Mental health literacy: a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment

Abstract

MJA 1997; 166: 182-186  

Introduction

The lifetime risk of developing a mental disorder is so high (nearly 50%)² that almost the whole population will at some time have direct experience of such a disorder, either in themselves or in someone close. A high public level of mental health literacy would make early recognition of and appropriate intervention in these disorders more likely.

Previous information on this topic is limited and is derived from national surveys on depression alone,^3-5 or on depression and schizophrenia.⁶ Although these surveys found that most people believed depression to be treatable,^3-5 most respondents had negative views about the effectiveness of medication for mental disorders. In contrast, counselling and psychotherapy were generally viewed more favourably.^3,4,6

To assess the mental health literacy of the Australian population, we surveyed a representative national sample of adults on their knowledge of and beliefs about schizophrenia and depression. We report our findings on the ability of this population to recognise these disorders and their beliefs about the effectiveness of various treatments.  

Methods

Sample

Fifty-six per cent of the sample was female and 74% Australian-born. The age distribution was: 21% aged 18-29, 25% aged 30-39, 22% aged 40-49, 16% aged 50-59, 11% aged 60-69 and 5% aged 70-74. The highest educational qualification was: secondary school certificate (51%), trade certificate/apprenticeship (11%), other certificate (17%), associate or undergraduate diploma (7%), bachelor's degree or higher (13%), still at school (1%). Weights were provided for each respondent, based on complex ratio estimation procedures, to adjust for probabilities of selection and to reduce non-response bias.⁷ Weighted percentages, which represent estimates of the whole of the Australian population aged 18-74, are presented here.  

Interview

After being shown the vignette and having it read out to them, respondents were asked two open-ended questions:

• "What would you say, if anything, is wrong with John/Mary?" and

• "How do you think John/Mary could best be helped?"

• Various people who could help (whether each category of person was likely to be helpful, harmful, or neither, for the person described);

• A range of possible treatments (whether each treatment was likely to be helpful, harmful, or neither, for the person described);

• Knowledge of likely prognosis;

• Knowledge of risk factors; and

• Beliefs associated with stigma and discrimination.

Ethical approval

Statistical analysis
Using the chi-squared test, all estimates were compared according to recognition of a mental health problem. Only differences significant at the 0.01 level (P < 0.01) are reported below.  

Results

Recognition

For the depression vignette, 39% correctly identified depression and 22% mentioned stress. In all, 72% mentioned a category that could be regarded as being within the sphere of mental health. Eleven per cent mentioned items that we categorised as physical disorders (e.g., viruses, nutritional deficiencies, cancer), and half of these respondents did not mention a mental problem. A further 17% gave only answers that were extremely variable, but which we grouped as "personal or employment-related problems", "problems with not being active or sociable enough", and "other". Seven per cent of the sample responded with "don't know".

For the schizophrenia vignette, although 84% mentioned at least one category in the sphere of mental health, only 27% recognised schizophrenia and a further 26% mentioned depression. Physical disorders were the only suggestion from 2% of the respondents, while 13% gave responses that described neither physical nor mental disorders (e.g., "has a problem"). There was less uncertainty with the schizophrenia vignette, however, in that only 4% responded with "don't know".  

Choice and rating of available help

For the depression vignette, the most frequent response was "see a doctor" (44%), followed by "see a counsellor" (23%) and "talk over with family or friends" (20%). A psychiatrist was mentioned by 8%, while 5% answered "don't know".

Responses for the schizophrenia vignette were: counsellor (31%), psychiatrist (28%), doctor (27%), family or friends (20%) and "don't know" (4%).

The respondents were given a list of people who might potentially provide help and were asked to rate the various helpers by saying whether each would be helpful or harmful (Figure 2a).

For the depression vignette, most of the respondents regarded GPs (83%), counsellors (74%), close friends (73%) and close family (70%) as helpful; around half the population rated telephone counselling services (53%), psychiatrists (51%) and psychologists (49%) as helpful. Fewer than 10% felt that any of the above groups would be harmful, although 43% believed it would be harmful for someone with depression to deal with it on their own. For the schizo phrenia vignette, most respondents regarded counsellors (81%), GPs (74%) and psychiatrists (71%) as helpful; a larger proportion of the population than for the depression vignette believed it would be harmful to try and deal with such problems alone (55%).

Rating of pharmacological treatments
Respondents were given a list of pharmacological treatments (Figure 2b) to rate as helpful or harmful. For the depression vignette, more of the respondents regarded each of the medications as harmful than helpful. The exception was the category vitamins, minerals, tonics or herbal medicines, which were regarded as helpful by 57% of respondents, and as harmful by 3%. Antidepressant medication was recognised as helpful by 29% and as harmful by 42% of respondents. For the schizophrenia vignette, antidepressants were regarded as helpful by 38% of respondents, followed by vitamins and minerals (34%) and antipsychotics (23%). The greatest percentage of "don't know" responses was for antipsychotics (about one-fifth of the respondents for both vignettes).

Rating of non-pharmacological treatments
When respondents were asked to rate non-pharmacological treatments (Figure 2c), most (for both the depression and the schizophrenia vignettes) regarded non-standard interventions (more physical or social activity; learn relaxation [including stress management, meditation or yoga courses]; reading about people with similar problems) as helpful and not harmful. On the other hand, most regarded admission to a psychiatric ward as harmful (depression, 62%; schizophrenia, 51%) and most regarded having electroconvulsive therapy (ECT) as harmful (depression, 72%; schizophrenia, 66%). For the depression vignette, psychotherapy was seen as helpful by 34% and harmful by 13%, compared with 55% helpful and 7% harmful for the schizophrenia vignette. The highest number of "don't know" responses was elicited for psychotherapy (16% for depression, 15% for schizophrenia) and for ECT (10% for depression and 14% for schizophrenia) (data not shown).

As opinions about treatment might vary according to whether or not the respondent thought the person in the vignette had a mental health problem, the respondents were divided accordingly. The major difference in findings was that those who did not perceive a mental health problem were more likely to rate treatments as "neither helpful nor harmful" or to respond "don't know" . However, the rank ordering of treatments in terms of helpfulness was generally similar. Spearman rank correlation coefficients for the depression vignette were 0.82 (people), 0.90 (medicines) and 0.98 (treatments), and for the schizophrenia vignette they were 0.87 (people), 0.71 (medicines) and 0.98 (treatments).  

Prognosis

Discussion

When respondents were asked about the helpfulness of various people, GPs were rated very highly for both vignettes. Only half the respondents thought that a psychiatrist or psychologist would be helpful for the person in the depression vignette, a proportion less than that cited for GPs, counsellors, close friends, family, and telephone counselling. While psychiatrists and psychologists were rated as relatively more helpful for the person in the schizophrenia vignette, they were nevertheless less likely to be rated as helpful than counsellors or GPs. This suggests that public perceptions of mental health specialists need to be changed.

Ratings given for the helpfulness of various treatments for depression are not consistent with the evidence of controlled trials, which have indicated that both antidepressant medication and psychotherapy are effective treatments. ^10,11 Antidepressants were rated as helpful by 29% of our sample and as harmful by 42%, while psychotherapy was rated as helpful by 34% and harmful by 13%. Both were regarded as less helpful than treatments such as vitamins and minerals and special diets. The treatment with the highest negative rating was ECT. Although the patient described to the respondents could not be regarded as severely depressed enough to warrant ECT, ¹¹ there is clearly a public perception that this treatment is harmful. The treatments that the public rated most highly were all non-standard in nature. These views may not be entirely misguided; there is evidence (e.g., from controlled trials) that physical exercise may have a positive effect on depression. ¹²

The findings were similar for the schizophrenia vignette. Although controlled trials show that antipsychotic medication is an effective treatment, ¹³ this was rated as helpful by 23% of the respondents and harmful by 34%; 20% did not offer an opinion. Similarly, admission to a psychiatric ward, which can be useful in the management of schizophrenia, ¹³ was rated as harmful by half the respondents. As with depression, non-standard interventions were the most likely to be rated as helpful.

Despite these negative opinions of, or ignorance about, the helpfulness of many standard treatments, the public clearly sees the conditions described in the vignettes as treatable. The predominant belief that mental disorders are treatable has also been found in overseas surveys, ^3,4 although a United States survey found that most respondents believed it possible to get better through one's own efforts. ⁵

There were some marked differences in responses to the depression and schizophrenia vignettes in terms of recognition, perceived helpfulness of treatments and prognosis. These differences show that the respondents did not see all mental disorders as the same and recognised that the condition described in the schizophrenia vignette required more vigorous intervention.

Our results also indicate that the views of many members of the public diverge from those of health professionals, particularly mental health specialists. Such differences may lead to unwillingness to accept help from mental health professionals, or to a lack of adherence to advice given. Clearly, if mental disorders are to be recognised early and appropriate action taken, the level of mental health literacy in the population should be raised. There has been considerable interest in trying to improve the recognition and management of mental disorders in primary care, ^10,14 but this knowledge needs to reach the consumers of services so that they can play a more effective role in the management of their own mental health.  

References

1. Nutbeam D, Wise M, Bauman A, et al. Goals and targets for Australia's health in the year 2000 and beyond. Canberra: Australian Government Publishing Service, 1993.
2. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51: 8-19.
3. McKeon P, Carrick S. Public attitudes to depression: a national survey. Ir J Psychol Med 1991; 8: 116-21.
4. Sims A. The scar that is more than skin deep: the stigma of depression. Br J Gen Pract 1993; 43: 30-31.
5. Regier DA, Hirschfeld RM, Goodwin FK, et al. The NIMH depression awareness, recognition, and treatment program: structure, aims, and scientific basis. Am J Psychiatry 1988; 145: 1351-1357.
6. Angermeyer MC, Matschinger H. Public attitude towards psychiatric treatment. Acta Psychiatr Scand 1996; 94: 326-336.
7. Australian Bureau of Statistics. Population survey monitor, August 1995 (No. 4103.0). Adelaide: ABS, 1995.
8. World Health Organization. The ICD-10 classification of mental and behavioural disorders. Diagnostic criteria for research. Geneva: WHO, 1993.
9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed) (DSM-IV). Washington DC: APA, 1994.
10. Depression Guideline Panel. Depression in primary care: Volume 2. Treatment of major depression. Clinical practice guideline, number 5. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1993.
11. The Quality Assurance Project. A treatment outline for depressive disorders. Aust N Z J Psychiatry 1983; 17: 129-146.
12. Byrne A, Byrne DG. The effect of exercise on depression, anxiety and other mood states: a review. J Psychosom Res 1993; 37: 565-574.
13. The Quality Assurance Project. A treatment outline for the management of schizophrenia. Aust N Z J Psychiatry 1984; 18: 19-38.
14. Ustun TB, Goldberg DP, Cooper JE, et al. A new classification for mental disorders with management guidelines for use in primary care: The ICD-10 PHC. Br J Gen Pract 1995; 45: 211-215.