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

Claire M Kelly, Anthony F Jorm and Annemarie Wright
Med J Aust 2007; 187 (7): S26. || doi: 10.5694/j.1326-5377.2007.tb01332.x
Published online: 1 October 2007

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.

Review method

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.

What young people and their supporters know about mental illness

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

What has been done to improve the knowledge and beliefs of young people and their supporters?

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.

What are the effective components in programs to improve mental health literacy?

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").

Summary of interventions to improve the mental health literacy of young people

Intervention/setting

Aims

Intervention

Evaluation

Results


Whole-of-community interventions

beyondblue: the National Depression Initiative (public awareness campaign)10

Australia

Evidence level: III-2*

To improve the knowledge and attitudes of the public about depression and related conditions, including people experiencing depression, their families and workplaces, young people, older people, and Indigenous Australians

Public awareness activities including distribution of posters, pamphlets and postcards, a website with information, television advertising, advertisements in print media and educational videos

Ongoing evaluation via the national depression monitor, and research done by independent bodies

Improvements in knowledge and attitudes of the public have been found in the Australian states where beyondblue is most active. beyondblue is a well known organisation, as evidenced by research asking about mental health organisations

The Mental Health Awareness in Action program11,12

United Kingdom

Evidence level: III-2*

To improve knowledge about mental illness and decrease stigma in those who support young people in the community, and police officers

Two 2-hour information sessions about mental illness. Half the participants had a consumer–educator facilitate one of the sessions to provide a personal perspective

Pre- and post-intervention questionnaires with 78 adults and 109 police officers

Improved post-intervention knowledge in both groups. No improvement in desired social distance. Contact with a consumer–facilitator did not predict improved attitudes


Community interventions targeted at young people

The Compass Strategy4

Australia

Evidence level: III-1*

To improve mental health literacy and help-seeking for depression and psychosis among young people

Community awareness campaign targeting an intervention region including cinema, radio and newspaper advertising, printed materials, a website and information telephone line, and close liaison with community service providers

Pre- and post- intervention mental health literacy survey (cross-sectional) conducted in intervention and control regions of Melbourne; 1200 respondents aged 12–25 years

Improved awareness of mental health campaigns; better identification of depression in self; improved help-seeking for depression; correct estimate of prevalence of mental health problems; increased awareness of suicide risk; reduction in perceived barriers to help-seeking


School-based interventions

MindMatters (“Understanding mental illness” materials)13,14

Australia

Evidence level: IV*

To increase mental health literacy and decrease social distance in secondary schools

Varied. MindMatters provides curriculum support materials to all schools in Australia, but the use of these is not standardised. Schools are encouraged to make the materials fit in with their own curriculum

No baseline questionnaires. Students and school staff completed post-intervention questionnaires

No change in social distance measures. Changes in mental health literacy could not be assessed

beyondblue Schools Research Initiative (mental health literacy component)15

Australia

Evidence level: III-1*

To increase mental health literacy and decrease social distance in secondary schools

Twenty-five intervention schools ran a number of resilience enhancing programs, mental health literacy curricula and related activities over a 3-year period, and mental health information sessions were conducted for the school community. Twenty-five matched schools were selected as controls

Questionnaires at different stages of the 3-year intensive intervention, in intervention and control schools

Expected in the next 12 months

Mental Illness Education16

Australia

Evidence level: IV*

To reduce stigmatising attitudes, and improve mental health literacy and help-seeking intentions in secondary school students

Information and awareness sessions run in-school by a presenter and either a consumer–educator or carer–educator, or both

Pre- and post-intervention questionnaires completed by students (n = 457) who did and did not attend the information sessions

Improvements in mental health literacy, including the ability to recognise mental illnesses; modest improvements in stigmatising attitudes; weak improvements in help-seeking intentions

The Science of Mental Illness curriculum supplement series (National Institute of Mental Health)17

United States

Evidence level: IV*

To improve knowledge and attitudes of students about mental health in Years 6–8 

Eight-week curriculum focusing on the science of mental illness, causes and risk factors, treatments, and stigma

Pre- and post-intervention questionnaires distributed to 1500 students

Improved knowledge about mental disorders; reduction in desired social distance and stigmatising attitudes; improved understanding of the biological nature of mental illness and treatments

Mental Health Awareness in Action program12  United Kingdom

Evidence level: IV*

To improve knowledge about mental illness and decrease stigma in secondary schools

Two 1-hour information sessions about mental illness. Half the students had a consumer–educator facilitate one of the sessions to provide personal perspective

Pre- and post-intervention and 1-month follow-up questionnaires

Significant improvements in stigmatising attitudes; small but significant improvements in knowledge. Improvement persisted at 1-month follow-up but had decreased. Greater and more lasting improvement among the students who had met a consumer–educator

Mental Illness Awareness Week program18

United States

Evidence level: III-2*

To increase help-seeking intention and improve attitudes toward psychiatrists in secondary school students

Psychiatry residents visited secondary schools and spoke to classes of students. Residents spoke about help-seeking, depression, professional help, drug and alcohol use, and suicide, but subject matter was not standardised

Students who received the intervention (n = 1380) and students who did not (n = 282) completed a post-intervention test

Students who were involved in the classroom sessions showed modest improvements in intention to speak to a counsellor or a psychiatrist. The talks were enjoyed by most and stimulated interest in learning about other sensitive topics

“Crazy? So what! It’s normal to be different”19

Germany

Evidence level: III-2*

To reduce stigmatising attitudes and decrease desired social distance from people with schizophrenia in secondary school students

A highly interactive “project week” involving meeting with and talking to a young person with schizophrenia, discussion of the impact of stigmatising attitudes, and information about living with schizophrenia

Pre- and post-test, with 90 students and 60 controls. One-month follow-up

Decrease in stigmatising and discriminatory attitudes toward people with schizophrenia. Increased willingness to enter a social relationship with a person with schizophrenia. Benefits were maintained at follow-up


Individual training programs

Mental health first aid20

Australia

Evidence level: II*

To improve recognition of mental health problems, teach participants to offer help and support to those suffering from mental health problems, and increase help-seeking through facilitation by participants

Twelve-hour course teaching recognition, causes, risk factors, and treatments for depression, anxiety disorders, psychosis, substance use disorders, and related crises

One uncontrolled trial with the public (n = 210); two randomised wait-list controlled trials in workplaces (n = 301); one randomised wait-list controlled effectiveness trial in a large rural area (n = 753)

Improved ability to identify psychosis and depression; greater concurrence with professionals about appropriate treatments; reduction in desired social distance from a person with mental illness; improved confidence in offering help; more help offered

Suicide Intervention Project21

Australia

Evidence level: IV*

To train peer supporters in a university environment to recognise emotional distress in fellow students, feel comfortable talking to them about feelings, and know when to suggest using services

Two-day Applied Suicide Intervention Skills Training (ASIST) program; Mental Illness Education session (consumers and carers speak of the experience of living with mental illness); presentations by university counselling services on campus; written materials

Pre-test (n = 42) and 2-week post-test (n = 27). Participants were assessed on mental health literacy, intention to offer help, number of conversations about feelings, perceived behavioural control, and social connectedness

Modest improvements in mental health literacy were detected, but no improvements in behaviour. Only 2 weeks elapsed between intervention and assessment. No follow-up evaluation was conducted


* National Health and Medical Research Council levels of evidence. I: Systematic review of randomised controlled trials. II: One properly designed randomised controlled trial. III-1: One well designed pseudo-randomised controlled trial. III-2: Non-randomised trials, case–control and cohort studies. III-3: Studies with historical controls, single-arm studies, or interrupted time series. IV: Case-series evidence.

  • Claire M Kelly1
  • Anthony F Jorm2
  • Annemarie Wright3

  • ORYGEN Research Centre, University of Melbourne, Melbourne, VIC.

Correspondence: ckel@unimelb.edu.au

Competing interests:

None identified.

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