Abstract
The term mental health literacy was first introduced in 1997 and defined as ‘knowledge and beliefs about mental disorders which aid their recognition, management and prevention’ [1]. The aim in coining this term was to draw attention to a neglected area. Whereas the public know a lot about other major health problems such as cancer and heart disease, they lack the same degrees of knowledge about mental disorders [2]. Since then, the term mental health literacy has come into widespread use in Australia and it has appeared as a national goal in a number of policy documents [3, 4]. The concept has also spawned quite a bit of research and it is the purpose of the present paper to summarize what we have learned since 1997 and what we still need to know. The summary below draws mainly on Australian research and particularly on the series of papers published in the current issue of the journal. Although a number of researchers in other countries started up similar lines of work at around the same time [5], this is arguably an area in which Australia has had a leading role.
What we know
Mental disorders are not well recognized by the public
The initial Australian survey of mental health literacy showed that many people cannot give the correct psychiatric label to a disorder portrayed in a depression or schizophrenia vignette [1]. Although this situation has since improved [6], there is still much room for improvement. Lack of appropriate recognition of disorders in oneself or others may lead to delays in seeking help and inappropriate help-seeking.
There is a gap between public and professional beliefs about treatment
There is a consensus among mental health professionals about the appropriate treatments for depression and schizophrenia [7]. However, the public do not always share a belief in these treatments. The biggest gap is in beliefs about medication for both depression and schizophrenia, and admission to a psychiatric ward for schizophrenia. These gaps may lead to a lack of appropriate help-seeking and a failure to adhere to recommended treatments. Ultimately, they may be an impediment to the implementation of evidence-based health care.
Stigma is a barrier to help-seeking
Inadequate knowledge is not the only factor limiting help-seeking. Negative attitudes are important as well. Such negative attitudes can involve self stigma in which a person has internalized the negative attitudes held by society and applied these to themselves, or it can be perceived stigma which involves the belief that others hold stigmatizing attitudes. Both of these are widespread and reduce the likelihood of a person who is depressed seeking 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 having close contact with someone developing a mental disorder or in a mental health crisis situation. How they respond may make a difference to whether the person gets professional help and feels supported by their social network. Such responses may be most critical for young people when they are first developing a disorder. Unfortunately, first aid skills are deficient. Many adolescents do not know how to respond to a friend's distress in a way that will facilitate appropriate help [9], and adults also have deficiencies in first aid skills [10].
There are several types of interventions that can improve mental health literacy
All of the above is quite negative, but research offers much hope. There is growing evidence that mental health literacy can be improved, both by populationwide interventions and individual training programs. At the population level there is evidence that beyondblue: the national depression initiative has contributed to some positive changes [11, 12] and, at the individual level, mental health first aid training and websites giving either good-quality information or cognitive–behavioural skills have been shown to be effective in randomized trials [13–15].
Mental health literacy is improving in the Australian population
Since the initial survey of mental health literacy in Australia in 1995, there have been some major improvements. Recognition of disorders in vignettes has increased substantially and beliefs about treatments have changed, including for medications [6]. There has also been an increase in awareness and knowledge about depression specifically [11, 16]. In general, public beliefs have become closer to those of health professionals. beyondblue 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 principle not difficult. As a society we do it all the time. However, changing deep-seated emotional reactions to mental disorders may be much harder. Despite stigma being one of the major concerns of patients, we know very little about how to reduce it. It is possible that by increasing knowledge we will also succeed in reducing stigma by overcoming misconceptions. However, given that clinicians are people with high mental health literacy, but not necessarily low in stigmatizing attitudes [17], it is clear that the two do not necessarily go together. Nevertheless, there is some evidence that mental health literacy interventions do have a small impact on reducing social distance and stigma [13, 15]. However, we need to do much better.
Has improved mental health literacy changed people's help-seeking behaviour?
There are various strands of evidence indicating that changing knowledge and beliefs about mental disorders will influence behaviour [18]. However, we need to know what is occurring at the population level. Has the increased belief in the value of help-seeking led to an increase in actual help-seeking? Similarly, has the increase in belief in antidepressants been, at least in part, responsible for the rise in antidepressant prescribing? And has adherence to evidence-based treatments increased?
Can we increase preventive action and early intervention?
Arguably, the key areas for action are prevention and early intervention with first-onset disorders. What can improved mental health literacy contribute to these aims? With major physical health problems like cancer and heart disease, there are population-wide health promotion programs to reduce risk factors and promote early detection. This sort of work has not occurred with mental disorders except on a limited basis. There have been efforts to reduce the duration of untreated disorders in young people, such as the Compass Strategy in Victoria [19]. There has been even less action to improve public knowledge of how to prevent mental disorders. It would be possible to disseminate information on how to modify one's own risk or the risk to others, and on effective self-help and first-aid strategies.
Does mental health literacy improve population mental health?
The ultimate question is whether improved mental health literacy leads to improved mental health. Again, at the individual level there is some tantalizing evidence that it can. Both Mental Health First Aid training and the BluePages website have been found to produce therapeutic effects [13, 15], even though both simply aim to improve mental health literacy and do not provide any therapy. However, will this be translated into gains at the population level? In Australia, we have not even begun systematically monitoring population mental health over time, so how would we know? Such a situation would be unthinkable with cancer and heart disease. We need to begin population monitoring of knowledge, attitudes, help-seeking behaviours and mental health.