underdeveloped area of interest is peer training. The Suicide Intervention Project21 trained a number of peer “gatekeepers”, to intervene when someone is suicidal in a university setting, but no similar work has been done with younger people. One reason that such training has not been developed is the possibility that it may be onerous and frightening for the young people who are expected to intervene when someone is distressed. However, as indicated by Kelly et al3 and Dunham,7 young people are unlikely to approach or engage adult help when a friend is distressed or suicidal, and peer gatekeeper training for young people could be as simple as teaching them to get the help of an adult if ongoing distress or thoughts of suicide are apparent. Given that young people are more likely to speak to a friend about distress than any health professional,5 a relatively simple intervention such as this may be successful.

There is little evidence as to what components of a program work when educating young people or adults about mental health. A review of the “active ingredients” of antistigma programs9 found that, in young people, greater improvement in stigmatising attitudes was predicted by contact with a consumer–educator. Adults claimed that the contact with the consumer–educator had the greatest impact on them in terms of the content of the course; however, no difference was found between those who did and did not have such contact.

There is, however, a great deal to be learned from the general health promotion literature. A recent review of the past 10 years’ mass media health campaigns22 found that there are seven important components of a successful campaign.

1. It is necessary to carry out preliminary research with the audience to whom the messages will be directed. Performing focus-group research or other qualitative research designs ensures that messages are tailored appropriately.
2. A proven theoretical base on which to build the campaign is essential. There are remarkably few campaigns that are able to demonstrate that they have a solid theoretical basis. Notable exceptions are the Suicide Intervention Project,21 which used the Theory of Planned Behaviour Model,23 and the Compass Strategy, which employed the Transtheoretical/Stages of Change Model,24 the Health Belief Model,25 and the Diffusion of Innovations Model.26 The Compass Strategy deserves a special note here, in particular because the whole strategy design, implementation and evaluation was informed by the evidence-based “Precede–Proceed” Model.27
3. It is important to divide the intended audience into relatively homogeneous groups, to ensure that messages are tailored to the needs and preferences of those groups.
4. Messages need to be designed to appeal to the different groups; for example, the needs of young people at high risk of mental health problems may be very different from the needs of young people in general, and the preferred style of messages may be very different for young adults and adolescents.
5. Messages should be placed with appropriate types of media; for example, messages directed at adolescents may be more effectively placed in cinema advertising and youth media, rather than in newspapers.
6. Evaluation must be carried out to ensure that the messages are reaching the target audience. If they are not, it is important to rethink the approach and try something different.
7. Campaigns must be evaluated to find out whether they have been successful in changing behaviours and attitudes, or meeting other goals. Evaluation built into any campaign, at any level, ensures that resources are not wasted.

The mental health literacy of young people and their supporters is an important area for continued research and intervention. In order for early intervention to occur, young people and their supporters must be able to recognise and respond appropriately to signs of distress, reduced functioning, and other signs of incipient mental illness. Future intervention research must focus on the most efficient ways of improving knowledge and promoting health-enhancing behaviour, such as help-seeking. Considerations of cost-effectiveness, as well as other resource issues like time and sustainability, must be prioritised. It is important that the lessons from past interventions designed to improve mental health literacy are used to inform the development and evaluation of more effective approaches, particularly with the new opportunities provided by Australian Government funding for headspace (the National Youth Mental Health Foundation) (see McGorry et al, "headspace: Australia’s National Youth Mental Health Foundation — where young minds come first").