Research on mental health literacy: what we knowand what we still need to know

Anthony F. Jorm, Lisa J. Barney, Helen Christensen, Nicole J. Highet, Claire M. Kelly,Betty A. Kitchener

Australian and New Zealand Journal of Psychiatry 2006; 40:3–5

The term mental health literacy was first introduced in1997 and defined as ‘knowledge and beliefs about mentaldisorders which aid their recognition, management andprevention’ [1]. The aim in coining this term was to drawattention to a neglected area. Whereas the public know alot about other major health problems such as cancer andheart disease, they lack the same degrees of knowledgeabout mental disorders [2]. Since then, the term mentalhealth literacy has come into widespread use in Australiaand it has appeared as a national goal in a number of pol-icy documents [3,4]. The concept has also spawned quitea bit of research and it is the purpose of the present paperto summarize what we have learned since 1997 and whatwe still need to know. The summary below draws mainlyon Australian research and particularly on the series ofpapers published in the current issue of the journal. Al-though a number of researchers in other countries startedup similar lines of work at around the same time [5], thisis arguably an area in which Australia has had a leadingrole.

Anthony F. Jorm, Professor (Correspondence); Lisa J. Barney, Postgraduatestudent; Helen Christensen, Professor and Director; Claire M. Kelly, ARHRFHugh Lydiard Fellow; Betty A. Kitchener, Mental Health First Aid ProgramDirector

Centre for Mental Health Research, Australian National Univer-sity, Canberra, Australian Capital Territory 0200, Australia. Email:ajorm@unimelb.edu.au

Nicole J. Highet, Senior Program Manager

beyondblue: the national depression initiative, Victoria, Australia

What we know

Mental disorders are not well recognized by thepublic

The initial Australian survey of mental health literacyshowed that many people cannot give the correct psy-chiatric label to a disorder portrayed in a depression orschizophrenia vignette [1]. Although this situation hassince improved [6], there is still much room for improve-ment. Lack of appropriate recognition of disorders inoneself or others may lead to delays in seeking help andinappropriate help-seeking.

There is a gap between public and professionalbeliefs about treatment

There is a consensus among mental health profes-sionals about the appropriate treatments for depressionand schizophrenia [7]. However, the public do not al-ways share a belief in these treatments. The biggest gapis in beliefs about medication for both depression andschizophrenia, and admission to a psychiatric ward forschizophrenia. These gaps may lead to a lack of appropri-ate help-seeking and a failure to adhere to recommendedtreatments. Ultimately, they may be an impediment to theimplementation of evidence-based health care.

Stigma is a barrier to help-seeking

Inadequate knowledge is not the only factor limitinghelp-seeking. Negative attitudes are important as well.

4 EDITORIAL

Such negative attitudes can involve self stigma in whicha person has internalized the negative attitudes held bysociety and applied these to themselves, or it can be per-ceived stigma which involves the belief that others holdstigmatizing attitudes. Both of these are widespread andreduce the likelihood of a person who is depressed seek-ing professional help [8].

First aid skills are deficient

Because of the high prevalence of mental disorders,members of the public have a high probability of havingclose contact with someone developing a mental disorderor in a mental health crisis situation. How they respondmay make a difference to whether the person gets profes-sional help and feels supported by their social network.Such responses may be most critical for young peoplewhen they are first developing a disorder. Unfortunately,first aid skills are deficient. Many adolescents do notknow how to respond to a friend’s distress in a way thatwill facilitate appropriate help [9], and adults also havedeficiencies in first aid skills [10].

There are several types of interventions that canimprove mental health literacy

All of the above is quite negative, but research offersmuch hope. There is growing evidence that mentalhealth literacy can be improved, both by population-wide interventions and individual training programs. Atthe population level there is evidence that beyondblue: thenational depression initiative has contributed to somepositive changes [11,12] and, at the individual level, men-tal health first aid training and websites giving eithergood-quality information or cognitive–behavioural skillshave been shown to be effective in randomized trials[13–15].

Mental health literacy is improving in the Australianpopulation

Since the initial survey of mental health literacy inAustralia in 1995, there have been some major im-provements. Recognition of disorders in vignettes hasincreased substantially and beliefs about treatments havechanged, including for medications [6]. There has alsobeen an increase in awareness and knowledge about de-pression specifically [11,16]. In general, public beliefshave become closer to those of health professionals. be-yondblue has been one contributor to this improvement,but there are undoubtedly many other influences.

What we still need to know

How can we reduce stigma?

Changing knowledge is something that is in principlenot difficult. As a society we do it all the time. However,changing deep-seated emotional reactions to mental dis-orders may be much harder. Despite stigma being oneof the major concerns of patients, we know very littleabout how to reduce it. It is possible that by increasingknowledge we will also succeed in reducing stigma byovercoming misconceptions. However, given that clini-cians are people with high mental health literacy, but notnecessarily low in stigmatizing attitudes [17], it is clearthat the two do not necessarily go together. Neverthe-less, there is some evidence that mental health literacyinterventions do have a small impact on reducing socialdistance and stigma [13,15]. However, we need to domuch better.

Has improved mental health literacy changedpeople’s help-seeking behaviour?

There are various strands of evidence indicating thatchanging knowledge and beliefs about mental disorderswill influence behaviour [18]. However, we need to knowwhat is occurring at the population level. Has the in-creased belief in the value of help-seeking led to an in-crease in actual help-seeking? Similarly, has the increasein belief in antidepressants been, at least in part, respon-sible for the rise in antidepressant prescribing? And hasadherence to evidence-based treatments increased?

Can we increase preventive action and earlyintervention?

Arguably, the key areas for action are prevention andearly intervention with first-onset disorders. What canimproved mental health literacy contribute to these aims?With major physical health problems like cancer and heartdisease, there are population-wide health promotion pro-grams to reduce risk factors and promote early detection.This sort of work has not occurred with mental disordersexcept on a limited basis. There have been efforts to re-duce the duration of untreated disorders in young people,such as the Compass Strategy in Victoria [19]. There hasbeen even less action to improve public knowledge ofhow to prevent mental disorders. It would be possibleto disseminate information on how to modify one’s ownrisk or the risk to others, and on effective self-help andfirst-aid strategies.

EDITORIAL 5

Does mental health literacy improve populationmental health?

The ultimate question is whether improved mentalhealth literacy leads to improved mental health. Again,at the individual level there is some tantalizing evidencethat it can. Both Mental Health First Aid training andthe BluePages website have been found to produce ther-apeutic effects [13,15], even though both simply aim toimprove mental health literacy and do not provide anytherapy. However, will this be translated into gains at thepopulation level? In Australia, we have not even begunsystematically monitoring population mental health overtime, so how would we know? Such a situation wouldbe unthinkable with cancer and heart disease. We needto begin population monitoring of knowledge, attitudes,help-seeking behaviours and mental health.

References

1. Jorm AF, Korten AE, Jacomb PA, Christensen H, Rodgers B,Pollitt P. “Mental health literacy”: a survey of the public’sability to recognise mental disorders and their beliefs about theeffectiveness of treatment. Medical Journal of Australia 1997;166:182–186.

2. Jorm AF. Mental health literacy: public knowledge and beliefsabout mental disorders. British Journal of Psychiatry 2000; 177:396–401.

3. Commonwealth Department of Health and Aged Care. Nationalaction plan for promotion, prevention and early intervention formental health. Canberra: Mental Health and Special ProgramsBranch, Commonwealth Department of Health and Aged Care,2000.

4. Commonwealth Department of Health and Aged Care. Nationalaction plan for depression. Canberra: Mental Health and SpecialPrograms Branch, Commonwealth Department of Health andAged Care, 2000.

5. Jorm AF, Angermeyer M, Katschnig H. Public knowledge ofand attitudes to mental disorders: a limiting factor in the optimaluse of treatment services. In: Andrews G, Henderson AS, eds.Unmet need in psychiatry. Cambridge: Cambridge UniversityPress, 2000:399–413.

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changes in Australia over 8 years. Australian and New ZealandJournal of Psychiatry 2005; 40:35–40.

7. Jorm AF, Korten AE, Jacomb PA, Rodgers B, Pollitt P. Beliefsabout the helpfulness of interventions for mental disorders: acomparison of general practitioners, psychiatrists and clinicalpsychologists. Australian and New Zealand Journal ofPsychiatry 1997; 31: 844–851.

8. Barney LJ, Griffiths KM, Jorm AF, Christensen H. Stigma aboutdepression and its impact on help-seeking intentions. Australianand New Zealand Journal of Psychiatry 2005; 40:51–54.

9. Kelly CM, Jorm AF, Rodgers B. Adolescents’ responses topeers with depression or conduct disorder. Australian and NewZealand Journal of Psychiatry 2005; 40:60–65.

10. Jorm AF, Blewitt KA, Griffiths KM, Kitchener BA, ParslowRA. Mental health first aid responses of the public: results froman Australian national survey. BMC Psychiatry 2005;5: 9.

11. Highet NJ, Luscombe G, Davenport TA, Burns JM, Hickie IB.Positive relationships between public awareness activity andrecognition of the impacts of depression in Australia. Australianand New Zealand Journal of Psychiatry 2005; 40:54–57.

12. Jorm AF, Christensen H, Griffiths KM. The impact ofbeyondblue: the national depression initiative on the Australianpublic’s recognition of depression and beliefs about treatments.Australian and New Zealand Journal of Psychiatry 2005; 39:248–254.

13. Kitchener BA, Jorm AF. Mental health first aid training: reviewof evaluation studies. Australian and New Zealand Journal ofPsychiatry 2005; 40:6–8.

14. Christensen H, Griffiths K, Groves C, Korten A. Free rangeusers and one hit wonders: community users of anInternet-based cognitive behaviour therapy program. Australianand New Zealand Journal of Psychiatry 2005; 40:58–61.

15. Christensen H, Griffiths KM, Jorm AF. Delivering interventionsfor depression by using the Internet: randomised controlled trial.British Medical Journal 2004; 328: 265.

16. Highet NJ, Hickie IB, Davenport TA. Monitoring awareness ofand attitudes to depression in Australia. Medical Journal ofAustralia 2002; 176 (Suppl):S63–S68.

17. Hocking B. Reducing mental illness stigma and discrimination –everybody’s business. Medical Journal of Australia 2003; 178:S47–S48.

18. Jorm AF, Medway J, Christensen H, Korten AE, Jacomb PA,Rodgers B. Public beliefs about the helpfulness of interventionsfor depression: effects on actions taken when experiencinganxiety and depression symptoms. Australian and New ZealandJournal of Psychiatry 2000; 34: 619–626.

19. The Compass Strategy. Newsletter No. 2, October 2001.Department of Psychiatry, University of Melbourne and MHSKY Youth Program.