Changes in mental health literacy about depression: South Australia, 1998 to 2004

Depression remains a major public health concern,1-3 and several studies have found shortcomings in its detection and management.4-7 One of the impediments to better recognition and treatment of depression has been identified as mental health literacy (defined as “knowledge and beliefs about mental disorders which aid their recognition, management or prevention”).8-10 It has been assumed that educational programs to enhance mental health literacy would improve health and social outcomes and reduce the overall health burden.

In the past few years, determined efforts have been made at government, professional, charitable and industry levels to enhance public knowledge about the ubiquity of mental disorders, particularly depression, and the effectiveness and availability of treatments. These have included the Better Outcomes in Mental Health Care program,11 which is part of the National Mental Health Strategy;12 the establishment of beyondblue: the national depression initiative,13 a predominantly federally funded body with contributions from a number of states; continuing education programs of the Royal Australian College of General Practitioners (http://www.racgp.org.au/) and the Royal Australian and New Zealand College of Psychiatrists (http://www.ranzcp.org/); publicity from the Mental Health Foundation of Australia (http://www.mhfa.org.au/main.htm); and marketing via general practice and specialist educational programs sponsored by pharmaceutical companies (http://www.spheregp.com.au/).

Issues addressed have included not only publicising the symptoms of depression, but also providing information about appropriate management of depression and reducing the stigma associated with seeking help.

We wanted to know whether there has been a change in mental health literacy in relation to depression and its management in the community. We report the findings of a mental health literacy survey in a random and representative sample of the South Australian community, using the same method as a 1998 survey,3,9 from which baseline values were obtained.

Data were collected in 2004 in a Health Omnibus Survey of both metropolitan and rural South Australians of at least 15 years of age.3 The Health Omnibus Survey is a user-pays survey for health organisations. The survey method, which is described in detail in Goldney et al,3 involves face-to-face interviews by experienced interviewers of one member of each of the randomly chosen households. The only difference in the 2004 survey, compared with that in 1998, was that more recent census data were used (2001 Census) to obtain the metropolitan and rural samples.14 Data were weighted according to benchmarks derived from the 2001 Census and 2002 estimated resident population15 to provide estimates representative of the South Australian population in terms of age, sex and region (metropolitan, non-metropolitan).

Mental health literacy was assessed using the questionnaire devised by Jorm et al8 which includes a vignette depicting either a woman (Mary) or man (John) with classic features of depression (Box 1). The methodology was identical to that used in the 1998 survey.9

Respondents were asked what they thought was wrong with the person described in the vignette and about any personal contact they may have had with persons with similar symptoms to those described in the vignette. They were also asked whether or not they themselves had experienced such symptoms or had sought and/or taken antidepressant medication for them. Open-ended questions (ie, more than one option could be selected) covered perception of the problem described in the vignette and what was the best form of help for a person with these problems. In forced-response questions, respondents were asked whether various professional or other interventions, as well as pharmacological interventions, would be helpful, neither helpful nor harmful, or harmful.

Ethical approval for the survey was provided by the Health Omnibus Steering Committee of the South Australian Health Commission.

Statistical analyses were undertaken using SPSS version 12.0.1 (SPSS Inc, Chicago, Ill, USA). For each mental health literacy variable, differences between the 2004 and 1998 weighted samples were examined using Pearson’s χ2 test.

Respondents’ experience of symptoms similar to those in the vignette is presented in Box 2. There was significantly greater identification with the person described in the vignette in 2004 compared with 1998, together with increased use of anti-depressants and treatment seeking.

Respondents’ perceptions of the problem experienced by the person in the vignette, and how that person could best be helped, are presented in Box 3 and Box 4. Significantly more respondents in the 2004 survey identified Mary (John) as having depression, and significantly fewer considered she (he) had suffered either psychological problems, a nervous breakdown, a work-related problem, stress, or a physical illness. There was also a significant reduction in the proportion of respondents who said they did not know what was wrong with the person described.

With regard to the choice of available help (Box 4), in 2004, there were significantly more respondents who recommended Mary (John) “see a doctor (GP)”, “have counselling” or “talk over problems with friends or family”, but there was no significant difference in recommendations about seeing a psychiatrist or psychologist, or taking medication. However, significantly fewer recommended “diversional activities”, or said they didn’t know what help should be sought by the person described in the vignette.

Results of whether or not specific professional or other interventions as well as various pharmacological treatments were perceived as helpful or harmful are presented in Box 5 and Box 6. Compared with the 1998 survey, respondents in 2004 were more likely to consider a doctor (GP), chemist (pharmacist), counsellor or social worker, telephone counselling, psychiatrist, psychologist, naturopath or clergy as helpful (Box 5). There were also significant reductions in the proportion of respondents who viewed the chemist (pharmacist), counsellor or social worker, telephone counsellor, psychiatrist or psychologist as harmful.

Regarding pharmacological treatments (Box 6), significantly more of the 2004 sample considered antidepressants, sleeping pills and tranquillisers as helpful, and significantly fewer considered these as harmful compared with the 1998 survey. Furthermore, in 2004, vitamins and minerals were less likely to be considered helpful and pain relievers less likely to be considered harmful.

While our findings of an increase in mental health literacy could simply be a reflection of changing community attitudes over time, it is unlikely that such changes could have occurred without the influence of the various initiatives to enhance public knowledge about mental disorders that we listed in the Introduction. However, we are unable to pinpoint which initiative has been primarily responsible, as was also the case with a survey of changes in public attitudes to depression in Great Britain after the “Defeat Depression Campaign” of the Royal College of Psychiatrists.16 However, Jorm et al17 recently reported greater changes in mental health literacy in those Australian states (which included South Australia) that had contributed funding to beyondblue: the national depression initiative. Mental health literacy also increased in the other states.17 Clearly, the increase in mental health literacy we found cannot be attributed to any one factor.

These mental health literacy improvements do not necessarily equate with better treatment outcomes for those suffering depression. However, there may be some association between these results and the findings of Hall et al — an increased use of antidepressants and fewer suicides in Australia.18 Other possible associations would be better compliance with treatment and increased use of web sites with information about depression, but such analyses were beyond the scope of our study.

The limitations of our study are firstly the response rate (65.9%), which although acceptable for surveys of this nature, and not significantly different from that of the 1998 survey (70.2%), meant that those with poor mental health literacy may have been excluded, thereby contributing to our findings. Secondly, our findings may not be generalisable to the broader Australian population, although we believe there is no reason to consider otherwise.

Notwithstanding these limitations, it is reassuring that the mental health literacy of a random and representative sample of South Australians in 2004 was significantly better than that of a 1998 sample. Whether this necessarily translates into better treatment outcomes and lower depression morbidity in the community is a matter for further research.