Mental Health Literacy programmes prevent and support ongoing management of youth anxiety and depression: consultation and literature review

doi:10.21203/rs.3.rs-3150262/v1

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Research Article

Mental Health Literacy programmes prevent and support ongoing management of youth anxiety and depression: consultation and literature review

https://doi.org/10.21203/rs.3.rs-3150262/v1

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Background

Enhancing young people's capacity to recognise, understand and manage emotional symptoms through mental health literacy (MHL) programmes may help attenuate the long-term burden of mental illness. This may be especially important in low-resource settings. We aimed to review the capacity of MHL programmes to prevent, support ongoing management, and reduce relapse of youth anxiety and depression. We explored both personal and contextual factors that could amplify their benefits, and through consultations with lived experience researchers, considered if and how these could be delivered in low-resource settings.

Methods

We systematically searched 6 databases for studies that evaluated the potential of MHL programmes to prevent, support ongoing management, and reduce relapse of youth anxiety and depression. We consulted young people and stakeholders on their perception of MHL programme delivery in low-resource countries/settings.

Results

We identified 17 relevant studies, covering a range of MHL programmes. Most MHL programmes targeted young people through educational settings. Teacher-delivered programs showed the clearest effects in improving recognition of anxiety/depression symptoms while programs supported by experts showed clearer effects on stigma reduction. Stakeholders highlighted the importance of MHL programmes and expressed possible barriers and solutions to implement them.

Conclusion

As young people are receptive to learning about mental health, it is critical to implement accessible MHL interventions early, especially in low-resource settings. Delivery by non-specialist practitioners in community settings could reflect one such strategy. Delivering these programmes may be a pre-requisite to understanding why and when individual resources are needed, bridging the gap in availability of mental health care.

Adolescents

Anxiety

Depression

Mental Health Literacy

Anxiety and depression are prevalent in young people, with most cases starting before the age of 14 years. Yet many cases go undetected and untreated (1) affecting capacity to live a fulfilling life (2). Inability to recognise, understand, and seek-help or self-manage such problems, could explain why many young people fail to seek and receive treatment for their difficulties (3, 4).

To address this gap, Mental Health Literacy (MHL) programmes have been developed to enhance help-seeking (and reduce stigma) through improving recognition of the signs and symptoms of different mental health problems; understanding of their causes and risk factors; knowledge of the range of treatments available and pathways to support; and identification of strategies for self-management (5, 6). Such programs have the advantage that they are versatile in their delivery; these can be delivered by mental health professionals or non-experts, in different contexts such as school, community, at home, etc., and using different modes like in person, telephone, or online platforms. MHL programmes can be developed to engage young people themselves and those who interact frequently with them (e.g., teachers, parents, peers) and can provide information about mental health problems in general or target specific conditions (6, 7).

There have been systematic reviews of MHL programmes efficacy in improving mental health in general across the world (8–10). These studies usually focus on a range of outcomes from only broadening knowledge on mental health disorders to mental health care and help-seeking behaviours, and stigma reduction. However, to our knowledge, none of these, focus specifically on knowledge around managing youth anxiety and depression. Indeed, a study of American youth suggested that fewer than 50% recognised depression (10) while a study among undergraduates from Sri Lanka, found that only 7.4% could recognise depression. It is also likely that most studies investigate MHL programmes as a preventative intervention, for example, as a universal programme targeted to all people. MHL programmes may also help to minimise relapse and assist ongoing management of symptoms in those already with anxiety and depression.

As accurate diagnosis and awareness about common mental health difficulties such as anxiety and depression are essential for facilitating early intervention in all countries, the delivery of MHL programmes may be even more critical in low-resource settings (11, 12). Low-to-middle income countries struggle with a lack of resources to manage the burden of severe and persistent mental illness, especially in young people (13–15). There are also limited educational opportunities and increased stigma regarding youth mental health problems (16, 17). Yet, there is little published data about the effectiveness of MHL programmes and pathways for their delivery in LMICs.

In this research, we aimed to review literature on the effectiveness of MHL programmes in supporting young people with anxiety and depression. We focused on universal programmes but also programmes aimed at helping young people to manage their anxiety and depression and those aimed at reducing relapse. In reviewing the literature, we were also interested to find out whether personal or contextual factors helped to boost any benefits of MHL programmes. Finally, because of the gap in MHL studies based in LMICs, we engaged and consulted young people and relevant stakeholders (child and adolescents’ psychiatrists, psychologists, and schoolteachers) from Nepal, Colombia, and East London (UK) on their views on the importance of MHL programmes and the barriers that contributed to low delivery schedules in low-resource settings. We therefore had 3 sets of Research Question (RQ):

RQ1: What is the effectiveness of MHL programmes in young people through as a) a universal prevention strategy for anxiety and depression, b) as a method to help ongoing management and preventing relapse of anxiety and depression?
RQ2: What are both personal and contextual factors that could amplify the effects of MHL programmes?
RQ3: How important is delivery of MHL programmes to young people growing up in low-resource settings and what are obstacles to delivering such programmes in these settings?

To address these research questions, we carried out (a) a systematic literature review and b) consultations with young people and stakeholders. Of note, consultations were considered to reflect service-user engagement and co-production efforts rather than to reflect qualitative research per se, consistent with the approach advocated by the Wellcome Trust Active Ingredients programme, of which the present review is a part of.

a) Literature review

Inclusion criteria for studies

Studies had to be a) published in a peer-reviewed journal, b) written in English, Spanish, Portuguese, French or Nepali, and c) reporting on data collected from humans following the delivery of a programme that was designed to improve youth anxiety and depression outcomes through "mental health literacy". Mental health literacy (MHL) programmes included those that sought to enhance understanding and recognition of mental health symptoms, help-seeking behaviour, reductions in stigma associated with mental health problems, or improvements in the self-management of symptoms. Studies that promoted self-management strategies only e.g., emotion regulation or coping in the absence of other components of MHL were excluded. Recipients of the MHL program were young people (mean age 14–24 years consistent with WHO definition) or those who working closely with young people in this age group (teachers, youth workers, counsellors, healthcare professionals, other general stakeholders). As we were interested in the long-term effects of MHL programmes, we only included longitudinal studies.

Search for and identification of studies

The review protocol was registered on PROSPERO (CRD 42021268706). Searches were completed in July 2021 for the following databases: Medline, Ovid, Embase, PsycNet, Virtual Health Library Regional Portal and NepJol using the search strategy shown in Appendix 1. We also checked the reference lists of the retrieved studies for relevant studies that could be included in the current review.

There were three review groups who took a third each of the articles, and independently screened the articles found based on their titles and abstracts and selected the studies that met the eligibility criteria. To screen and select the articles, we used the Rayyan QCRI (18) web app to facilitate the process of references classification and discussion. Discrepancies were resolved by consulting a third-party researcher (FBR or SD) who referred to the original text.

Data extraction and synthesis

Data were extracted using standardised data collection forms by some authors the authors. We extracted the following information: date, title, journal and authors of published study; country of study sample; gender balance; ethnicity information; age range and mean age; who the mental health literacy programme is aimed at; whether the programme is a standardised one used in other publications; number of sessions; who delivered the intervention and where; and whether it specifically focuses on youth anxiety/depression or is a general literacy programme that includes anxiety/depression outcomes. We also recorded which outcome measures were used; and noted relevant pre and post intervention means. We also included details on young peoples' engagement with and compliance to programme requirements, and any qualitative assessment of the acceptability and tolerability of these programmes.

The studies included varied greatly in terms of study design, target population, interventions and comparators used, instruments of measurement, and points for follow-up and evaluation of outcomes. Taking this into account, performing a meta-analysis of the results was not a viable option. As a result, data synthesis was performed based on narrative summaries and in the summary we included the reported effect measure.

b) Consultations with young people and stakeholders

Twenty-four young people with lived experiences of anxiety and depression from Nepal (N = 13, age range-14-24, 46% male), Colombia (N = 9, age range = 14–24 years old, 44% male) and East London in the UK (N = 2, 17 and 20 years, 0% male) shared their views on mental health literacy and their experiences of accessing any relevant programmes. Young people from East London were consulted in 1-2-1 interviews, while the other young people were invited to 2 focus groups of 5 and 4 people, divided in 14-19-year-old, and a 20–24-year-old group respectively. Members of the research team facilitated focus groups.

Eleven stakeholders working with young people (defined as those aged 14.00-24.99 years) across countries were also invited to consultations about our research topic. The 4 stakeholders from Nepal were a clinical psychologist, a counsellor, a schoolteacher and a child and adolescent psychiatrist. The 3 stakeholders from Colombia were a child and adolescent psychiatrist, a psychologist, and a teacher. UK stakeholders reflected 2 secondary school teachers in pupil referral units, often schooling young people growing up in deprived areas; 1 trainee mental health practitioner working in a school teams organised through child and adolescent clinical services; and 1 research associate within a non-governmental organisation fundraising and campaigning for young peoples’ mental health. Consultations with stakeholders focused on their role and experiences working with young people; their perceived barriers to accessing mental health support and the best ways to enhance literacy of mental health to young people in their care, and how such programs could be facilitated in these settings. All consultations were conducted by an author in each country (FBR, SD, JL), and these lasted between 45 and 60 minutes. Focus groups and interviews were recorded and transcribed verbatim. Anonymised transcripts were used to provide complementary insights to those generated by our systematic review.

A total of 14,884 studies were identified (1767 duplicates). Ninety-three articles were double screened in the complete manuscript. Seventeen studies were included in our review (Fig. 1) (Tables 1 and 2). Studies were from ten countries including, five from the US, three from Australia, two from the UK, and 1 from each of the following countries: Finland, Taiwan, Hong Kong, Malaysia, Singapore, Mexico, and Germany.

In terms of overall methodological design, studies varied in which aspects of mental health literacy they measured but most measured literacy, 10 of the studies measured depression literacy, 1 measured anxiety literacy and 3 measured both anxiety and depression literacy. Studies measuring mental health literacy assessed knowledge or ability to recognition of symptoms, sometimes using a vignette. Six of the studies measured help-seeking intentions and/or attitudes and 2 studies measured helping intentions. Thirteen of the studies measured stigma around mental health or help-seeking. A few studies, 3 out of 17, assessed actual emotional symptoms. Most studies used pre and post measures. Twelve of the studies included a comparison group. Where a comparison group was included, this was usually a “no intervention” group (10 out of 17), controlling for passage of time and repeated measurements. Interventions were delivered by peers, teachers, parents, and trained professionals. The length of time between the end of the programme and the assessment varied between 1 week to 6 months.

RQ1a: MHL programs as universal prevention and differences across delivery modes

Fifteen studies reported data from “universal” interventions (Table 1): 14 of these directly targeted unselected young people (although some also aimed to improve literacy among teachers(19) and 1 targeted parents of young people (20). Thirteen of the studies that were aimed at young people identified participants through schools or universities and were therefore delivered within these educational environments. These varied by the exact mode of delivery: 4 were delivered by teachers who had received training on the program (21–24), 4 were largely facilitated by experts, either clinically, academically or by experience (25–27), 1 study involved both teachers and experts across different phases of the program (28), 1 relied on peer-to-peer communication(29) and 4 used an online platform. Programmes varied in the length of the sessions (from one week to those that were self-paced) (25, 30–32). The remaining study recruited through the community(32) and used an online platform to deliver the programme.

In terms of the teacher delivery programmes, all these improved literacy around depression relative to the control group (19, 24, 33) or pre-intervention levels (34) with some sizeable effects despite intervals of up to 4 months between the end of the intervention and assessment. The Adolescent depression Awareness Program that consisted in educational sessions up to 6 hours, showed an OR: 3.3 to improve the literacy in depression (19, 33, 35). Effects on stigma around mental health were not always assessed but where they were, these were more inconsistent, with one study reporting reduced stigma (19) and the other reporting no change (33). Only one of these studies measured help-seeking, finding significant increases in reported help-seeking (24). All these programmes were delivered by teachers and in scholar settings.

Interestingly, within programmes delivered by experts, improvements in literacy were less consistent across studies (36–38). In contrast, stigma clearly reduced in at least 3 studies (38–40), with one study reporting more mixed results across different measures (36). Only two studies assessed help-seeking with improvements in self-reported behaviours and intentions (28, 39)(36). In the one study involving both teachers and experts, this largely raped improvements on all three outcomes (28). However, one study(39) directly assessing whether an additional intergroup contact condition to a psychoeducation workshop could improve outcomes and found that these benefits were only limited to attitudinal stigma reduction. On measures of emotional well-being, literacy and help-seeking, the educational workshop alone showed significant benefits. Only 2 studies assessed actual anxiety and depression symptoms and reported inconsistent findings. Melo-Carrillo and colleagues (41), at a one-year follow-up, found that youths who participated in the psychoeducation program had lower depression scores than those who did not. Nevertheless, Costin and colleagues(32) found no significant changes in depressive symptoms between the intervention and control groups at a much shorter interval (one week) between the end of the intervention and the assessment.

Table 1

*Studies investigating universal delivery of Mental Health Literacy programs.*
Authors (year)	Country	Details of MHL program	Sample size	Presence/ nature of control group	Duration between end of program and assessment	Findings on relevant outcomes
Interventions delivered in schools or universities to young people by teachers
Schiller et al. (2014)	Germany	Researcher developed information booklet- ‘‘Paul down in the dumps. Understanding depression in adolescents’’, (15-minutes, self-paced), aimed at adolescents, delivered in schools as a booklet	19 schools 628 participants	No control group	1 month	Depression Literacy: Knowledge enhancement for Symptoms (η2 = 0.45), Treatment (η² = 0.17), Antidepressants (η² = 0.56), Suicidality (η² = 0.36), Depression as disorder (η² = 0.07), Causes (η² = 0.10), Helping behaviour (η² = 0.09).
Swartz et al. (2017)	US	The Adolescent Depression Awareness Program (ADAP) (3-hours) aimed at students, delivered in school by teachers	6679 students	No intervention control	4 months	Depression literacy: After controlling for pre-intervention scores, more students were depression literate at the follow-up assessment in the intervention group (54.6%) compared to the control group (36.3%) (Odd’s ratio = 3.30). Stigma: No significant impact of intervention on follow-up mental health stigma
Beaudry et al. (2019)	US	Adolescent Depression Awareness Program aimed at adolescents (number/length of sessions were not reported), delivered in schools by teachers	15 Schools 201 students	No intervention control	4 months	Depression Literacy: Those who received the ADAP curriculum showed greater improvements in depression knowledge compared to those in the control group (Est. =1.07, SE = .25, p < .001). Help seeking: ADAP facilitated self-reported help-seeking behaviour including in those at-risk
Miller et al., (2019)	US	Adolescent Depression Awareness Program (6 hours), aimed at pupils, delivered in schools by teachers	54 schools, 87 teachers, 6679 pupils	No intervention control	4 months	Depression literacy: Intervention group increased from 69.7–78.2% while control group decreased from 68.2–71.3% Stigma: Intervention group decreased from 9 to 8.5 while control group decreased from 9.2 to 8.7
Interventions delivered in schools or universities to young people by mental health professionals or the research team
Hart et al. (2018)	Australia	Teen Mental health first aid (MHFA, 3 x 75-minute sessions) aimed at students, delivered in school by trained instructors	1942 students	Active control (cross-over design)	1 week	Depression and anxiety literacy: There was no significant difference between groups on depression literacy at the 1-week follow-up, but the intervention group received higher scores for anxiety literacy at the 1-week follow-up than the control group (Odd’s ratio = 3.34). Helpful intentions: Greater increases in ‘helpful intentions’ in intervention than control group (Cohen’s d’s = .05-0.58) and decreases in harmful intentions in intervention than control group (Cohen’s d = 0.15–0.41). There was also higher confidence in helping (Cohen’s d = 0.22–0.37). Stigma: Some reductions but extent of differences are not consistent across scales and vignettes.
Chisholm et al. (2016)	UK	Time to Change (intergroup contact to reduce stigma, 20 minutes) and an educational intervention (1-day) aimed at students, delivered by volunteers and mental health professionals	6 schools, 31 classes, 657 adolescents	Educational intervention only	2 weeks	Attitudinal stigma: improved in both conditions with no significant effect of condition (Cohen’s d = 0.01) Knowledge-based stigma, mental health literacy, resilience, and help-seeking attitudes: improved significantly in the education-only group compared with the education plus contact group. Emotional well-being scores: participants in the education-alone condition had greater improvements in emotional well-being levels than participants in the contact and education condition, (Cohen’s d = 0.05).
Han and Sue-Huei (2014)	Taiwan	Researcher-developed neurobiology psychoeducation lecture about depression (30-minutes) aimed at students, delivered at university, by a clinical psychologist	132 students	No intervention control	2 weeks	Depression literacy: Participants in the intervention group were more likely to take a biological attribution than the control group (Cohen’s d = 0.40) Stigma: Participants in the intervention group were more likely to approach a depressed individual (Cohen’s d = 0.79)
Onnela et al. (2021)	Finland	Researcher-developed psychoeducation course (4 x 45-minute sessions), aimed at students, delivered in schools by mental health professionals	162 eighth-grade students	No intervention control	2 months	Anxiety and depression literacy: There was no significant improvement compared to pre-intervention or the control group. Stigma: Attitudes to considering mental health problems as medical illnesses rather than personality traits of weakness changed from pre- to post-intervention (Cohen’s d = 0.53–0.60)
Interventions delivered in schools or universities to young people by a combination of teachers and mental health professionals
Lai et al. (2016)	Hong Kong SAR, China	“Little Prince is Depressed” (12 45–60-minute sessions) aimed at students, delivered in school in two phases led by those with a professional background (counselling, social work) and teachers	3391 students	No-intervention control	4 to 5 months	Mental health literacy: Compared to the control group, the professional-led and teacher-led intervention phases showed greater literacy (Cohen’s d = 0.64–0.70) Help-seeking behaviours: Some changes in help-seeking but these were not consistent across professionals, teachers, friends. Stigma: Compared to the control group, the professional-led and teacher-led intervention phases showed more positive attitudes to those with mental health problems (Cohen’s d = 0.29–0.34)
Interventions delivered in schools or universities to young people by their peers
Parikh et al. (2018)	US	Youth-developed Peer-to-Peer Depression Awareness Program (One day, 6 hrs kick-off conference), aimed at “peer advocates who created their own depression awareness campaigns (5 months) targeting other students, delivered in schools by peer advocates (who were supported by the research team)	10 schools 878 students	No control group	1 week	Depression literacy: Non-P2P member showed statistically significant improvement in depression literacy (measured in terms of numbers of items ticked) at post-test (Cohen’s d = 0.45). Stigma: Significant reduction in reported discomfort about being seen entering the office of the school social worker or psychologist (Cohen’s d = 0.15). Significantly more at ease talking about mental health difficulties with their friends (Cohen’s d = 0.15). Six of the ten subitems for the item linked to school climate and stigma showed statistically significant improvement (Cohen’s d = 0.07–0.22)
Interventions delivered in schools or universities to young people by an online program
Costin et al. (2009)	Australia	Researcher-developed, depression information sent via health e-cards (self-paced), aimed at young adults, delivered in the community through personalised emails	348 young adults	Active control	3 weeks	Depression literacy: There were no pre-to-post changes in either group on recognition of depression symptoms. Help-seeking intentions and knowledge: There were no significant changes in these variables in the intervention relative to the control group. Depression symptoms: There were no significant changes on symptoms in the intervention relative to the control group.
Davies et al. (2018)	UK	Mental Health First Aid (MHFA) e-learning course (6–8 hours, self-paced), aimed at medical students to assist themselves or their peers, delivered online	55 students	No intervention control	6 weeks	Anxiety and depression literacy: There were no pre-to-post changes in either group on recognition of depression or anxiety symptoms. Mental health first-aid intentions: At post-intervention this was higher in the intervention than the control group (Cohen’s d = 0.89). Stigma: At post-intervention, this was reduced in the intervention than the control group (Cohen’s d = 0.25)
Shahwan et al. (2020)	Singapore	Researcher developed anti-stigma intervention that also included education about depression (50-minutes), aimed at students, delivered at university by academic and experience experts and modes (lecture, video and question/answer session)	6 universities 390 students	No control group	3 months	Help seeking propensity: This increased from pre-intervention to 3-months (Cohen’s d = 0.51) Indifference to stigma: This increased from pre-intervention to 3-months (Cohen’s d = 0.34).
Melo-Carrillo et al. (2012)	Mexico	Researcher developed psychoeducational program (length of time varied across students depending on whether they consulted a mental health support group), aimed at medical students	1958 students	No intervention control group (those who did not attend the psychoeducation programme)	1 year	Depression symptoms: Students who attended the psychoeducation program had lower depression scores (collapsed across 4 years) compared to those who did not (Cohen’s d = 0.21)
Interventions aimed at parents
Hurley et al. (2018)	Australia	Researcher-developed brief mental health literacy workshop (1-hour), aimed at parents, delivered in youth sports clubs, by the research team	540 parents	No intervention control	1 month	Anxiety and depression literacy: After controlling for pre-intervention scores, the intervention group showed a large difference (cohen’s d > 5) on literacy scores compared to the control group. Knowledge of Help-seeking: After controlling for pre-intervention scores, the intervention group showed a large difference (cohen’s d = 3.7) on knowledge of help-seeking compared to control group. Stigma: There were no differences on stigmatising attitudes between the intervention and control group

Finally, the study aimed at parents (27) also reported a significant difference in depression and anxiety literacy scores and knowledge of help-seeking in the intervention group compared to the control group; however, there were no statistically significant changes in stigmatizing attitudes between the groups.

RQ1b: MHL programs in ongoing management or preventing relapse and differences across delivery modes/contexts.

Two of the studies (Table 2) reported effectiveness of MHL among students with pre-existing symptoms of depression. Ibrahim and colleagues (42) screened for students with high depression scores, who were also from low-income families. Administering a 1-day workshop around depression, the study found significant increases in depression literacy and mental help-seeking attitudes in the intervention compared to the control group, along with a reduction in self-stigma. Effect sizes were moderate across outcomes, showing d = 0.44 for depression literacy and self-stigma on help-seeking, and d = 0.3 on mental help-seeking attitude. King and colleagues (43) explored whether delivering psychoeducation to a nominated support person of suicidal young people who were hospitalised reduced suicidal ideation, attempts and depressive symptoms 6 months later, compared to a no-intervention control group. No significant main effect of intervention was demonstrated on key outcome measures.

RQ2: Personal factors that amplify the therapeutic benefits of MHL programs

Some of these studies reported associated factors that facilitate or enhance the potential MHL effectiveness. One study conducted in the US, was a depression and stigma literacy program delivered to 6679 high school students by teachers for four months, it found that teachers levels of literacy were correlated with students’ understanding of depression at post-

Table 2

*Studies investigating the effects of Mental Health Literacy among students with symptoms of depression.*
Authors (year)	Country	Details of MHL program	Sample size	Presence/ nature of control group	Duration between end of program and assessment	Findings on relevant outcomes
Ibrahim et al. (2020)	Malaysia	Researcher developed Depression Literacy Program (1 day program) aimed at adolescents (low-income families), delivered in schools by facilitators	101 students selected for high depression scores	No intervention control	3 months	Depression Literacy: After controlling for pre-intervention scores, the intervention group showed greater scores than the control group (Cohen’s d = 0.44) Mental help-seeking attitude: After controlling for pre-intervention scores, the intervention group showed greater scores than the control group (Cohen’s d = 0.30) Self-stigma on help-seeking: After controlling for pre-intervention scores, the intervention group showed decreased self-stigma than the control group (Cohen’s d = 0.44)
King et al. (2006)	US	Youth-Nominated Support Team, psychoeducation (2-hours), aimed at the support person of psychiatrically hospitalized adolescents, delivered in hospital through an intervention specialist	236 adolescents	No intervention control	6 months	Suicidal ideation, attempts and depressive symptoms: There were no significant changes on these outcome measures in the intervention relative to the control group.

intervention, the intervention group from 69.7–78.2% vs. control group from 68.2–71.3% (19).

In the study carried out by King and colleagues (26) of psychoeducation support to the social network of hospitalized young people, there was some suggestion that benefits were more apparent in girls than boys. Also, biological explanations of mental health symptoms presents additional benefits regarding depression literacy (d = 0.40) and stigma reduction (d = 0.79) (38).

Further, technology represents an option to delivery programmes. In one study that an e-learning course (6–8 hours, self-paced) (30) there was an improvement on mental health first-aid intentions (d = 0.98) and stigma reduction (d = 0.25). Nevertheless, in another study that used emails (32) there were no changes on depression literacy, help-seeking behaviours, or depressive symptoms.

RQ3: MHL in low-resource settings

Of the 17 studies included in our review, two of these countries are considered middle-income countries (Malaysia, México), with none from low-income countries. To address this gap, we consulted young people and stakeholders on whether they thought MHL programs were important for their countries or settings. Their views are captured in Textbox 1. These testimonies show that young people recognised the importance of early MHL programmes to prevent later negative outcomes. This view was shared by professionals who thought this should reflect a cross-sector approach that foster a change in new generations, that enable children to talk about mental health and avoid pointing it out as a flaw. In this line, consultors point out the new challenges might impact mental health, then having a knock-on effect on everything else the young person does.

We also sought their feedback on what barriers there were for delivering MHL programs. They recognised that mental health is a little talked topic, nevertheless, the younger group (14–18 years old) expressed to be more comfortable talking about MH, than the older group (19–24 years old). Many respondents talked about stigma as an obstacle to search and to acquire mental health treatment. For example, it might be facilitated by the media, for example, movies about dangerous people that have mental health issues, cultural stereotypes such as that men do not cry, o the association between mental health workers with negative situations or mental health workers in roles where they must scold children. Others talked about elevated costs of mental health services, mainly for children. Participants shared with us experiences where mental health professionals were associated with negative feelings including feeling vulnerable when approaching a mental health worker. Finally, they pointed out the lack of knowledge as a great barrier in approaching to a MHL programme (Textbox 2).

They also talked about how such programs could be facilitated in these settings, such as promote it in the daily life and in youth environments and liking it with real-life situations, as well as add MHL programmes at the curriculum of students and facilitate it with technology. Additionally, they highlighted the idea to normalize mental health care and help-seeking behaviours, and they oriented to get it by ensuring that all individual interventions must be in safe and confidential context (Textbox 3).

Textbox 1. Perceptions of how MHL is important in low-resource settings

“…mental Health Literacy (MHL) works by helping people better understand their mental health and encourages them to seek help and support by understanding mental health disorders and its treatment.” (21-year-old female, Nepal)

“It is important to improve MHL because later on, the young people will talk to us and ask us, although I find that in this generation more is known about that” (22 years old male, Colombia)

“In contemporary Nepalese context, mental illnesses are not acknowledged as illnesses of the body, as physical illnesses readily are. People view it as a personal weakness and a character flaw. It makes it very difficult for the sufferers to share their problems with others.” (23-year-old male, Nepal)

“These days the issue of bullying and passing negative comments is very common; the cases of suicide are increasing dramatically. So, to make ourselves strong and resilient, we need knowledge of mental health.” (17-year-old male, Nepal)

“MHL is important. Mental health care must start from prevention before they come to our consultation because, at this point, many people would leave without opportunity” (child and adolescent psychiatrist, Colombia)

“Mental Health Literacy programs need to be considered as the basic requirement to promote young people’s mental health. In a country like ours, with very low investment in the mental health sector, such programs can help to prevent as well as early detection of mental health problems” (Clinical Psychologist, Nepal)

“There is extreme lack of knowledge of mental health among people in Nepalese society, even educated people lack proper knowledge of it, such a program will definitely help promote the mental health of youths and society at large”. (Counsellor working with children and adolescents, Nepal.)

“I think it is important because young people often do not recognize what they feel and express their discomfort with us, but sometimes we do not have enough tools to face the situation” (Teacher, Colombia)

"I think it's really important that people staying on top of the kind of challenges that young people are dealing with and the way those might be impacting mental health because mental health challenges, then having a knock-on effect on everything else the young person does. It's essential that that support is there to make sure that any mental health problems that a young person experience". (Special Education Needs teacher I, UK).

“Caring for the mental health of the population begins with the education of young people. I believe that education should not be only from health professionals, but from homes, schools and supported by public policies” (Psychologist, Colombia)

"Unfortunately, our students and sometimes due to their learning needs or lack of supervision around access to things on the Internet. Some of the YouTube links are probably not appropriate and they may it may lead them to suicide forums online chat rooms, and they just don't have the technical knowledge or literacy levels to perhaps filter what they're hearing". "The danger is that that they will view themselves incorrectly because of the information they're receiving". (Special Education Needs teacher II, UK)

Textbox 2. Young people and stakeholder’s perceptions about barriers to delivering MHL programmes

“We fear being stigmatized when we try to share with others, and we sometimes sense that even our family members hold judgmental attitudes when we share about our mental problems. And this impedes the sharing of mental health-related issues.” (15-year-old female, Nepal)

"I think there is some stigmatization of mental health because it is associated with diseases seen in movies and dangerous people" (17 years old male, Colombia)

"Before it was more difficult to talk about feelings, there was more fear about it, and we were more attached to stereotypes, such as that men do not cry ... perhaps because of fear of being vulnerable" (22 years old male, Colombia)

“At school, they did not tell us much about mental health, there was a psychologist, but she appeared when they would scold us. However, they never told us how to take care of mental health. They only spoke to us about weight and other physical illnesses" (19 years old female, Colombia)

“Like I am from a Pakistani background and when I was growing up it was pretty much, it was very much stigmatised, but I don’t feel it is the case anymore. I mean I hope not” (20 year old female, East London, UK)

“Many patients cannot access mental health professionals because it is usually expensive, and due to the health system, they can wait for appointments for more than three months” (Child and adolescent psychiatrist, Colombia)

"I feel like being from a BAME background, I feel like because there was such a big stigma there was more like easier to go to a teacher but speaking from a person who was born and raised in London you would go to your parents first wouldn't you?". "I think this is why I was thinking about the class thing earlier when your parents are more educated on it they are more able to pick up on it as well, um because you can imagine a parent who has gone to university or had a higher level of education they would probably be able to recognise yeah my child is sad". (17-year old female, East London)

“Lack of proper knowledge and insufficient mental health facilities are the major barriers to promoting young people's mental health in Nepal” (Child and Adolescent Psychiatrist, Nepal)

“Most people do not attend the consultation because they are afraid of being singled out. They think it is only for crazy people” (psychologist, Colombia)

“People are not aware that mental health problems are curable. People are afraid and hesitant to share about their mental health problems”. (School Teacher, Nepal)

There are lots of superstitions and stigma related to mental health problems in our society, we need to address them first to enhance mental health of young people” (Counselor, Nepal)

“working with parents have actually found it quite hard, because you know you're relying on the parents to implement the skills and strategies at home, though, you know, things can get lost in like them their understanding, especially because I work in such a diverse bar where english is often second language for lots of these parents, so I think you know there's also like an issue about do they fully understand.” (Trainee, low-intensity practitioner UK)

Textbox 3. Participants' suggestions to implement MHL interventions

“MHL programs are best delivered at a very young age, in a face-to-face manner, by employing diverse means of engrossing stuff such as plays, videos, experience-sharing sessions by those who have overcome mental disorders, artistic expressions, etc… Also, in the current rapid growing technological age it can be delivered through different social media and school-based curriculum as well” (22-year-old male, Nepal).

“In public transport stations, there are advertising posters, there you could put up signs with help lines, strategies to take care of mental health, awareness campaigns, etc.” (Psychologist, Colombia)

"I think it's [important for young people to know more about mental health], I think when I was growing up I would have preferred it to be sort of throughout primary school time as well because I only got the information in secondary and I feel like a lot of problems were underlined all throughout then but I never knew that, all you know is that you're sad or lonely, you don't really know that there's something bigger than that and I think it's really early on yeah” (20 year old female, East London, UK).

“…it works more effectively when delivered face-to-face in a very simple form that is understandable by general population (educated and uneducated both). Also, when the knowledge is practically explained by linking it to our real-life situations, why and how it occurs.” (21-year-old female, Nepal).

“We can implement interventions promoted by young people in environments where young people tend to be and that the interventions have a more significant impact, also that help to normalize mental health care and the search for help, also that reduce stigma and involve family members of young people who want to participate” (Child and adolescent psychiatrist, Colombia)

“But we did have some people from CAMHS come and sort of that but to me that’s always the best way and also like even like leaflets/posters and that I know most people just throw them away but there are some people who keep them so.” (20-year old female, East London, UK)

“And again, similar to the support we provide for special education needs there's a bit of kind of a problem with siloed working where and you know this this organization or this department or this kind of local council provision is and dealing with this and teachers are dealing with this and there's not that kind of regular conversation or connection that you need in order to make sure you can refer young people quickly that you can make sure that they access the support they need and immediately, and I think teachers can sometimes feel a bit lost of where to go what to do so while you can provide kind of that emotional support in school.” (Research Associate at Non-governmental Organisation, UK)

“Interventions in MHL should be aimed at teaching us to recognize our feelings, manage emotions, how to maintain good mental health” (24 years old female, Colombia)

“MHL programs should be delivered at schools, information on mental health needs to be incorporated into the curriculum” (Counsellor, Nepal).

“MHL programs can be delivered at any place by any medium, but it must be well designed and authentic” (Psychiatrist, Nepal).

MHL programmes are an important method of facilitating treatment seeking or even self-management of anxiety and depression emerging in young people. We addressed three questions in our report that examined whether MHL programmes improved knowledge and understanding of anxiety and depression, and improved help-seeking behaviour or intentions, and reduced stigma. We also explored which delivery contexts showed more consistent benefits in relation to MHL programs compared to others. We were especially interested in MHL programs that increased literacy, help-seeking, self-management, and reduced stigma in lower-resource countries/settings. While accurate diagnosis and awareness about common mental health difficulties such as anxiety and depression are essential for facilitating early intervention in all countries, the delivery of MHL programmes may be even more critical in low-resource settings (11, 12). LMICs struggle with a lack of resources to manage the burden of severe and persistent mental illness, especially in young people (13–15). There are also limited educational opportunities and increased stigma regarding youth mental health problems (16, 17).

Our systematic review revealed 17 studies that delivered MHL programmes to ultimately improve anxiety and depression symptoms. We found few mental health literacy intervention studies specifically focused on anxiety and or depression among youths. Most of the articles screened were focused on improving mental health literacy rather than a specific disorder or symptoms. Given that there have already been quite a few reviews in this area, we decided to only include those that had a focus on youth emotional symptoms, given that these are especially hard-to-detect by others, and sometimes young people themselves. We also decided to limit studies to those that included an interval between the end of the programme and the assessment, to reduce any demand effects that may emerge if the post-intervention assessment is delivered too early. Most of these studies (15) targeted all young people (universal prevention) rather than help with the ongoing management or reduction in relapse in those who already had symptoms of anxiety and depression, where only two studies were found. The study found a paucity of specific intervention studies targeted at improving mental health literacy among youths with pre-existing anxiety and or depression.

The universal prevention studies generally showed that MHL programmes can improve a) literacy around depression and anxiety, including correct recognition of signs and symptoms and different treatment options; b) facilitate help-seeking behaviours, possibly by enhancing knowledge of options and shaping intentions; and c) reduce some aspects of stigma e.g., towards other people with mental health problems or even the self. However, there appeared to be different patterns of benefits across different delivery modes. MHL programs delivered by teachers appeared to be clearest at improving literacy of anxiety and depression, possibly because this is not dissimilar to other curriculum-based learning. In contrast, MHL programs delivered by experts (both academic, clinical and experts by experience) yielded clear and consistent effects on stigma. Although there was only one peer-to-peer MHL program, this seemed promising. These kinds of interventions by peers may foster a comfortable feeling in young people, and help improve college students' attitudes, perceived knowledge, and helping behaviours (44, 45). In contrast, Internet-based health resources were somewhat less consistent in their results, possibly because it is harder to ensure compliance as well as engagement. One intervention targeting parents also showed potential in improving literacy and being able to seek help for their child; effects on stigma were less apparent. Finally, only one of the two interventions helping young people to manage pre-existing symptoms or to avoid further episodes of distress showed mixed findings – with the study targeting young people directly showing the more beneficial effects.

There were few studies directly measuring moderators of the impact of MHL programs. Those studies found that teachers´ literacy is correlated with students’ understanding of depression (19), that some interventions could had a higher impact in girls than boys (43), and that participants' emotional well-being scores improved their MHL (39). These are factors that could be useful for enhance MHL reception, and to plan programmes considering the integration between these findings and the view expressed in our consultations.

Consultations with young people with lived experiences of anxiety and depression, and relevant stakeholders (teachers, mental health practitioners) recognised the importance of MHL programs. They recognised that mental health is a topic that is infrequently discussed, but younger people said that they feel more comfortable talking about this topic compared to some of the older generation. Yet, they also recognised barriers that included stigmatization, fear of being vulnerable, hesitation to talk about one’s feelings, lack of knowledge and awareness, lack of conducive environment to share one’s feelings and school authorities’ indifference towards mental health issues. Similarly, they recognised difficulties in accessing opportune care by the health system to manage mental health related topics. They oriented to normalise seeking help and talking about mental health and decrease stigma considering that all individual interventions must be a safe and confidential space. These consultations also showed ways to overcome these obstacles, including delivering MHL programs at an early age, incorporating MHL into school curricula, delivering MHL programs using alternative mediums, e.g., social media platforms. Participants also emphasized that such programs needed to be accessible, comprehensible for all and could be made more authentic by implementing through young people. Theses opinions could enhance the applicability and acceptance of MHL programmes and give us insights about the needs and required adaptations to implement these programmes in LMICs, considering that most of the found studies were developed in high income countries.

Limitations

As we decided to focus only on mental health literacy around anxiety and depression symptoms and associated help-seeking and stigma – and only studies that involved an interval between the program and the post-intervention assessment – fewer studies were included in the review. In part, this may be because the term ‘mental health literacy’ is not always used to describe programs that are essentially doing this. For example, some may refer to such programs under education or general well-being interventions. However, broadening the search to include such general terms would not be practical for identifying relevant studies. Thus, we may have under-estimated the number of relevant studies. Second, a smaller number of studies also meant it was difficult to draw firm conclusions across the heterogeneous characteristics of studies, in terms of outcomes assessed, types of measures used to assess outcomes, interval between the end of the program and the post-intervention assessment, the use of control conditions, the age group of the sample and the specific program and protocol used. Thus, it was difficult to draw firm conclusions on overall effectiveness across the different outcomes and even harder to compare different delivery modes e.g., those delivered by teachers or mental health experts to young people. For this reason, we neither could do a meta-analysis. There were far fewer studies assessing programs that targeted young people but were delivered by peers, or those that specifically targeted parents of young people – and those that were used to help young people with anxiety/depression (or suicidal ideation/behaviour) to manage their symptoms. Perhaps the latter represents an area for future research, to improve relapse rates. Indeed, youth is a period to deliver such interventions before negative cognitive and behavioural patterns become entrenched. Finally, we were unable to capture the perspectives of policymakers to reflect governmental priorities relating to the delivery of mental health literacy programs in low-resource settings.

Delivering MHL has many advantages. First, improving MHL may be a pre-requisite to understanding why and when individual resources e.g., emotion regulation, coping, are needed and how they work. This is especially important in sociocultural contexts, where there are limited educational opportunities and increased stigma regarding youth mental health. Second, programs to improve MHL can be delivered by non-specialist practitioners in community settings (e.g., schools, non-governmental organisations), making it a cheaper approach to preventing/managing youth anxiety and depression than those requiring one-to-one therapist time, especially in lower-resource settings. Based on our review, we suggest that implementing new MHL programmes is important in youth, considering this is a period of heightened learning and flexibility (46).

This is important to clinicians because improved MHL could bridge the gap in mental health care, so they should be open to answering questions and playing an active role in teaching good mental health practices. More interventions should be tested in LMICs context, considering that most of the articles were made in high-income countries, and the sociocultural context could modify MHL interventions´ effectiveness. If found to be effective, policy makers in low-resource countries and settings should facilitate and support the implementation of these programmes due their cost-effectiveness, and possible savings in disease burden, considering that it could be implemented in school and social settings.

LMICs: Low to middle income countries; MHL: Mental Health Literacy; RQ: Research question; UK: United Kingdom; US: United States.

Ethics approval and consent to participate

This was a systematic review paired with lived experience consultations with young people. Therefore, ethical approval for the study was not needed, as we followed the NIHR guidance stating that it is not necessary ethics to conduct an involvement activity like this, where we involved the community and stakeholders in responding research question of public health interest. We declare that all methods were carried out in accordance with relevant guidelines and regulations. This consultation was approved by the Pontificia Universidad Javeriana´s Vicerrectoría de Extension y Relaciones Interinstitucionales.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used or analysed during the current study will be available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests related to the research studies outlined in this research paper.

Funding

This work was carried out under the auspices of the Wellcome Trust’s Mental Health programme. This work responds to the request for proposals for an insight analysis into one “Active Ingredient” underpinning interventions for youth depression and/or anxiety.

Acknowledgements

We thank Wellcome Trust’s Mental Health programme for the support and interest in enhance mental health in the young population. Also, we thank all participants that share with us their opinions and experiences shown in this manuscript.

Authors contribution

FBR, SD, JL led the study and made the consultations in Colombia, Nepal and UK respectively, also developed the manuscript. FBR, SD, JL, VB designed and carried out the search strategy, as well as developed the conception and design of the study, manuscript revision, interpretation of data. AB, RP, AK, AP, DT, NK screened obtained articles. FBR, SD resolved discrepancies. All authors read and accept the manuscript.

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No competing interests reported.

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Mental Health Literacy programmes prevent and support ongoing management of youth anxiety and depression: consultation and literature review

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Abstract

Background

Methods

Results

Conclusion

Figures

Background

Methods

a) Literature review

Inclusion criteria for studies

Search for and identification of studies

Data extraction and synthesis

b) Consultations with young people and stakeholders

Results

RQ1a: MHL programs as universal prevention and differences across delivery modes

RQ2: Personal factors that amplify the therapeutic benefits of MHL programs

RQ3: MHL in low-resource settings

Discussion

Limitations

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1