Centre for Mental Research, The Australian National University, Canberra 0200, Australia
![]() |
ABSTRACT |
---|
Aims To introduce the concept of mental health literacy to a wider audience, to bring together diverse research relevant to the topic and to identify gaps in the area.
Method A narrative review within a conceptual framework.
Results Many members of the public cannot recognise specific disorders or different types of psychological distress. They differ from mental health experts in their beliefs about the causes of mental disorders and the most effective treatments. Attitudes which hinder recognition and appropriate help-seeking are common. Much of the mental health information most readily available to the public is misleading. However, there is some evidence that mental health literacy can be improved.
Conclusions If the public's mental health literacy is not improved, this may hinder public acceptance of evidence-based mental health care. Also, many people with common mental disorders may be denied effective self-help and may not receive appropriate support from others in the community.
![]() |
INTRODUCTION |
---|
![]() |
DEFINITION AND CONCEPTUAL FRAMEWORK |
---|
If people experience disabling psychological symptoms or have close contact with others who have such problems, they will attempt to manage those symptoms. People's symptom-management activities will be influenced by their mental health literacy. If successful, these symptom-management activities may lead to a reduction in disabling symptoms and also a change in mental health literacy. In this framework, the person affected by the symptoms (either personally or through close contact) is seen as the primary agent in symptom management, with professional help being one of a range of strategies he or she might try. This perspective is important because it leads to a greater emphasis on increasing public (rather than professional) knowledge and skills about mental health and on empowering the person experiencing disabling symptoms. The need for the public to have greater mental health literacy is highlighted by the high lifetime prevalence of mental disorders (up to 50%, according to Kessler et al, 1994), which means that virtually everyone will either develop a mental disorder or have close contact with someone who does.
![]() |
RECOGNITION OF MENTAL DISORDERS |
---|
Is the inability to use a correct psychiatric label and lack of knowledge of symptomatology of any significance? These failures of mental health literacy may cause problems of communication with health practitioners. It is well known that patients with mental disorders are often missed by general practitioners (GPs). Aspects of the GP interviewing style are known to be associated with rate of detection (Goldberg & Huxley, 1992), but the patient's mode of interacting with the GP is also important. Detection of a mental disorder is greater if the patient presents his or her symptoms as reflecting a psychological problem (Herran et al, 1999; Kessler et al, 1999) and explicitly raises the problem with the GP (Bowers et al, 1990; Jacob et al, 1998). Although GP recognition may not be sufficient in itself to benefit the patient (Goldberg et al, 1998; Simon et al, 1999), it is a first step towards effective action.
![]() |
KNOWLEDGE AND BELIEFS ABOUT CAUSES |
---|
Beliefs about causes may alter patterns of help-seeking and response to treatment. For example, in Malaysia belief by psychiatric patients in supernatural causes was associated with greater use of traditional healers and poorer compliance with medication (Razali et al, 1996). In a US controlled trial of psychotherapy for depression, belief in relationship causes was associated with a better outcome in behavioural therapy, while belief in existential causes was associated with a better outcome in cognitive therapy (Addis & Jacobson, 1996).
![]() |
KNOWLEDGE AND BELIEFS ABOUT SELF-HELP |
---|
Knowledge of how to help others is a related component of mental health literacy. Very little research has been done on the topic, but a Swiss survey found that the public have difficulty in dealing with mental disorders, saying they do not know how to behave, are afraid of making mistakes and do not have sufficient knowledge (Brändli, 1999).
![]() |
KNOWLEDGE AND BELIEFS ABOUT PROFESSIONAL HELP |
---|
When the public are asked about various therapies, a strikingly consistent finding across many countries is very negative beliefs about medication for a range of mental disorders (Regier et al, 1988; Angermeyer et al, 1993; Priest et al, 1996; Jorm et al, 1997a; Fischer et al, 1999; Hillert et al, 1999; Jorm et al, 2000a). The public's belief about medication is in sharp contrast to both the evidence from randomised controlled trials and the views of mental health professionals that anti-depressant and antipsychotic medications are effective (Jorm et al, 1997c; Caldwell & Jorm, 2000). The public's negative views about psychotropic medication also contrast with their own positive views about medication for common physical disorders (Hillert et al, 1999). The reasons given by the public for their negative views of psychotropic medication are perceived side-effects, such as dependence, lethargy or brain damage, and the belief that the treatments deal only with the symptoms and not the causes (Angermeyer et al, 1993; Priest et al, 1996; Fishcher et al, 1999). One interpretation of these findings is that the negative attributes of benzodiazepines have become generalised to all types of psychotropic medication (Angermeyer et al, 1993). Indeed, the public do not seem to discriminate between different types of psychotropic medication, in contrast to mental health professionals who are quite specific in their recommendations (Jorm et al, 1997c). An Australian survey found that other treatments specifically associated with psychiatrists, such as electroconvulsive therapy (ECT) and admission to a psychiatric ward, are also viewed very negatively by the public, with more people believing they are harmful than helpful (Jorm et al, 1997a). Anecdotal evidence would support the conclusion that such beliefs are widespread in other countries as well.
Natural remedies, such as vitamins and herbs, are viewed much more positively by the public (Angermeyer & Matschinger, 1996c; Jorm et al, 1997a) and are not generally seen as sharing the negative attributes of psychotropics (Fischer et al, 1999).
Another consistent finding across a range of countries is very positive views about psychological treatments such as counselling. (McKeon & Carrick, 1991; Priest et al, 1996; Jorm et al, 1997a, 2000a) and psychotherapy (Angermeyer & Matschinger, 1996c; Hillert et al, 1999). Indeed, the public's views tend to be more positive than those of professionals (Furnham et al, 1992; Jorm et al, 1997c). What is most surprising is that psychological interventions are seen by the public as highly effective for psychotic disorders (Angermeyer & Matschinger, 1996c; Jorm et al, 1997c, 2000a) and even, according to an Austrian survey, for dementia (Jorm et al, 2000a).
What are the consequences of the public's beliefs about treatment? The most obvious is that negative beliefs about medication may lead to failure to seek medical help and lack of compliance with any medication recommended (Fischer et al, 1999). It has been proposed that greater account should be taken of patients' views in negotiating the treatment approach. In this regard, the term concordance, which implies a two-way negotiation between doctor and patient, is more appropriate than compliance (Mullen, 1997). Public beliefs about professional help may also affect the help-seeking of others. It has been found that professional help for depression is more likely to occur when another person recommends that help be sought (Dew et al, 1991), so the views of significant others about treatment may also be influential.
![]() |
ATTITUDES THAT FACILITATE RECOGNITION AND HELP-SEEKING |
---|
![]() |
KNOWLEDGE OF HOW TO SEEK MENTAL HEALTH INFORMATION |
---|
Other important influences are journalists' reports and television and cinema dramas depicting mental disorders. In the UK, 32% cited the media as their main source of information (Wolff et al, 1996). Unfortunately, these media often tend to report on the negative aspects. In a survey of the German public, 64% said that they had read about a person with a mental illness who had committed a violent crime and 50% about someone who became addicted to prescribed drugs, but only 17% had read about persons with mental illnesses who became able to lead a normal life by taking their medication (Hillert et al, 1999). It is clear that such negative reporting has an impact. Another German study was able to show that two attempts on the lives of prominent politicians by persons with a mental disorder led to a marked increase in negative attitudes (Angermeyer & Matschinger, 1995). People with mental disorders are also frequently portrayed as violent or having other undesirable characteristics in fictional accounts in the cinema and on television (Hyler et al, 1991; Wilson et al, 1999). Although violence is a problem in a small proportion of people suffering from severe mental disorders (Torrey, 1994), the public clearly overestimate this risk, on the basis of media reports and dramatic portrayals (Wolff et al, 1996; Link et al, 1999).
Finally, there are sources of knowledge, such as books, libraries, the internet and courses of study, available to those with better education and resources. While it is known that some self-help books are best-sellers and that some mental health websites receive a large number of hits, the overall impact of such sources on mental health literacy is unknown. There is a need for greater quality control of such sources to ensure that the public gets accurate information. For example, a recent study of the top 20 depression websites found the overall quality of the information was poor when evaluated against clinical practice guidelines (K. Griffiths, personal communication, 2000; further details available from the author upon request).
![]() |
COGNITIVE ORGANISATION OF MENTAL HEALTH LITERACY |
---|
![]() |
IMPROVING MENTAL HEALTH LITERACY |
---|
In the UK there was the Defeat Depression Campaign run by the Royal College of Psychiatrists and the Royal College of General Practitioners from 1992 to 1996 (Paykel et al, 1998). This campaign aimed to educate the public about depression and its treatment, to encourage earlier treatment-seeking and to reduce the stigma of depression. It included use of radio, television and print media. National surveys carried out at the beginning, middle and end of the campaign showed small but significant changes in the percentage of the public who believe that antidepressants are effective and who would be willing to seek professional help. It is impossible to say whether these changes were solely due to the campaign, but the results are certainly encouraging.
In Norway, there has recently been a campaign in one county aimed at reducing the duration of untreated psychosis by encouraging early help-seeking (Johannessen, 1998). As well as targeting the public, this campaign was aimed at health care providers, educators and treatment centres. It involved radio, newspaper, cinema and television advertisements. Public surveys carried out before and after the campaign showed a large increase in knowledge of the terms psychosis and schizophrenia. There is also early evidence that help-seeking behaviour has changed and that the duration of untreated psychosis has decreased.
Another approach is to target specific subgroups of the public. This approach is exemplified by the work of Wolff et al (1999), who educated the public in a neighbourhood where a group house for those with mental illnesses was being established. In this study, one such neighbourhood received an education campaign, while another acted as a control. The campaign consisted of an educational package with information sheets and a video, social events to establish contact with the group house, a formal reception and informal discussion sessions. Pre- and post-surveys in the experimental and control neighbourhoods showed only a small effect on public knowledge, but revealed less fear and more social contact with the group house residents in the experimental neighbourhood. Another targeted population subgroup is high-school students. Fairly brief classroom instruction has been found to improve willingness to seek professional help (Battaglia et al, 1990; Esters et al, 1998).
Finally, there are attempts to improve the quality of information presented in the media through expert input. Although mental health experts frequently make themselves available for media comment, there is virtually no research on the effects of doing so. However, in an analysis of four media items derived from lay sources and three from psychiatrists, Nairn (1999) found that the psychiatrists presented mental disorders in a less negative manner, but the journalists tended to undermine their message to produce a more newsworthy story.
![]() |
IMPLICATIONS FOR MENTAL HEALTH CARE |
---|
A second consequence of poor mental health literacy is that the task of preventing and helping mental disorders is largely confined to professionals. However, the prevalence of mental disorders is so high that the mental health workforce cannot help everyone affected and tends to focus on those with more severe and chronic problems. If there are to be greater gains in prevention, early intervention, self-help and support of others in the community, then we need a mental health literate society in which basic knowledge and skills are more widely distributed.
![]() |
Clinical Implications and Limitations |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() |
REFERENCES |
---|
Addis, M. E. & Jacobson, N. S. (1996) Reasons for depression and the process and outcome of cognitive-behavioural psychotherapies. Journal of Consulting and Clinical Psychology, 64, 1417-1424.[CrossRef][Medline]
Alem, A., Jacobsson, L., Araya, M., et al (1999) How are mental disorders seen and where is help sought in a rural Ethiopian community? A key informant study in Butajira, Ethiopia. Acta Psychiatrica Scandinavica, 100, 40-47.[Medline]
Andrews, G., Hall, W., Teesson, M., et al (1999) The Mental Health of Australians. Canberra: Commonwealth Department of Health and Aged Care.
Angermeyer, M. C. & Matschinger, H. (1995) Violent attacks on public figures by persons suffering from psychiatric disorders: their effect on the social distance towards the mentally ill. European Archives of Psychiatry and Clinical Neuroscience, 245, 159-164.[Medline]
Angermeyer, M. C. & Matschinger, H. (1996a) Relatives' beliefs about the causes of schizophrenia. Acta Psychiatrica Scandinavica, 93, 199-204.[Medline]
Angermeyer, M. C. & Matschinger, H. (1996b) The effect of diagnostic labelling on the lay theory regarding schizophrenic disorders. Social Psychiatry and Psychiatric Epidemiology, 31, 316-320.[Medline]
Angermeyer, M. C. & Matschinger, H. (1996c) Public attitude towards psychiatric treatment. Acta Psychiatrica Scandinavica, 94, 326-336.[Medline]
Angermeyer, M. C. & Matschinger, H. (1996d) The effect of personal experience with mental illness on the attitude towards individuals suffering from mental disorders. Social Psychiatry and Psychiatric Epidemiology, 31, 321-326.[Medline]
Angermeyer, M. C. & Matschinger, H. (1999) Social representations of mental illness among the public. In The Image of Madness: The Public Facing Mental Illness and Psychiatric Treatment (eds J. Guimon, W. Fischer & N. Sartorius), pp. 20-28. Basel: Karger.
Angermeyer, M. C., Däumer, R. & Matschinger, H. (1993) Benefits and risks of psychotropic medication in the eyes of the general public: results of a survey in the Federal Republic of Germany. Pharmacopsychiatry, 26, 114-120.[Medline]
Angermeyer, M. C., Matschinger, H. & Riedel-Heller, S. G. (1999) Whom to ask for help in case of mental disorder? Preferences of the lay public. Social Psychiatry and Psychiatric Epidemiology, 34, 202-210.[CrossRef][Medline]
Battaglia, J., Coverdale, J. H. & Bushong, C. P. (1990) Evaluation of a mental illness awareness week program in public schools. American Journal of Psychiatry, 147, 324-329.[Abstract]
Bhatara, V. S., Sharma, J. N., Gupta, S., et al (1997) Rauwolfia serpentina: the first herbal antipsychotic. American Journal of Psychiatry, 154, 894.[Medline]
Bowers, J., Jorm, A. F., Henderson, S., et al (1990) General practitioners' detection of depression and dementia in elderly patients. Medical Journal of Australia, 153, 192-196.[Medline]
Brändli, H. (1999) The image of mental illness in Switzerland. In The Image of Madness: The Public Facing Mental Illness and Psychiatric Treatment (eds. J. Guimon, W. Fischer & N. Sartorius), pp. 29-37. Basel: Karger.
Caldwell, T. M. & Jorm, A. F. (2000) Mental health nurses' beliefs about interventions for schizophrenia and depression: a comparison with psychiatrists and the public. Australian and New Zealand Journal of Psychiatry, in press.
Cuijpers, P. (1997) Bibliotherapy for unipolar depression: a meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 28, 139-147.[CrossRef][Medline]
Dew, M. A., Bromet, E. J., Schulberg, H. C., et al (1991) Factors affecting service utilization for depression in a white collar population. Social Psychiatry and Psychiatric Epidemiology, 26, 230-237.[Medline]
Esters, L. G., Cooker, P. G. & Ittenbach, R. F. (1998) Effects of a unit of instruction in mental health on rural adolescents' conceptions of mental illness and attitudes about seeking help. Adolescence, 33, 469-476.[Medline]
Fischer, W., Goerg, D., Zbinden, E., et al (1999) Determining factors and the effects of attitudes towards psychotropic medication. In The Image of Madness: The Public Facing Mental Illness and Psychiatric Treatment (eds J. Guimon, W. Fischer & N. Sartorius), pp. 162-186. Basel: Karger.
Furnham, A., Wardley, Z. & Lillie, F. (1992) Lay theories of psychotherapy, III: Comparing the ratings of lay persons and clinical psychologists. Human Relations, 45, 839-858.
Goldberg, D. & Huxley, P. (1992) Common Mental Disorders: A Bio-Social Model. London & New York: Routledge.
Goldberg, D., Privett, M., Ustun, B., et al (1998) The effects of detection and treatment on the outcome of major depression in primary care: a naturalistic study in 15 cities. British Journal of General Practice, 48, 1840-1844.[Medline]
Herran, A., Vázquez-Barquero, J.
L. & Dunn, G. (1999) Patients' attributional style is
important factor. British Medical Journal,
318, 1558.
Hillert, A., Sandmann, J., Ehmig, S. C., et al (1999) The general public's cognitive and emotional perception of mental illnesses: an alternative to attitude-research. In The Image of Madness: The Public Facing Mental Illness and Psychiatric Treatment (eds J. Guimon, W. Fischer & N. Sartorius), pp. 56-71. Basel: Karger.
Hyler, S. E., Gabbard, G. O. & Schneider, L. (1991) Homicidal maniacs and narcissistic parasites: stigmatization of mentally ill persons in the movies. Hospital and Community Psychiatry, 42, 1044-1048.[Medline]
Jacob, K. S., Bhugra, D., Lloyd, K. R., et al (1998) Common mental disorders, explanatory models and consultation behaviour among Indian women living in the UK. Journal of the Royal Society of Medicine, 91, 66-71.[Abstract]
Jacobs, D. G. (1995) National Depression Screening Day: educating the public, reaching those in need of treatment, and broadening professional understanding. Harvard Review of Psychiatry, 3, 156-159.[Medline]
Johannessen, J. O. (1998) Early intervention and prevention in schizophrenia: experiences from a study in Stavanger, Norway. Seishin Shinkeigaku Zasshi. Psychiatria et Neurologia Japonica, 100, 511-522.[Medline]
Jorm, A. F., Korten, A. E., Jacomb, P. A., et al (1997a) Mental health literacy: a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia, 166, 182-186.[Medline]
Jorm, A. F., Korten, A. E., Jacomb, et al (1997b) Public beliefs about causes and risk factors for depression and schizophrenia. Social Psychiatry and Psychiatric Epidemiology, 82, 143-148.
Jorm, A. F., Korten, A. E., Jacomb, et al (1997c) Helpfulness of interventions for mental disorders: beliefs of health professionals compared with the general public. British Journal of Psychiatry, 171, 233-237.[Abstract]
Jorm, A. F., Korten, A. E., Jacomb, et al (1997d) Belief systems of the general public concerning the appropriate treatments for mental disorders. Social Psychiatry and Psychiatric Epidemiology, 32, 468-473.[Medline]
Jorm, A. F., Angermeyer, M. & Katschnig, H. (2000a) Public knowledge of and attitudes to mental disorders: a limiting factor in the optimal use of treatment services. In Unmet Need in Psychiatry (eds G. Andrews & S. Henderson), pp. 399-413. Cambridge: Cambridge University Press.
Jorm, A. F., Christensen, H., Medway, J., et al (2000b) Public belief systems about the helpfulness of interventions for depression: associations with history of depression and professional help-seeking. Social Psychiatry and Psychiatric Epidemiology, in press.
Kessler, D., Lloyd, K., Lewis, G., et al
(1999) Cross sectional study of symptom attribution and
recognition of depression and anxiety in primary care. British
Medical Journal, 318,
436-440.
Kessler, R. C., McGonagle, K. A., Zhao, S., et al (1994) Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 8-19.[Abstract]
Lin, E., Goering, P., Offord, D. R., et al(1996) The use of mental health services in Ontario: epidemiologic findings. Canadian Journal of Psychiatry, 41, 572-577.[Medline]
Linde, K., Ramirez, G., Mulrow, C. D., et al
(1996) St John's wort for depression - an overview and
meta-analysis of randomised controlled trials. British Medical
Journal, 313,
253-258.
Link, B. G., Phelan, J. C., Bresnahan, M., et al (1999) Public conceptions of mental illness: labels, causes, dangerousness, and social distance. American Journal of Public Health, 89, 1328-1333.[Abstract]
Martinsen, E. W. (1994) Physical activity and depression: clinical experience. Acta Psychiatrica Scandinavica, 377 (suppl.), 23-27.
Matschinger, H. & Angermeyer, M. (1996) Lay beliefs about the causes of mental disorders: a new methodological approach. Social Psychiatry and Psychiatric Epidemiology, 31, 309-315.[Medline]
McKeon, P. & Carrick, S. (1991) Public attitudes to depression: a national survey. Irish Journal of Psychological Medicine, 8, 116-121.
Mullen, P. D. (1997) Compliance becomes
concordance. British Medical Journal,
314,
691-692.
Nairn, R. (1999) Does the use of psychiatrists as sources of information improve media depictions of mental illness? A pilot study. Australian and New Zealand Journal of Psychiatry, 33, 583-589.[CrossRef][Medline]
Nutbeam, D., Wise, M., Bauman, A., et al (1993) Goals and Targets for Australia's Health in the Year 2000 and Beyond. Canberra: Australian Government Publishing Service.
Parker, G. B. & Brown, L. B. (1982) Coping behaviors that mediate between life events and depression. Archives of General Psychiatry, 39, 1386-1391.[Abstract]
Paykel, E. S., Hart, D. & Priest, R. G. (1998) Changes in public attitudes to depression during the Defeat Depression Campaign. British Journal of Psychiatry, 173, 519-522.[Abstract]
Priest, R. G., Vize, C., Roberts, A., et al
(1996) Lay people's attitudes to treatment of depression:
results of opinion poll for Defeat Depression Campaign just before its launch.
British Medical Journal,
313,
858-859.
Raguram, R., Weiss, M. G., Channabasavanna, S. M., et al (1996) Stigma, depression, and somatization in south India. American Journal of Psychiatry, 153, 1043-1049.[Abstract]
Razali, S. M., Khan, U. A. & Hasanah, C. I. (1996) Belief in supernatural causes of mental illness among Malay patients: impact on treatment. Acta Psychiatrica Scandinavica, 94, 229-233.[Medline]
Regier, D. A., Hirschfeld, R. M. A., Goodwin, F. K., et al (1988) The NMH depression awareness, recognition, and treatment program: structure, aims, and scientific basis. American Journal of Psychiatry, 145, 1351-1357.[Abstract]
Regier, D. A., Narrow, W. E., Rae, D. S., et al (1993) The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective I-year prevalence rates of disorders and services. Archives of General Psychiatry, 50, 85-94.[Abstract]
Rippere, V. (1979) Scaling the helpfulness of antidepressive activities. Behaviour Research and Therapy, 17, 439-449.[CrossRef][Medline]
Simon, G. E., Goldberg, D., Tiemens, B. G., et al (1999) Outcomes of recognized and unrecognized depression in an international primary care study. General Hospital Psychiatry, 21, 97-105.[CrossRef][Medline]
Torrey, E. F. (1994) Violent behavior by individuals with serious mental illness. Hospital and Community Psychiatry, 45, 653-662.[Medline]
Wilson, C., Nairn, R., Coverdale, J., et al (1999) Mental illness depictions in prime-time drama: identifying the discursive resources. Australian and New Zealand Journal of Psychiatry, 33, 232-239.[CrossRef][Medline]
Wolff, G., Pathare, S., Craig, T., et al (1996) Community knowledge of mental illness and reaction to mentally ill people. British Journal of Psychiatry, 168, 191-198.[Abstract]
Wolff, G., Pathare, S., Craig, T., et al (1999) Public education for community care: a new approach. In The Image of Madness: The Public Facing Mental Illness and Psychiatric Treatment (eds J. Guimon, W. Fischer & N. Sartorius), pp. 105-117. Basel: Karger.
Received for publication February 4, 2000. Revision received May 12, 2000. Accepted for publication May 15, 2000.