Of the 226 papers assessed, following removal of duplicates, 66 met the inclusion criteria under the following categories: Review, Systematic Reviews & Meta-Analyses (n=4), Qualitative studies (n=9), Quantitative Non-Randomized studies (n=20), Quantitative Randomized studies (n= 3), Mixed method studies (n=8), Delphi Studies (n=20), and other studies (n=2). Details of search results are included in the supplementary file of this review.
Systematic reviews and Meta-analyses
Two meta-analyses (Hadlaczky et. al., 2014)(Maslowski et. al., 2019), a combined systematic review & meta-analysis (Morgan et. al., 2018) and a review (Bell et. al., 2018) were included in the review. Using the PRISMA checklist (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), the details of each review’s compliance are detailed in table 2.
Hadlaczky et al. (2014) assessed 15 studies evaluating MHFA training delivered over a 9 or 12-hour period using meta-analysis. The samples typically consisted of a self-nominated population. As reported in this review, MHFA training improved trainees’ mental health knowledge and reduced participants’ negative attitudes with a combined mean effect size of 0.56 (95% CI= 0.38 – 0.74; p < 0.001) for the identification of mental health problems and trainees’ the knowledge about effective treatment. The observed differences in negative attitudes pre & post measures was reported as moderate (effect size = 0.28 (95% CI= 0.22 – 0.35; p < 0.001). While MHFA training was also reported to be effective in increasing trainees’ ‘help-providing’ behavior with a reported small effect size (0.25, 95% CI = 0.12 – 0.38; p < 0.001) this was based on the opportunities that trainees had to provide help, rather than actual help.
Morgan et al. (2018) identified 18 studies (4 cluster-RCTs, 10 RCTs, and 4 controlled trials), six were included in the previous meta-analysis by Hadlaczky and colleagues (2014) which were 4 controlled trials and 2 RCTs, the others were excluded because they were only single-group pre/post studies. Like the studies included in Hadlaczky’s meta-analysis, most were conducted in Australia (n=8), while others were conducted across North America (n=5), Europe/UK (n=4) and Hong Kong (n=1)
In line with Hadlaczky et al., (2014), Morgan & colleagues (2018) reported an improvement in trainees’ knowledge, the study interpreted their effect sizes based on Cohen’s work (Cohen, 1992) and they have reported a high effect size at post-intervention (d = 0.72 (95% CI = 0.59, 0.86; p < 0.001), which was smaller (moderate based on Cohen’s guideline) at 6-month follow-up (d = 0.54 (95% CI = 0.43,0.64; p < 0.001) and 12 month follow-up (d = 0.31(95% CI = 0.09,0.53; p < 0.006). Small effects were reported for stigmatizing attitudes across all post intervention periods. Further analyses were conducted exploring the type of stigma, most included measures for social distance and personal stigma. Additionally, the perceived confidence levels of mental health first aiders have been consistently reported to significantly improve post-intervention (0.58 (95% CI = 0.29, 0.87; p < 0.001) & 0.46 (95% CI = 0.31, 0.62; p < 0.001) at 6-months follow-up (Morgan et al., 2018). The effect sizes for trainees’ intentions to provide MHFA post-intervention were moderate 0.75 (95% CI = 0.60, 0.91; p < 0.001), and 0.55 (95% CI = -0.08, 1.18; p .085) at 6-months and a smaller effect size was reported (0.26 95% CI = -0.12, 0.64; p .182) at 12months follow-up.
Furthermore, there was not a statistically improvement post-intervention in the amount of help provided following MHFA training, but small improvements of 0.23 (95% CI = 0.08, 0.38: p .002) at 6-months post-intervention. In addition, no statistically significant improvement was reported in trainees’ and recipients’ mental health accessed via trainees of the intervention compared to baseline, pre-intervention (Morgan et al., 2018).
Maslowski et al. (2019) meta-analysis reported a similar outcome to Morgan’s’ (2018) with additional outcomes for the distress levels of trainees and ‘recipient outcomes’. Effect sizes were reported using Hedges’ g (Freeman et al., 1986), which was considered based on its precise estimate when sample sizes are small. Effect size magnitude was interpreted based on the standards of small (0.20–0.49), medium (0.50–0.79) and large (0.80 or greater) which is similar to Cohen’s guidelines. The effect size for trainees’ knowledge was moderate (0.53, 95% CI = 0.39, 0.66; p < 0.001), which was similar to the outcomes reported by Hadlaczky et al. (2014), whereas Morgan et al. (2018) reported effect sizes ranging from 0.22 to 0.72 for trainees’ knowledge and recognition of recipients’ mental health issues at post-intervention, and 6-months respectively. Regarding the attitudinal changes of trainees, the results reported were consistent with Morgan’s with a small effect of 0.18. Moreover, the review reported a moderate effect size 0.50 (95% CI = 0.34, 0.67; p < 0.001), relative to that from Hadlaczky et al. (2014; 0.25) for the combined self-reported behavioural and confidence outcomes for the trainees of MHFA.
Recipients in the studies Maslowskis’ reviewed were not direct recipients. Two studies (Jorm et al., 2010 ; Lipson et. al., 2014) included in Maslowski’s meta-analysis observed outcomes in a general population where MHFA was introduced. Lipson & colleagues (2014) surveyed residents of a university hall of residence, while current students of teachers trained on MHFA in a school year were surveyed by Jorm & colleagues (2010). Based on the review, Maslowskis reports, there were no reported effects on recipient’s outcome which was observed based on changes in psychological distress of the recipients.
A evidence synthesis review carried out by Bell & colleagues (Bell et al., 2018) investigated the application of MHFA in workplace settings. The review included 22 studies with the intention to answer the three research questions which investigated if there been an increase in awareness of mental health amongst employees (i.e. all staff employed by an organisation, including leaders/managers) receiving MHFA training; if there is any evidence of improved management of mental health in the workplace as a consequence of the introduction of MHFA training; and if there are evidences that the content of the MHFA training has been considered for workplace settings. They included the following study design; 13 single studies, 3 reviews, 3 single study protocol and 3 Delphi studies. In line with the previously reported systematic review & meta-analyses, the Bell et al review reported consistent evidence that MHFA raises employees’ knowledge of mental illnesses. MHFA trainees were more aware of where to find information and professional support and have shown increased confidence to render help to individuals experiencing a mental health crisis. The review also highlighted the lack of evidence from the published studies about the impact of introduction of MHFA in workplaces on the support provided by those trained and the sustainability of such actions of support. In addition, Bell et al reported limited evidence to on the adaptability of MHFA to different workplaces.
In sum, all the review studies included in this section reported on trainee related outcomes which showed an improvement of moderate or high at different time-points. Most significant trainee outcomes reported were knowledge of mental health, confidence of trainees to help someone struggling with a mental health crisis, trainees’ attitudes was also reported with closer attention placed on different forms of stigma and the trainees psychological distress as a result of the MHFA training. Whereas the effect on the so-called recipients ranged from none too small with the reviews reporting recipient related outcomes around changes in the psychological distress which were all indirectly observed via trainees. However, none of the reviews found studies that gathered data from actual recipients of MHFA.
Quantitative Non-Randomized & Randomized studies
Twenty-three studies are reviewed in this section, the detailed characteristics of the studies & their quality checks are shown in Table 3 & 4.
Fifteen (65%) of the included studies were non-randomized cohort studies that adopted the use of either a pre & post study or time series design (pre, post, and follow-up design). Sample sizes range from n = 29 (Borrill, 2010) to 606,941 (El-Amin et. al., 2018). The remaining included studies comprised 2 (9%) quantitative non-randomized controlled trials, 2 (9%) quantitative non-randomized cross-sectional studies, 1 (4%) quantitative non-randomized descriptive study, and 3 (13%) randomised control trials.
Improvement in the perceived confidence levels of participants following MHFA training was generally reported. Boukouvalas et al. (2018) & El-Den et al.(2018) observed changes in confidence levels using simulated patient case studies amongst university pharmacy students and the use of vignettes assessed with an ALGEE-based assessment rubic. These vignettes were reported to satisfy diagnostic criteria and correct recognition has been validated by a group of mental health professionals in Australia (Morgan et. al., 2013).
Hart et al. (2018) utilized a cluster-randomized crossover trial to assess the efficacy of the teen version of the MHFA intervention used in schools to encourage students’ supportive behaviours towards their peers. The study also assessed, the quality of first aid intentions, recognition of mental health, beliefs about the helpfulness of adults and their measures of stigmatizing beliefs. Trainees were assessed against individuals who were also trained within the same study on a physical first aid course (PFA). All outcomes except the measures of stigmatizing beliefs were observed using a vignette with characters, John & Jeanie presenting with suicidal ideation/depression and social anxiety/phobia, respectively. The vignette was developed based on teaching in the teenMHFA training.
The study reported a medium effect size favouring teenMHFA (ds = 0.50–0.58) based on a group-by-time interaction for the primary outcome. The primary outcomes, ‘helpful first aid intentions’ towards John/Jeanie, showed significant group-by-time interactions with medium effect sizes favoring tMHFA. In comparison to the PFA group, teenMHFA also reported a medium effect size and improvement in trainees’ confidence supporting a peer (ds = 0.22–0.37) and there was a medium effect size but small improvement in the number of adults rated as helpful (ds = 0.45–0.46). However, reductions in effect sizes were observed in stigmatizing beliefs (ds = 0.12–0.40) and ‘harmful first aid intentions’ towards John/Jeanie (ds = 0.15–0.41).
Studies carried out by organizations in the UK via post-training questionnaires show that of 616 (88%) of MHFA trainees who responded post-course, 34 (6%) trainees) reported they used their MHFA skills when in contact with someone experiencing mental health distress (Brett-Jones, 2010). MacDonald et al. (2008) reported that 54 (85%) of trainees who completed their follow-up questionnaire had reported offering help to individuals struggling with mental health issues. Heer et al. (2010) reported 100 (68.5%) of their respondents had reportedly used the MHFA training to help someone with a mental health problem post-training. Most of the respondents reported the type of help offered was listening (Heer, 2010; Macdonald et al., 2008) and giving assurances and information (Macdonald et al., 2010), two aspects of the ALGEE approach.
Three studies investigated the relationship between trainees’ intention to provide help and the actual behavior of providing help in a bid to assess trainees’ skills post-intervention (Rossetto et. al., 2014; Yap & Jorm, 2012). Rossetto et al. (2014) investigated participants’ responses to a vignette developed by the creators of MHFA (Kitchener & Jorm, 2006) which was benchmarked against the ALGEE criteria. Responses were scored based on the level of details in each of the components of the action plan. However, the link between trainee’s intention and their actual behaviour remains unclear. Methodology adopted by both studies is problematic in understanding the relationships between intentions and actual behaviour as the studies involved retrospective reporting of behaviour.
In Summary, there are limited studies evaluating the effects of MHFA training beyond a 6-month post intervention period, except a trial by Mohatt et al. (2017), and recent ones by Hart et al. (2018) and Reavley et al. (2018), indicating a need to measure the persistency of effects over a longer-term period. There has also been a lack of well-designed experimental, adequately powered studies (RCT or C-RCT) despite reviews (Hadlaczky et al., 2014; Maslowski et al., 2019; Morgan et al., 2019) identifying these as a consistent knowledge gap.
Nine qualitative studies from Australia (4) and Wales (2), Hong Kong (1), Sweden (1), and the USA (1) are included in the review. Detailed characteristics of the studies & their quality checks are shown in Table 5.
All included qualitative studies reported that part of the aim of conducting the studies was to explore the benefit of MHFA training for trainees. Improved confidence in relation to helping someone with a mental health condition was a common theme in the descriptive benefits of MHFA training across the studies. One Australian study (Jorm et. al., 2005), identified a positive perceived impact both on an intra-personal level emphasizing MHFA trainees’ perceived empathy and confidence levels in providing help to others, and on an inter-personal level, focusing on how trainees manage crises.
A Swedish study (Svensson et al., 2015) reported participants referred to MHFA as a “toolbox” (p500) that increased their self-reported confidence to help someone with suspected mental distress. An Australian study using a case-study approach (Bovopoulos et. al., 2018) involving 14 participants reported more help-seeking behavior among workers which they reported as being associated with having MHFA trainees in the workplace, over and above that provided by Human Resources prior to the introduction of MHFA.
Two studies explored the experiences of Instructors in delivering MHFA training. Instructors interviewed in a Welsh study by Terry (2010) expressed the need for prerequisite mental health knowledge as an essential tool to enable them give relevant examples on how to identify mental health crises.
Undergraduate nursing student trainees of a MHFA training intervention in Hong Kong reported communication and interpersonal skills as key gains from MHFA training (Hung et. al., 2019). Other gains reported in a study by Pierce et al. (2010) are participants’ perceived sense of empowerment to assist anyone who might be experiencing mental distress within their football club and their local community. An American study (Ploper et. al., 2015) reported that the presence of practical information in MHFA training and action plans developed in the training equipped trainees with skills to assist people experiencing mental distress, but there is no evidence of the assessment of the skills to which the authors allude.
Furthermore, Hung et al (2019) explored the impact of MHFA training on the trainees’ awareness of their own mental health. Their findings suggest that MHFA training may enhance the personal awareness of the trainee’s mental health as a secondary effect of enhancing their skills at helping others.
Bovopoulos et al. (2016) have also reported on MHFA instructors’ experiences and perspectives of delivering MHFA courses in Australia. The main finding reported is that participants identified the need to adapt courses to suit the needs of first aiders from a range of cultural backgrounds and organizations. The influence of various organizational complexities on several outcomes needs to be further explored.
Bovopoulos et. al. (2018) explored the experiences of MHFA trainees or MHFA officers as the study calls them. Interviews were conducted across organizations that had previously adopted MHFA and appointed MHFA officers. Detailed analysis of participants responses reported the need for MHFA training to be offered to all staff in a bid to encourage a more acceptable atmosphere to have a mental health discussion within the workplace.
In sum, qualitative studies seek to describe, and explain participants’ experiences of the issue’s researchers’ study, using themes ‘emerging’ from participants’ narratives, and often drawing upon theoretical and conceptual insights as explanatory tools. But the data reported in the studies included here are largely impressionistic and provide little evidence about the impact of MHFA training on trainees’ actual skills, especially in the application and impact of MHFA in ‘real-world’ settings where their skills are sought. The perceived gains in trainees’ confidence, whether assessed by trainees or instructors, are arguably redundant in the absence of the application of the supposed confidence in practice, whether tested on the training, or in practice post-training. None of the included studies explored participants’ impressions of the long-term effects of MHFA training on participants’ confidence, the different ways participants implemented the interventions in their various settings, or possibilities and pitfalls implementing MHFA with recipients.
Mixed Method Studies
Eight studies were included three Australian, two American, two British, and one Canadian study. Details of the studies included are in Table 6 alongside details of their quality checks.
Massey et. al. (2014) reported MHFA training increased participants’ knowledge of mental health conditions amongst those trained when compared with participants individuals in a control group under pre & posttest conditions (effect size difference = 1.06). In addition, Massey & colleagues reported an increase in trainees’ interactions with individuals with mental health conditions (Pretest=75%, Posttest=86%), recognizing more cases of mental health conditions (recognition of 2-4 people; pretest 58%, posttest 80%). However, a report of participants’ openness towards people with a mental health condition, measured by vignette (Jorm et al., 2005) showed no difference from pre to posttest when compared with the those who did not receive training (t(79) = -0.68, p >.05), However, participants in the qualitative component of the same study reported a perceived increase in their sensitivity and openness to people living with mental distress.
A similar mixed method study observed comparable results when MHFA training was delivered to coaches of a football team. The results reported by Massey et. al. (2014) have also been observed in a study by Talbot et al. (2017) showing that post-training, trainees reported that MHFA training helped in the promotion of treatment seeking as an indirect benefit of MHFA, though the study was based in a rural sector where trainees identified the lack of formal services which made it difficult to capture completed referrals based on contact with a mental health first aider.
Narayanasamy et al.’s feasibility study (2018) undertook a 3 investigation of the implementation, use and utility of MHFA in the workplace. Of all 139 respondents that filled out the survey, the study reported that the most common way which organizations have identified/selected trainees of MHFA training was via a general invitation sent out to employees with a selection criterion also implemented in some cases. Another common way was by direct request for training from employees whilst other organizations handpicked people from amongst their trainees. The study also reported on how trainees raised awareness of MHFA post-training; the most common strategy was the use of posters 72(51.8%); sharing of MHFA info about mental health & wellbeing in the workplace 69 (49.6%), running mental health days 63 (45.3%) and intranet links 55 (39.6%). The study also reported the mean effects of anticipated outcomes on the impact of MHFA in different workplaces was 28.07 which was higher than the actual mean effects (24.22) post-training based on feedback from their respondents Another cited issues such as the inclusion of more practical elements into MHFA education like more role-play sessions to rehearse the newly acquired skill from the training. On the other hand, 22 participants were interviewed across 6 organizations (2 public sector, 2 private sector & 2 Not-for-profit sector). The aim of the interviews was to further explore the implementation & use of MHFA. The study reported that having a clear rationale for introducing training, well-motivated MHFA coordinators and the existence of MHFA networks as important elements to successful implementation of MHFA in the workplace.
In sum, studies included in this section have explored the effect of MHFA using a mixed method approach. Similar to studies included in previous sections, there is a lack of longer follow-up period to observe the effects on MHFA across studies that explored the effects on trainees of MHFA (Massey et al., 2014; Narayanasamy et al., 2018). Retrospective rating of skills by trainees without the use of a validated survey instrument does not give a true picture of effects as adopted by Talbot & colleagues (2017). Again, studies testing the impact of MHFA on recipients are lacking.
The Delphi technique is known as a method of eliciting and refining group judgments (Dalkey, 1969). Studies using this methodology have been included in this review to understand how MHFA is administered to achieve its intended outcomes.
Following the development of MHFA, several problem-specific guidelines designed to enable mental health first aiders to better use the ALGEE approach were developed using Delphi- consensus methods. Fifteen studies are included here. The detailed characteristics of the studies & their quality checks are shown in Table 7. While all included studies were conducted in Australia, the process of consensus was mostly international, with panels consisting of experts based in the USA, Ireland, UK, Canada, and New-Zealand.
This section has highlighted a range of guidelines on how to provide MHFA interventions to address specific issues ranging from mental health problems to other within different groups and communities. The development of these guidelines has been based on the main elements of MHFA (ALGEE) on how to support someone struggling with any form of mental health problem. However, the ALGEE steps have no scientifically established theoretical basis as they cannot be easily mapped against any evidence-based behaviour change taxonomies such as those developed by Michie et al. (2013). Furthermore, there is no empirical evidence to show the impact of the developed guidelines on their intended recipients. The impact of the guidelines on recipient outcomes remains a serious gap in the literature.
A recently completed UK NIHR funded study - Wellbeing for Secondary Education (WISE), investigated two aspects of MHFA: the impact on teacher wellbeing, including effects on teachers’ reports of depression, their sickness absence, and under-performance at work, and the impact on pupils’ mental health and wellbeing. At the time of writing, there has been no published data from the main study, however, data from the pilot study shared by the authors reported an increase in confidence, knowledge, and self-reported helping behaviour amongst teachers, (Kidger et al., 2016), consistent with previous studies that have reported trainees outcomes (e.g.: Morgan et al., 2018)