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Archives of Psychiatric Nursing 32 (2018) 757–763
Contents lists available at ScienceDirect
Archives of Psychiatric Nursing
journal homepage: www.elsevier.com/locate/apnu
Mental health literacy levels
a,⁎
b
Jing Ling Tay , Yi Fen Tay , Piyanee Klainin-Yobas
T
c
a
Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, Singapore 539747, Singapore
National University of Singapore, 21 Lower Kent Ridge Rd, Singapore 119077, Singapore
Alice Lee Centre for Nursing Studies, Yoo Loo Lin School of Medicine, National University of Singapore Level 2, Clinical Research Centre, Block MD11 10Medical Drive,
Singapore 117597, Singapore
b
c
A R T I C LE I N FO
A B S T R A C T
Keywords:
Mental health literacy levels
Education
Globally, mental disorders affect 25% of the society. This discursive paper aims to illustrate the mental health
literacy levels in the public. Mental health literacy (MHL) is the understanding of mental health conditions,
which helps in their prevention, recognition and treatment. Unfortunately, the public has minimal understanding of mental disorders, leading to poor recognition and delay in treatment. There is a need to conduct good
quality research to assess the MHL levels among public and tailor interventions to enhance MHL among the
public. This will ensure early detection of mental disorders, leading to early recovery and greater quality of life
among the society. Nurses have a great role to play in leading these public educations, and enhancing a healthy
and happy nation.
Introduction
Worldwide, mental disorders affect 25% of the population (World
Health Organisation, 2001). Anxiety disorders and depression are the
leading contributing causes of disability globally. About 450 million
experiences from mental disorders worldwide, establishing mental
disorders as a pandemic reason for disability, morbidity, and mortality,
due to suicide. The typical public's poor understanding of mental disorder delayed its recovery process. Due to the overall poor mental
health literacy of the public, mental disorder is poorly recognised and
its treatment often delayed, shredding years of good quality of life off
those experiencing mental health disorder. Yet these can be halted and
even reversed with elevated mental health literacy (MHL) levels within
the society.
Globally, much resource was devoted to health literacy. This includes educating the public about specific diseases, early screening,
detection and management of those diseases. Some conditions that
were ceaselessly targeted were heart diseases, stroke, and cancer.
Mental health conditions, on the other hand, are neglected.
Mental health literacy (MHL) was introduced in 1997 in the literature. Since then, research revolving MHL had been actively conducted in Australia (Jorm et al., 2006). MHL is the ‘knowledge and
beliefs about mental disorders, which aid their recognition, management or prevention’ (Jorm et al., 1997, p. 182). It is having the
knowledge of the preventive measures, symptoms, treatment modality
and treatment locations of mental disorders (Jorm, 2012). It also
⁎
includes being knowledgeable about the strategies to support self or
others experiencing from mental health conditions. Among those experiencing from a mental condition, MHL includes knowing how to
manage the illness. Among care-givers, MHL includes having the
knowledge of effective support rendered to the family who mentalhealth condition (Reavley & Jorm, 2013).
Importance of MHL
Adversities, including deaths, have occurred due to the lack of
mental health literacy in the community. About 450 million experiences from mental disorders worldwide, establishing mental disorders
as a pandemic reason for disability, morbidity, and mortality, due to
suicide. So much more lives could be saved if the community simply
had a better knowledge of mental health conditions and could identify
such conditions and seek appropriate and timely treatment.
Moreover, the typical public's poor understanding of mental disorder delayed its recovery process. Due to the overall poor mental
health literacy of the public, mental disorders are poorly recognised and
their treatment often delayed, shredding years of good quality of life off
those experiencing mental health disorder. Yet these can be halted and
even reversed with elevated mental health literacy (MHL) levels within
the society. Elevated MHL can enhance the mental health, happiness
and wellness worldwide. Hence, it is important to examine the MHL
levels among the public.
Being able to identify mental health conditions is merely the tip of
Corresponding author.
E-mail addresses: [email protected] (J.L. Tay), [email protected] (Y.F. Tay), [email protected] (P. Klainin-Yobas).
https://doi.org/10.1016/j.apnu.2018.04.007
Received 23 November 2017; Received in revised form 16 March 2018; Accepted 18 April 2018
0883-9417/ © 2018 Elsevier Inc. All rights reserved.
Archives of Psychiatric Nursing 32 (2018) 757–763
J.L. Tay et al.
(37.3%–48.8%), and lastly, social phobia (10.5%–30.2%) (Furnham,
Annis, & Cleridou, 2014). Among 202 Australian adolescents,
33.8%–67.5% could identify depression in a vignette (Burns & Rapee,
2006). In a more recent population-based survey, MHL was lower; only
23.4% of 1678 Australian adolescences were able to identify depression
(Lam, 2014).
In Australia again, a longitudinal national survey of 6019 sample
conducted over 16 years in 3 time period: 1995, 2003/4 and 2011 demonstrated that public is able to recognise depression better (Reavley &
Jorm, 2012). In 1995, among 2164 sample, only 39% and 27%, could
precisely identify depression and schizophrenia respectively. The mislabelling of mental disorders as ‘stress’ or ‘life problem’ hindered professional help-seeking. By 2011, 75% could correctly identify depression, about 30% could identify schizophrenia and post-traumatic stress
disorder but only 9.2% recognised social phobia (Reavley & Jorm,
2011). Therefore, over the 16 years in Australia, there was a reduction
of depression being mislabelled as stress, nervous breakdown or psychological problems. This enhancement in depression recognition rates
has been attributed to campaigns such as ‘beyondblue’. Hence, public
campaigns were illustrated to raise overall public's MHL levels.
When comparing Australia (3998 participants) and Japan (2000
participants), Japanese were reluctant to utilise psychiatric diagnosis.
In the depression vignette, only 22.6% of Japanese, as compared with
65.3% of Australians, use depression to label the vignette case (Jorm
et al., 2005).
Among 440 samples from British, Malaysia and Hong Kong, the
British were best at labelling correct psychiatric diagnosis to vignettes
of obsessive compulsive disorder, depression, schizophrenia, ADHD,
child depression and bipolar disorder, followed by Hong Kongers, and
lastly, Malaysians (Loo, Wong, & Furnham, 2012).
Among 1207 Australian young adults, appropriate recognition of
mental disorders was associated with correct help-seeking behaviours
and less associated with adverse strategies such as using drugs, or
handling the symptoms alone (Wright, Jorm, Harris, & McGorry, 2007).
Hence, being able to recognise symptoms as mental health problems are
crucial for early treatment.
Generally, psychiatric diagnosis baffles the public. Inability to recognise mental health problems in oneself or others hinder early detection and help-seeking behaviours. Although ability to recognise
mental disorders had improved over the decades, and the public got
better at recognising depression, they remained clueless about other
mental health problems, such as schizophrenia.
the iceberg. Knowing the causes and treatment for these mental health
conditions is extremely crucial too. Without this knowledge, treatment
continues to be delayed and deprived for those who really need it. Many
patients, whose family were ignorant about their mental health conditions, deprived them from seeking treatment and instead sought help
from religious leaders. These families attributed the cause of such
strange manifestations of mental health conditions to spiritual possessions (Kayrouz et al., 2015; Tay, Chan, Ho, & Lal, 2017). This delayed
help-seeking behaviour, in turn, obstructs prompt healing. Many of the
remaining patients never get to receive treatment. They are often
brought to the mental health institution forcefully by police, court or
transferred from other hospitals. (Al-Khafaji, Loy, & Kelly, 2014). With
every delay in treatment, patient takes a longer time to recover (Golay
et al., 2016).
In summary, low mental health literacy rates caused under-reported
and undiagnosed mental health conditions. These trigger a slippery
slope of untreated disorders, unemployment, morbidity, mortality, increased stressed faced by caregivers and the disastrous loss of precious
lives to suicide and homicide. There is an immediate urgency to understand the MHL levels among the public. Hence, the aim of this
opinion paper is to explore the mental health literacy levels in the
public.
Mental health literacy levels
(i) Recognising mental health problems
Mental health conditions are often untreated for many years,
leading to increased relapses, suicidal attempts, reduced remission rates
and worsening overall outcomes. The length of untreated mental health
problems was, 8.2 years, and 14.5 years, for (anxiety and depression),
and bipolar disorder, respectively (Drancourt et al., 2013). Among the
273 Australian patients with anxiety and mood disorder, nearly 7 years
were required to identify a problem, and another 1.3 years lapsed between recognition and help-seeking behaviours (Thompson, Issakidis, &
Hunt, 2008).
A cross-sectional stratified cluster sample of 4938 Portuguese youth
aged 14–24 years old, revealed that only 27.2% and 5.5% could identify
depression and mental disorder respectively, in a vignette (Loureiro
et al., 2013). The depression vignette was more commonly regarded as
stress, having a nervous breakdown or age crisis. Surprising, the recognition of Schizophrenia was better (42.4%), although identification
of psychosis was only 22.2% (Loureiro et al., 2015).
In Germany, a longitudinal study conducted in 1993 and 2001, of
2094 and 5025 samples respectively, concluded that public could recognise mental disorders better over the years (Angermeyer, Holzinger,
& Matschinger, 2009). 17.1% and 26.9% could identify schizophrenia
and depression, respectively. In 1993, and this increased to 22.4% and
37.5%. However, these statistics are still low. In Sweden, 66% of the
3538 participants failed to identify depression. (Dahlberg, Waern, &
Runeson, 2008). Among 317 British, more were able to identify OCD
(64.67%), but few could identify panic disorder, separation anxiety
disorder and generalised anxiety disorder (1.26%–5.99%) (Furnham &
Lousley, 2013).
Americans were more likely to correctly identify mental health
problems. Amidst 1104 American high school students, 40% recognised
depression, but only 1% could identify social phobia (Coles et al.,
2016). Among 1393 American adults, 58.5% and 41.9% could correctly
identify depression and ADHD (attention deficit hyperactivity disorder)
(Pescosolido et al., 2008). Canadians also had higher rates recognising
mental disorders. Among 3047 Canadian, 75.6% could correctly identify depression in a vignette (Wang et al., 2007).
Amidst 370 British young adults, addiction (65.1%–87.4%) was best
identified, followed by bulimia (45.5%–77.2%), OCD (41.9%–70.7%),
anorexia (55.8%–81.3%), ADHD (42.4%–70.6%), depression
(33.3%–74.4%), bipolar disorder (14.2%–46.2%), schizophrenia
(i) Positive attitude that promotes recognition and help-seeking
Stigma is a great hindrance affiliated with mental health problems.
Stigma is the process of labelling and stereotyping, leading to disastrous
consequences of status loss and severe isolation (Link & Phelan, 2001).
A typical conception is that mentally-ill patients are peculiar, unpredictable and dangerous (Martin, Pescosolido, Olafsdottir, & McLeod,
2007). These adverse attitudes result in self- stigma where those experiencing psychiatric symptoms internalise these negative attitudes. It
induces depression, feelings of shame, low self-esteem, causing poor
medication compliance, leading to higher relapse, unemployment and
homelessness, diminishing overall recover and quality of life
(Chronister, Chou, & Liao, 2013).
Such effects of stigma also deter those, who experienced the prodromal stages of mental disorders, from seeking treatment. Delayed
treatment aggravates the illness, causing irreparable damage, making
the illness harder to treat. Such experiences were often hidden in their
own houses by family members who were petrified of being known
about the association with them. Many are unemployed, and sometimes, homeless. Therefore, positive public attitude that enhances recognition and help-seeking is crucial.
In America, 248 depressed geriatric participants had high levels of
perceived stigma, and hence not willing to seek professional treatment
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Archives of Psychiatric Nursing 32 (2018) 757–763
J.L. Tay et al.
problems, nervous breakdown or as a ‘work-related problem’ (Goldney,
Dunn, Grande, Crabb, & Taylor, 2009, p 478).
In Germany, the causes of schizophrenia was attributed to, chronologically, interpersonal issues (from family/friends), brain disease,
work stress and lastly, genetics (Angermeyer et al., 2009). Depression
was regarded as due to, chronologically, interpersonal issues, work
stress, genetics and lastly, brain disease. In America, 67% attributed
mental disorders to neurobiological factors, and hence acknowledged
professional help more (Pescosolido et al., 2010).
Various beliefs about causative factors of mental health problems
would also modify treatment-seeking behaviours and treatment success.
For instance, beliefs of interpersonal relationships causes and existential causes lead to greater outcomes in behavioural and cognitive
therapy, respectively (Addis & Jacobson, 1996).
and this is even more apparent in African American elderly (Conner
et al., 2010). Conversely, among 5555 university students in America,
perceived stigma had no association with help-seeking behaviours,
unlike personal stigma. Personal stigma was higher among younger,
male, international, poorer, more religious or Asian students. Moreover,
perceived stigma was much higher than personal stigma (Eisenberg,
Downs, Golberstein, & Zivin, 2009). Similarly, a systematic review ascertained that perceived stigma is negatively correlated with helpseeking among young adults (Gulliver, Griffiths, & Christensen, 2010).
Positively, cross-sectional survey conducted among six European
countries: France, Belgium, Italy, Germany, Netherlands, and Spain,
which utilised random sampling of household population (n = 8796),
concluded that 73.1% to 81.5% of the Europeans would not be extremely embarrassed (if at all), should their friends realized that they
are seeking professional psychiatric help (ten Have, de Graaf, Ormel,
Vilagut, Kovess, Alonso, & ESEMeD/MHEDEA 2000 Investigators,
2010). Similarly, in America, surveys conducted in 1009–1992 (5388
sample) and again in 2001–2003 (4319 sample) concluded that participants were subsequently less embarrassed if their friends found out
about their mental problems (Mojtabai, 2007). As a result, they felt
more comfortable (40.3% from 27.1%), and were more willing (41.4%
from 35.6%) to seek professional treatment for severe emotional problems.
In contrast, among 300 rural Australians, high levels of stigma were
reported, and majority (87.7%) preferred informal rather than professional help, which was regarded as last resort. However, this perceived
stigma did not hinder help-seeking from general practitioner (Komiti,
Judd, & Jackson, 2006). In India, for both depression and psychosis
vignettes, 240 participants desired social distance, as they depicted
those with mental health problems as dangerous (Kermode, Bowen,
Arole, Pathare, & Jorm, 2009).
A survey among 1835 sample across 14 European countries, established that mental health patients, who lived in less stigmatizing
countries, had greater perceived access to knowledge, greater rates of
help-seeking and treatment usage, lower rates of perceived discrimination and self-stigma, and were overall, more empowered
(Evans-Lacko, Brohan, Mojtabai, & Thornicroft, 2012).
In Germany, a longitudinal study conducted among public in 1993
and 2001 illustrated that, despite improvements in overall MHL levels,
there were no improvements in the desire for social distance
(Angermeyer et al., 2009). Similarly, 1073 Swiss psychiatric professionals held negative stereotypes towards mental health patients. 60%
felt that psychiatric patients should have their license revoked, 29% felt
that female psychiatric patients should have an abortion, and most
desired social distance towards those experiencing from schizophrenia
rather than depression (Nordt, Rössler, & Lauber, 2006).
This statistics are shocking; how could we expect the public's attitude to improve when professionals, who help psychiatric patients on a
daily basis, view them with such revulsion?
(iii) Knowledge of treatment available
Despite the best evidenced-based treatment, the public has to recognise that the treatment available is useful, other Hence, it is important to find out the public's views of professional treatments.
Among 202 Australian adolescents, counsellor is identified as the
best help (57.7%), followed by, friends (41.8%), family (40.8%) for
depression (Burns & Rapee, 2006). Unfortunately, only 9.9%, 6.2% and
4.2% endorsed professional, psychologist and psychiatrist, respectively.
In another Australian research conducted among 3746 students
aged 12–25 years old and their parents, counsellors (90%–94%) and
general practitioner (88%–97%) were endorsed most, followed by close
friend (82%–95%), phone counselling (77%–81%), close family
(77%–89%), psychologists (64%–87%), psychiatrist (60%–72%), teachers (33%–56%), lastly, dealing alone (5%–8%) in the depression
vignette. In the psychosis vignette, counsellors was still regarded as
most useful (90%–94%), followed by general practitioner (78%–97%),
phone counselling (77%–81%), psychologist (70%–87%), close family
(70%–88%), close friend (76%–94%), psychiatrist (66%–80%), teacher
(28%–52%), and lastly, dealing alone (2%–7%) (Jorm & Wright, 2007).
Conversely, British young adults, endorsed psychologists or psychiatrist best, and internet and books last, although informal help such
as (parents, friends, school counsellors) were popular too (Furnham
et al., 2014).
Interventions deemed most useful in the depression vignette was,
counselling (91%–94%), relaxation training (86%–94%), exercising
(85%–92%), meditation (66%–88%), sunlight (62%–81%), massages
(59%–75%), mental health service (52%–71%), vitamins (52%–62%),
acupuncture (31%–45%), antidepressants (32%–44%), sleeping pills
(12%–20%), antipsychotics (5%–12%), cognitive behavioural therapy
(28%–47%), psychiatric ward (15%–22%), and lastly, tranquilizers
(1%–4%). For the psychosis vignette, the most useful interventions
were considered to be counselling (92%–96%), relaxation training
(86%–93%), exercising (82%–91%), mediation (71%–80%), sunlight
(69%–73%), mental health services (66%–72%), massages (58%–70%),
cognitive
behavioural
therapy
(45%–48%),
antidepressants
(36%–51%), vitamins (36%–44%), antipsychotics (21%–28%), sleeping
pills (12%–18%), acupuncture (27%–40%), psychiatric wards
(21%–34%)and lastly, tranquilizers (2%–6%)(Jorm & Wright, 2007).
Portuguese youths, on the other hand, viewed friends (80.9%) and
family members (75.1%) as being more important than psychiatrists
(55.1%), or general practitioners (74.6%) in a depression vignette. They
do, however, rated psychologist as being the most helpful, among the
mental healthcare team (89%). In contrast, when given a schizophrenia
vignette, Portuguese youth were more open to professional services
(71.4%–88.1%). Informal help like friends and family members
(62.3%–68.3%), and telephone helplines, teachers and social workers
(62.3%–68.3%), were considered less helpful than professional services: general practitioners (71.4%), psychiatrists (78.1%) and friends
(72.7%) (Loureiro et al., 2015).
For depression treatment, Portuguese youths deemed vitamins the
(ii) Knowledge of causative and risk factors
In Western countries, the public attribute mental health problems as
a result of personal/character weaknesses, social causes, especially new
stressors (Angermeyer & Dietrich, 2006; Kermode et al., 2009; Wang
et al., 2007). In Asia countries, mental health problems are often attributed to religious reasons such as, witchcraft, or being possessed by
demons or evil spirits. Such belief will impair treatment-seeking behaviours because patients and families would tend to seek treatment
from religious leaders such as church pastors, Malay shaman (bomoh)
or Chinese mediums. Gravely, these patients would be less compliant to
medications (Chong, Mythily, & Verma, 2005).
In South Australia, surveys conducted among 3034 participants in
1998, 2004 and 2008, concluded that participants could identify
mental disorders better over the decades. There was increased correct
labelling of depression, and less attribution to stress, psychological
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Archives of Psychiatric Nursing 32 (2018) 757–763
J.L. Tay et al.
(52.8%–54.3%), and sleeping pills (38.1%–56.8%). Amidst professional
treatment, stress management including, relaxation, yoga, meditation
were the favourite at 89.6%. Those who had contact with psychiatric
patients viewed professional treatment, including medications, more
positively and non-evidenced based interventions such as vitamins,
more critically.
Only 61%–68.8% acknowledged psychiatrist help and 6.7%–20%
endorsed hospital admission. Non-professional interventions were far
more popular: exercising (77.6%) and self-help books (72%) (Dahlberg
et al., 2008).
Among 240 participants in India, vitamins, herbals and tonics
(90.4%) were deemed more useful than appetite stimulants (90%),
sleeping pills (77.5%), and other medications (6.8%) (Kermode et al.,
2009).
In a depression vignette, 45.8%, 17.4% and 10.6%, of 3047
Canadian, endorsed general practitioner, counsellor, pharmacological
treatment, respectively (Wang et al., 2007).
In summary, the public endorse help from their loved ones over
professional mental health treatment. They tend to prefer non-pharmacological interventions over pharmacological treatment. The public's
faith and belief in professional treatment influence help-seeking behaviours. Being overly dependent on loved ones or informal help might
delay professional treatment. Public also prefers counsellors (who are
non-psychiatric trained) over psychiatric professionals such as psychiatrists and psychologists. Additionally, the public viewed psychotropic as harmful and often preferred non-pharmacological treatment
over pharmacological treatment, such as generic counselling, relaxation
and stress management. Despite the available evidence-based treatment, it can only be good treatment if the public believe that professional services can be useful.
most useful, followed by tea, anti-depressants and tranquilizer.
Dismally, antipsychotics, hypnotics, tranquilizers and anti-depressants
were considered harmful, ranging from 28.6%–37.3% (Loureiro et al.,
2013). Conversely, fewer youths deemed psychotrophics as harmful
(12.4%–19.5%) in the schizophrenia vignette. In fact, 31.1%–54%
deemed psychotrophics useful, although non-evidenced based treatment such as vitamins (35.8%) and tea (39.9%) were also acknowledged (Loureiro et al., 2015).
A survey among 999 Australian concluded that 20% felt that antidepressants were harmful. They have lower MHL, were less educated,
less exposed to depression and also disliked other professional treatments including psychological interventions (Jorm, Christensen, &
Griffiths, 2005).
In South Australia, longitudinal surveys among 3034 participants in
1998, 2004 and 2008, illustrated the reduction in perceived usefulness
of clergy. However, in 2008, the participants were less likely to deem
mental health professionals as being helpful, as compared in 2004
(Goldney et al., 2009). Although most longitudinal surveys demonstrated improvements in overall MHL, this survey depicts differently.
The Australian longitudinal national survey of 6019 sample conducted over 16 years in 3 time period: 1995, 2003/4 and 2011 demonstrated a reduction of nominating families/ friends, counsellors,
psychiatrists and medications as potential help, with an increase in the
election of psychiatrist, telephone counsellors and general practitioner
as the better help, in depression (Reavley & Jorm, 2012). In depression
with suicidal ideations, early and chronic schizophrenia, there was an
increased recognition of in the usefulness of psychiatrists, GPs, psychologists. In social phobia and post-traumatic stress disorder, counselling was deemed more useful. Medications such as anti-depressants,
antipsychotics were increasingly deemed as useful interventions (50%),
rather than harmful (Reavley & Jorm, 2012). However, there were
equal endorsement for minerals and vitamins (up to 49.3%). Despite
overall MHL increment, the research concluded that MHL in Australia
could still appreciate, especially for schizophrenia, anxiety disorders
and their treatments. The MHL improvements in Australia demonstrated that public campaigns would make a significant difference in
public's MHL.
In a longitudinal study in Germany, conducted in 1993, then 2001,
there was an increase in endorsement of seeking professional help, and
reduction in seeking help from confidant or priest for schizophrenia
(Angermeyer et al., 2009). There was also an increase in endorsement
of anti-psychotics (from 36.3% to 50.6%). Despite that, psychotherapy
was still regarded as the best treatment by public (81.5%) for schizophrenia, contrary to evidenced based practice which affirms pharmacological treatments over non-pharmacological treatments in psychosis.
For depression, the public rather seek a confidant, than seek professional help, although, like schizophrenia, there was an increase in endorsement of psychotropic drugs (from 29.5% to 38.7%).
Only 56.8% to 88.2% of the Europeans would be likely to seek
professional assistance, when experiencing psychiatric symptoms.
Furthermore, 30% of the Europeans deemed professional help as equal
as or worse than no help (ten Have et al., 2010). Although stigma is not
a considerable problem in European countries, Europeans lacked faith
in the mental health professionals.
Japanese tended to prefer seeing psychiatrists over general practitioner, and endorsed several medications (sleeping pills, antipsychotics
and tranquilizers; 22.6%–38.4%) more than Australians did (Jorm,
Nakane, et al., 2005). Unfortunately, with electroconvulsive therapy,
only 5.9%–6.4% of Australians and 1.4%–2.2% of Japanese are agreeable. Similarly, only 1.9%–7.2% of Swedish endorsed electroconvulsive
therapy (Dahlberg et al., 2008).
3538 participants in Sweden preferred help from close families and
friends (76.8%–90.5%) over help from general practitioners, psychiatrists or psychologists (49.5%–77.6%), although psychologist was most
popular among the three. With medications, antidepressants were
deemed most useful (47.6%–74.4%), followed by vitamins
(iv) Knowledge of self-help strategies available
Since only 33% of the public seek professional help when experiencing mental health symptoms (World Health Organisation (WHO),
2001), proper self-help interventions are crucial. Self-help strategies
equate interventions that such as informational booklets, website administering cognitive behavioural therapy. Self-help strategies are
viewed much more positively than professional interventions.
Among 3746 Australian students aged 12–25 years old and their
parents, for the depression vignette, non-professional interventions that
were endorsed were, support group (82%–86%), self-help book
(62%–75%), information from website (56%–68%), and lastly, vitamins
(46%–62%), In the psychotic vignette, non-professional interventions
that were endorsed were support group (89%–92%), information from
website (50%–67%), self-help (49%–73%), and vitamins (36%–44%)
(Jorm & Wright, 2007). Similarly, in Sweden, among 3538 participants,
only 61% - 68.8% acknowledged psychiatrist help and 6.7%–20% endorsed hospital admission. Non-professional interventions were far
more popular: exercising (77.6%) and self-help books (72%) (Dahlberg
et al., 2008).
A population-based survey conducted among Australian adolescents, using a depression vignette, concluded that 67.7% intended to
seek help, with majority preferring informal help from parents (57.1%).
When come into contact with someone with depression, 65.7% of
people would help. The most popular method to help was, active listening (87.9%), telling the person to get their act together (87.5%),
cheer him up (71.3%) and 63.4% recommend professional help.
However, only 22.7% would ask about suicidal thoughts, and just 1.9%
yearned for help from service (Lam, 2014).
Through stratified cluster sampling, 4938 Portuguese youths aged
14–24, deemed effective treatment as, in a chronological order, relaxation techniques (82.9%), getting professional therapy (74.8%), increased physical activity (66.2%), mediation (62.7%), seeking professional service (59.3%), joining support group (49.9%), self-help book
(48.3%) or web-site (45.9%) about personal psychiatric symptoms
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Archives of Psychiatric Nursing 32 (2018) 757–763
J.L. Tay et al.
(v) Knowledge of resources of mental health information
(Loureiro et al., 2013). In contrast, as for the schizophrenia vignette,
professional help (79.3%–81.3%) was considered most useful, followed
by relaxation (73.1%), exercising (67%), mediation (59.8%), support
group (56.5%), reading up about condition (43.3%–45.3%), and lastly,
getting sunlight, acupuncture (25.9%–35.3%) (Loureiro et al., 2015).
Drinking alcohol and smoking were considered harmful in both vignettes.
In the depression vignette, interventions deemed most effective to
help others were, active listening, followed by, seeking professional
help, and attempting to cheer her up. Ignoring her (84.5%), encouraging her to drink alcohol (87.5%) and asking if she is suicidal (52%)
were considered harmful interventions (Loureiro et al., 2013). These
results resembled the results from the schizophrenia vignette (Loureiro
et al., 2015).
Knowledge of preventing mental conditions is also part of self-help
strategies of MHL. Among the 4938 Portuguese youths, all the interventions that were stated on the questionnaire were deemed useful to
prevent mental health problems, except for (having a religion). Those
interventions were: engaging with family and friends, avoiding stressful
situations, avoid drugs and alcohol and finding time to relax (Loureiro
et al., 2013; Loureiro et al., 2015).
Between Australians and healthcare professionals, there was a gap
in the beliefs of effectiveness of interventions. The healthcare professionals endorsed mental health services, and interventions from psychiatrists and pharmacological management. However, 968 Australian
youngsters (12–25 years old) and 531 of their parents, preferred informal interventions by loved-ones (76%–92%), generic counselling
and stress reduction interventions (Jorm, Morgan, & Wright, 2008).
Other self-help strategies endorsed were, mediation (75%–80%), selfhelp book (73%), website information (72%), getting sunlight (71%).
Between Australians and Japanese, Japanese endorsed counselling
and talking with family or friends, as compared with Australians (Jorm,
Nakane, et al., 2005). For similarities, more than half of Australians and
Japanese endorsed exercising, reading about symptoms from books or
websites, going out, emailing experts or contacting health educator,
over professional treatment such as hospital admission, psychotherapy,
relaxation training and hypnosis. In terms of differences, Japanese
prefer more private information sources, such as from the internet or
books, rather than seeking help from health educator/experts.
In a cross cultural study between 440 British, Malaysians and Hong
Kongers, professional help was endorsed most by the British and Hong
Kongers, while Hong Kongers and Malaysians preferred informal help
by loved ones more (Loo et al., 2012).
Among 240 participants in India, for the depression vignette, informal help was preferred over hospital admission (64.6%). Informal
helps equates providing affection (99.2%), active listening (96.3%),
distraction (93.3%), exercising (87.5%) and special diet (71.7%). For
the psychosis vignette, except for informal help, all other informal interventions were more welcome than hospital admission (81.7%).
Interestingly, as a cultural belief, 10.1%–15% regarded arranged marriage as an effective intervention for psychosis (Kermode et al., 2009).
The high prevalence of mental health problems meant that most
public had experience mental health conditions, directly or indirectly.
People with mental health conditions often seek help from their
families, friends, colleagues, who are most usually not psychiatrictrained. Hence, how these lay-persons helped, would make a significance difference as to whether they seek professional treatment.
Unfortunately, research demonstrated that the general public lack
ability and knowledge to help those with psychiatric problems.
As mentioned in the above, counselling, relaxation training, exercising, meditation, sunlight, massages, vitamins, acupuncture, are
viewed more positively than mental health service (Jorm & Wright,
2007). Such informal self-help strategies were popular even in severe
mental health conditions like schizophrenia, demonstrating the misconception that public has about professional mental health treatment.
Traditional media such as televisions, newspapers, and movies often
degrade mental health patients and treatment, portraying them in a
repugnant light. Mental health patients are often depicted as alone,
with no family or social connections, and were unpredictable, violent,
scary and murderous (Stuart, 2006). Mental health patients are not
deemed as someone who can fully recover or become productive societal members.
Furthermore, mental health treatment was often portrayed as forced
or solitary confinement and treatments such as electro-convulsive
therapy and psychosurgery were deemed horrifying. Such negative
media depictions, of those experiencing from mental disorders, diminished their self-esteem, help-seeking actions, and medication compliance and impede overall recovery.
Multiple personality disorders were heavily sensationalized,
through books, movies and shows. Until now, the general public still
mistaken schizophrenia with multiple personality disorder, and often
cite schizophrenia patients as having ‘dual personality’, ‘changing
personality’. However, there is a universal lack of research to quantify
public's knowledge of resources of mental health information.
Factors affecting MHL
Age
Among Americans, older adults were better at identifying depression and ADHD, although they resented the term mental disorder
(Pescosolido et al., 2008). Conversely, in Australia, the younger groups
are better at identifying schizophrenia and depression compared with
the elderly (> 70 years old). However, young adults (aged 18 to
24 years old) often mistaken schizophrenia with depression (Farrer,
Leach, Griffiths, Christensen, & Jorm, 2008). The elderly tend to attribute schizophrenia to individual weaknesses.
All ages rated doctor consultation as the best help. Young adults
were more likely to endorse friends, family, counselling and selfreading as being useful (Farrer et al., 2008).
Gender
A systematic review has detected gender differences in MHL.
Females are more accepting, more helpful, less angry, but more fearful
towards those with mental conditions (Holzinger, Floris, Schomerus,
Carta, & Angermeyer, 2012). Females also believed psycho-social factors, rather than the person himself, is responsible for the mental disorders. Females were better at recognising mental disorders than males
(Coles et al., 2016; Dahlberg et al., 2008; Furnham & Lousley, 2013;
Pescosolido et al., 2008; Wang et al., 2007).
Although there are no gender differences revolving informal help,
females tend to recommend professional help more than males (Coles
et al., 2016; Holzinger et al., 2012). In another research, however,
concluded that females were more likely to seek help both informal and
formal help (family members, general practitioners, psychologists and
psychiatrists) (Furnham et al., 2014). Females also preferred psychological treatment. Males preferred individual help, such as, use of internet, and coping alone.
With medications, there is conflicting evidence about gender differences. Females tended to endorsed minerals, vitamins or herbal remedies while males endorsed tranquilizers, sleeping medications or
alcohol. In summary, females had higher MHL levels than males.
Discussion
MHL between mental health professionals and general public
Despite the overall increase in literacy and qualifications around the
761
Archives of Psychiatric Nursing 32 (2018) 757–763
J.L. Tay et al.
Conclusion
world, there is an astonishing gap of the MHL between mental health
professionals and the general public. This is because health care professionals possessed expert knowledge that is evidence-based, whereas
the public's knowledge is adopted from media and personal experience
and often the public's seemingly ignorance baffles professional.
However, it is crucial to first understand the public's views, and then
introduce to them the conventional treatment. Even the best treatment
will never work, without the public's faith in evidence-based practice.
MHL levels are low in the public. MHL can be increased with specific interventions. Such interventions can be provided in the primary
care or in mainstream or online media. Nurses have a great role to play
in leading these public educations, and enhancing public health as a
whole. Such public educations serve as primary prevention measures,
and can potentially reduce stigma and increase early help-seeking behaviours, which will reduce morbidity, mortality and promote early
recovery. Hence, nurses play an important role in preserving and enhancing healthy and happy nations worldwide.
Identification of knowledge gap
‘Mental health literacy’ surfaced in literature in 1990s, and since
then, had been intensively explored in Australia. Subsequently some
research revolving MHL had been conducted in Europe. However, most
countries, especially those in Asia have yet to examine MHL in depth.
Furthermore, existing MHL research predominantly targeted
healthcare professionals; to elevate their knowledge and skills to care
for mental health patients. Therefore, the mental health literacy of the
public was neglected (Jorm, 2012).
Overseas research that measured mental health literacy often only
measured a few aspects of MHL, rather than its entire 6 domains. Most
MHL research focused on the recognition of the illness, and preferred
interventions, although there were a total of six components of MHL.
Moreover, studies that were conducted, although in the same country,
produced conflicting results and varying MHL levels. This might be
attributed to the methodological limitations of the studies.
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Methodological limitations in literature
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Recommendation for nursing practice
Generally, psychiatric diagnosis puzzles the public. This poor MHL
impairs early detection and treatment of the mental health problems,
because general practitioners often under-diagnosed mental health
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disorders to psychosocial factors rather than biological factors. Public
education that mental disorders are caused by biological factors will
enhance help-seeking behaviours and treatment compliance.
Hence, there is still much work to be done to enhance public's MHL.
It is much easier, more cost-effective and less time-consuming for one
healthcare professional to educate the entire public, than to let the
misled, vulnerable person, who experiences psychiatric symptoms, to
slip through the cracks, never get treated, and become decompensated
forever.
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