Mental health literacy levels

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Mental health literacy levels ⁎

Jing Ling Taya, , Yi Fen Tayb, Piyanee Klainin-Yobasc a

Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, Singapore 539747, Singapore National University of Singapore, 21 Lower Kent Ridge Rd, Singapore 119077, Singapore Alice Lee Centre for Nursing Studies, Yoo Loo Lin School of Medicine, National University of Singapore Level 2, Clinical Research Centre, Block MD11 10Medical Drive, Singapore 117597, Singapore b c

A R T I C LE I N FO

A B S T R A C T

Keywords: Mental health literacy levels Education

Globally, mental disorders affect 25% of the society. This discursive paper aims to illustrate the mental health literacy levels in the public. Mental health literacy (MHL) is the understanding of mental health conditions, which helps in their prevention, recognition and treatment. Unfortunately, the public has minimal understanding of mental disorders, leading to poor recognition and delay in treatment. There is a need to conduct good quality research to assess the MHL levels among public and tailor interventions to enhance MHL among the public. This will ensure early detection of mental disorders, leading to early recovery and greater quality of life among the society. Nurses have a great role to play in leading these public educations, and enhancing a healthy and happy nation.

Introduction Worldwide, mental disorders affect 25% of the population (World Health Organisation, 2001). Anxiety disorders and depression are the leading contributing causes of disability globally. About 450 million experiences from mental disorders worldwide, establishing mental disorders as a pandemic reason for disability, morbidity, and mortality, due to suicide. The typical public's poor understanding of mental disorder delayed its recovery process. Due to the overall poor mental health literacy of the public, mental disorder is poorly recognised and its treatment often delayed, shredding years of good quality of life off those experiencing mental health disorder. Yet these can be halted and even reversed with elevated mental health literacy (MHL) levels within the society. Globally, much resource was devoted to health literacy. This includes educating the public about specific diseases, early screening, detection and management of those diseases. Some conditions that were ceaselessly targeted were heart diseases, stroke, and cancer. Mental health conditions, on the other hand, are neglected. Mental health literacy (MHL) was introduced in 1997 in the literature. Since then, research revolving MHL had been actively conducted in Australia (Jorm et al., 2006). MHL is the ‘knowledge and beliefs about mental disorders, which aid their recognition, management or prevention’ (Jorm et al., 1997, p. 182). It is having the knowledge of the preventive measures, symptoms, treatment modality and treatment locations of mental disorders (Jorm, 2012). It also

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includes being knowledgeable about the strategies to support self or others experiencing from mental health conditions. Among those experiencing from a mental condition, MHL includes knowing how to manage the illness. Among care-givers, MHL includes having the knowledge of effective support rendered to the family who mentalhealth condition (Reavley & Jorm, 2013). Importance of MHL Adversities, including deaths, have occurred due to the lack of mental health literacy in the community. About 450 million experiences from mental disorders worldwide, establishing mental disorders as a pandemic reason for disability, morbidity, and mortality, due to suicide. So much more lives could be saved if the community simply had a better knowledge of mental health conditions and could identify such conditions and seek appropriate and timely treatment. Moreover, the typical public's poor understanding of mental disorder delayed its recovery process. Due to the overall poor mental health literacy of the public, mental disorders are poorly recognised and their treatment often delayed, shredding years of good quality of life off those experiencing mental health disorder. Yet these can be halted and even reversed with elevated mental health literacy (MHL) levels within the society. Elevated MHL can enhance the mental health, happiness and wellness worldwide. Hence, it is important to examine the MHL levels among the public. Being able to identify mental health conditions is merely the tip of

Corresponding author. E-mail addresses: [email protected] (J.L. Tay), [email protected] (Y.F. Tay), [email protected] (P. Klainin-Yobas).

https://doi.org/10.1016/j.apnu.2018.04.007 Received 23 November 2017; Received in revised form 16 March 2018; Accepted 18 April 2018 0883-9417/ © 2018 Published by Elsevier Inc.

Please cite this article as: Tay, J.L., Archives of Psychiatric Nursing (2018), https://doi.org/10.1016/j.apnu.2018.04.007

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(37.3%–48.8%), and lastly, social phobia (10.5%–30.2%) (Furnham, Annis, & Cleridou, 2014). Among 202 Australian adolescents, 33.8%–67.5% could identify depression in a vignette (Burns & Rapee, 2006). In a more recent population-based survey, MHL was lower; only 23.4% of 1678 Australian adolescences were able to identify depression (Lam, 2014). In Australia again, a longitudinal national survey of 6019 sample conducted over 16 years in 3 time period: 1995, 2003/4 and 2011 demonstrated that public is able to recognise depression better (Reavley & Jorm, 2012). In 1995, among 2164 sample, only 39% and 27%, could precisely identify depression and schizophrenia respectively. The mislabelling of mental disorders as ‘stress’ or ‘life problem’ hindered professional help-seeking. By 2011, 75% could correctly identify depression, about 30% could identify schizophrenia and post-traumatic stress disorder but only 9.2% recognised social phobia (Reavley & Jorm, 2011). Therefore, over the 16 years in Australia, there was a reduction of depression being mislabelled as stress, nervous breakdown or psychological problems. This enhancement in depression recognition rates has been attributed to campaigns such as ‘beyondblue’. Hence, public campaigns were illustrated to raise overall public's MHL levels. When comparing Australia (3998 participants) and Japan (2000 participants), Japanese were reluctant to utilise psychiatric diagnosis. In the depression vignette, only 22.6% of Japanese, as compared with 65.3% of Australians, use depression to label the vignette case (Jorm et al., 2005). Among 440 samples from British, Malaysia and Hong Kong, the British were best at labelling correct psychiatric diagnosis to vignettes of obsessive compulsive disorder, depression, schizophrenia, ADHD, child depression and bipolar disorder, followed by Hong Kongers, and lastly, Malaysians (Loo, Wong, & Furnham, 2012). Among 1207 Australian young adults, appropriate recognition of mental disorders was associated with correct help-seeking behaviours and less associated with adverse strategies such as using drugs, or handling the symptoms alone (Wright, Jorm, Harris, & McGorry, 2007). Hence, being able to recognise symptoms as mental health problems are crucial for early treatment. Generally, psychiatric diagnosis baffles the public. Inability to recognise mental health problems in oneself or others hinder early detection and help-seeking behaviours. Although ability to recognise mental disorders had improved over the decades, and the public got better at recognising depression, they remained clueless about other mental health problems, such as schizophrenia.

the iceberg. Knowing the causes and treatment for these mental health conditions is extremely crucial too. Without this knowledge, treatment continues to be delayed and deprived for those who really need it. Many patients, whose family were ignorant about their mental health conditions, deprived them from seeking treatment and instead sought help from religious leaders. These families attributed the cause of such strange manifestations of mental health conditions to spiritual possessions (Kayrouz et al., 2015; Tay, Chan, Ho, & Lal, 2017). This delayed help-seeking behaviour, in turn, obstructs prompt healing. Many of the remaining patients never get to receive treatment. They are often brought to the mental health institution forcefully by police, court or transferred from other hospitals. (Al-Khafaji, Loy, & Kelly, 2014). With every delay in treatment, patient takes a longer time to recover (Golay et al., 2016). In summary, low mental health literacy rates caused under-reported and undiagnosed mental health conditions. These trigger a slippery slope of untreated disorders, unemployment, morbidity, mortality, increased stressed faced by caregivers and the disastrous loss of precious lives to suicide and homicide. There is an immediate urgency to understand the MHL levels among the public. Hence, the aim of this opinion paper is to explore the mental health literacy levels in the public. Mental health literacy levels (i) Recognising mental health problems Mental health conditions are often untreated for many years, leading to increased relapses, suicidal attempts, reduced remission rates and worsening overall outcomes. The length of untreated mental health problems was, 8.2 years, and 14.5 years, for (anxiety and depression), and bipolar disorder, respectively (Drancourt et al., 2013). Among the 273 Australian patients with anxiety and mood disorder, nearly 7 years were required to identify a problem, and another 1.3 years lapsed between recognition and help-seeking behaviours (Thompson, Issakidis, & Hunt, 2008). A cross-sectional stratified cluster sample of 4938 Portuguese youth aged 14–24 years old, revealed that only 27.2% and 5.5% could identify depression and mental disorder respectively, in a vignette (Loureiro et al., 2013). The depression vignette was more commonly regarded as stress, having a nervous breakdown or age crisis. Surprising, the recognition of Schizophrenia was better (42.4%), although identification of psychosis was only 22.2% (Loureiro et al., 2015). In Germany, a longitudinal study conducted in 1993 and 2001, of 2094 and 5025 samples respectively, concluded that public could recognise mental disorders better over the years (Angermeyer, Holzinger, & Matschinger, 2009). 17.1% and 26.9% could identify schizophrenia and depression, respectively. In 1993, and this increased to 22.4% and 37.5%. However, these statistics are still low. In Sweden, 66% of the 3538 participants failed to identify depression. (Dahlberg, Waern, & Runeson, 2008). Among 317 British, more were able to identify OCD (64.67%), but few could identify panic disorder, separation anxiety disorder and generalised anxiety disorder (1.26%–5.99%) (Furnham & Lousley, 2013). Americans were more likely to correctly identify mental health problems. Amidst 1104 American high school students, 40% recognised depression, but only 1% could identify social phobia (Coles et al., 2016). Among 1393 American adults, 58.5% and 41.9% could correctly identify depression and ADHD (attention deficit hyperactivity disorder) (Pescosolido et al., 2008). Canadians also had higher rates recognising mental disorders. Among 3047 Canadian, 75.6% could correctly identify depression in a vignette (Wang et al., 2007). Amidst 370 British young adults, addiction (65.1%–87.4%) was best identified, followed by bulimia (45.5%–77.2%), OCD (41.9%–70.7%), anorexia (55.8%–81.3%), ADHD (42.4%–70.6%), depression (33.3%–74.4%), bipolar disorder (14.2%–46.2%), schizophrenia

(i) Positive attitude that promotes recognition and help-seeking Stigma is a great hindrance affiliated with mental health problems. Stigma is the process of labelling and stereotyping, leading to disastrous consequences of status loss and severe isolation (Link & Phelan, 2001). A typical conception is that mentally-ill patients are peculiar, unpredictable and dangerous (Martin, Pescosolido, Olafsdottir, & McLeod, 2007). These adverse attitudes result in self- stigma where those experiencing psychiatric symptoms internalise these negative attitudes. It induces depression, feelings of shame, low self-esteem, causing poor medication compliance, leading to higher relapse, unemployment and homelessness, diminishing overall recover and quality of life (Chronister, Chou, & Liao, 2013). Such effects of stigma also deter those, who experienced the prodromal stages of mental disorders, from seeking treatment. Delayed treatment aggravates the illness, causing irreparable damage, making the illness harder to treat. Such experiences were often hidden in their own houses by family members who were petrified of being known about the association with them. Many are unemployed, and sometimes, homeless. Therefore, positive public attitude that enhances recognition and help-seeking is crucial. In America, 248 depressed geriatric participants had high levels of perceived stigma, and hence not willing to seek professional treatment 2

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problems, nervous breakdown or as a ‘work-related problem’ (Goldney, Dunn, Grande, Crabb, & Taylor, 2009, p 478). In Germany, the causes of schizophrenia was attributed to, chronologically, interpersonal issues (from family/friends), brain disease, work stress and lastly, genetics (Angermeyer et al., 2009). Depression was regarded as due to, chronologically, interpersonal issues, work stress, genetics and lastly, brain disease. In America, 67% attributed mental disorders to neurobiological factors, and hence acknowledged professional help more (Pescosolido et al., 2010). Various beliefs about causative factors of mental health problems would also modify treatment-seeking behaviours and treatment success. For instance, beliefs of interpersonal relationships causes and existential causes lead to greater outcomes in behavioural and cognitive therapy, respectively (Addis & Jacobson, 1996).

and this is even more apparent in African American elderly (Conner et al., 2010). Conversely, among 5555 university students in America, perceived stigma had no association with help-seeking behaviours, unlike personal stigma. Personal stigma was higher among younger, male, international, poorer, more religious or Asian students. Moreover, perceived stigma was much higher than personal stigma (Eisenberg, Downs, Golberstein, & Zivin, 2009). Similarly, a systematic review ascertained that perceived stigma is negatively correlated with helpseeking among young adults (Gulliver, Griffiths, & Christensen, 2010). Positively, cross-sectional survey conducted among six European countries: France, Belgium, Italy, Germany, Netherlands, and Spain, which utilised random sampling of household population (n = 8796), concluded that 73.1% to 81.5% of the Europeans would not be extremely embarrassed (if at all), should their friends realized that they are seeking professional psychiatric help (ten Have, de Graaf, Ormel, Vilagut, Kovess, Alonso, & ESEMeD/MHEDEA 2000 Investigators, 2010). Similarly, in America, surveys conducted in 1009–1992 (5388 sample) and again in 2001–2003 (4319 sample) concluded that participants were subsequently less embarrassed if their friends found out about their mental problems (Mojtabai, 2007). As a result, they felt more comfortable (40.3% from 27.1%), and were more willing (41.4% from 35.6%) to seek professional treatment for severe emotional problems. In contrast, among 300 rural Australians, high levels of stigma were reported, and majority (87.7%) preferred informal rather than professional help, which was regarded as last resort. However, this perceived stigma did not hinder help-seeking from general practitioner (Komiti, Judd, & Jackson, 2006). In India, for both depression and psychosis vignettes, 240 participants desired social distance, as they depicted those with mental health problems as dangerous (Kermode, Bowen, Arole, Pathare, & Jorm, 2009). A survey among 1835 sample across 14 European countries, established that mental health patients, who lived in less stigmatizing countries, had greater perceived access to knowledge, greater rates of help-seeking and treatment usage, lower rates of perceived discrimination and self-stigma, and were overall, more empowered (Evans-Lacko, Brohan, Mojtabai, & Thornicroft, 2012). In Germany, a longitudinal study conducted among public in 1993 and 2001 illustrated that, despite improvements in overall MHL levels, there were no improvements in the desire for social distance (Angermeyer et al., 2009). Similarly, 1073 Swiss psychiatric professionals held negative stereotypes towards mental health patients. 60% felt that psychiatric patients should have their license revoked, 29% felt that female psychiatric patients should have an abortion, and most desired social distance towards those experiencing from schizophrenia rather than depression (Nordt, Rössler, & Lauber, 2006). This statistics are shocking; how could we expect the public's attitude to improve when professionals, who help psychiatric patients on a daily basis, view them with such revulsion?

(iii) Knowledge of treatment available Despite the best evidenced-based treatment, the public has to recognise that the treatment available is useful, other Hence, it is important to find out the public's views of professional treatments. Among 202 Australian adolescents, counsellor is identified as the best help (57.7%), followed by, friends (41.8%), family (40.8%) for depression (Burns & Rapee, 2006). Unfortunately, only 9.9%, 6.2% and 4.2% endorsed professional, psychologist and psychiatrist, respectively. In another Australian research conducted among 3746 students aged 12–25 years old and their parents, counsellors (90%–94%) and general practitioner (88%–97%) were endorsed most, followed by close friend (82%–95%), phone counselling (77%–81%), close family (77%–89%), psychologists (64%–87%), psychiatrist (60%–72%), teachers (33%–56%), lastly, dealing alone (5%–8%) in the depression vignette. In the psychosis vignette, counsellors was still regarded as most useful (90%–94%), followed by general practitioner (78%–97%), phone counselling (77%–81%), psychologist (70%–87%), close family (70%–88%), close friend (76%–94%), psychiatrist (66%–80%), teacher (28%–52%), and lastly, dealing alone (2%–7%) (Jorm & Wright, 2007). Conversely, British young adults, endorsed psychologists or psychiatrist best, and internet and books last, although informal help such as (parents, friends, school counsellors) were popular too (Furnham et al., 2014). Interventions deemed most useful in the depression vignette was, counselling (91%–94%), relaxation training (86%–94%), exercising (85%–92%), meditation (66%–88%), sunlight (62%–81%), massages (59%–75%), mental health service (52%–71%), vitamins (52%–62%), acupuncture (31%–45%), antidepressants (32%–44%), sleeping pills (12%–20%), antipsychotics (5%–12%), cognitive behavioural therapy (28%–47%), psychiatric ward (15%–22%), and lastly, tranquilizers (1%–4%). For the psychosis vignette, the most useful interventions were considered to be counselling (92%–96%), relaxation training (86%–93%), exercising (82%–91%), mediation (71%–80%), sunlight (69%–73%), mental health services (66%–72%), massages (58%–70%), cognitive behavioural therapy (45%–48%), antidepressants (36%–51%), vitamins (36%–44%), antipsychotics (21%–28%), sleeping pills (12%–18%), acupuncture (27%–40%), psychiatric wards (21%–34%)and lastly, tranquilizers (2%–6%)(Jorm & Wright, 2007). Portuguese youths, on the other hand, viewed friends (80.9%) and family members (75.1%) as being more important than psychiatrists (55.1%), or general practitioners (74.6%) in a depression vignette. They do, however, rated psychologist as being the most helpful, among the mental healthcare team (89%). In contrast, when given a schizophrenia vignette, Portuguese youth were more open to professional services (71.4%–88.1%). Informal help like friends and family members (62.3%–68.3%), and telephone helplines, teachers and social workers (62.3%–68.3%), were considered less helpful than professional services: general practitioners (71.4%), psychiatrists (78.1%) and friends (72.7%) (Loureiro et al., 2015). For depression treatment, Portuguese youths deemed vitamins the

(ii) Knowledge of causative and risk factors In Western countries, the public attribute mental health problems as a result of personal/character weaknesses, social causes, especially new stressors (Angermeyer & Dietrich, 2006; Kermode et al., 2009; Wang et al., 2007). In Asia countries, mental health problems are often attributed to religious reasons such as, witchcraft, or being possessed by demons or evil spirits. Such belief will impair treatment-seeking behaviours because patients and families would tend to seek treatment from religious leaders such as church pastors, Malay shaman (bomoh) or Chinese mediums. Gravely, these patients would be less compliant to medications (Chong, Mythily, & Verma, 2005). In South Australia, surveys conducted among 3034 participants in 1998, 2004 and 2008, concluded that participants could identify mental disorders better over the decades. There was increased correct labelling of depression, and less attribution to stress, psychological 3

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(52.8%–54.3%), and sleeping pills (38.1%–56.8%). Amidst professional treatment, stress management including, relaxation, yoga, meditation were the favourite at 89.6%. Those who had contact with psychiatric patients viewed professional treatment, including medications, more positively and non-evidenced based interventions such as vitamins, more critically. Only 61%–68.8% acknowledged psychiatrist help and 6.7%–20% endorsed hospital admission. Non-professional interventions were far more popular: exercising (77.6%) and self-help books (72%) (Dahlberg et al., 2008). Among 240 participants in India, vitamins, herbals and tonics (90.4%) were deemed more useful than appetite stimulants (90%), sleeping pills (77.5%), and other medications (6.8%) (Kermode et al., 2009). In a depression vignette, 45.8%, 17.4% and 10.6%, of 3047 Canadian, endorsed general practitioner, counsellor, pharmacological treatment, respectively (Wang et al., 2007). In summary, the public endorse help from their loved ones over professional mental health treatment. They tend to prefer non-pharmacological interventions over pharmacological treatment. The public's faith and belief in professional treatment influence help-seeking behaviours. Being overly dependent on loved ones or informal help might delay professional treatment. Public also prefers counsellors (who are non-psychiatric trained) over psychiatric professionals such as psychiatrists and psychologists. Additionally, the public viewed psychotropic as harmful and often preferred non-pharmacological treatment over pharmacological treatment, such as generic counselling, relaxation and stress management. Despite the available evidence-based treatment, it can only be good treatment if the public believe that professional services can be useful.

most useful, followed by tea, anti-depressants and tranquilizer. Dismally, antipsychotics, hypnotics, tranquilizers and anti-depressants were considered harmful, ranging from 28.6%–37.3% (Loureiro et al., 2013). Conversely, fewer youths deemed psychotrophics as harmful (12.4%–19.5%) in the schizophrenia vignette. In fact, 31.1%–54% deemed psychotrophics useful, although non-evidenced based treatment such as vitamins (35.8%) and tea (39.9%) were also acknowledged (Loureiro et al., 2015). A survey among 999 Australian concluded that 20% felt that antidepressants were harmful. They have lower MHL, were less educated, less exposed to depression and also disliked other professional treatments including psychological interventions (Jorm, Christensen, & Griffiths, 2005). In South Australia, longitudinal surveys among 3034 participants in 1998, 2004 and 2008, illustrated the reduction in perceived usefulness of clergy. However, in 2008, the participants were less likely to deem mental health professionals as being helpful, as compared in 2004 (Goldney et al., 2009). Although most longitudinal surveys demonstrated improvements in overall MHL, this survey depicts differently. The Australian longitudinal national survey of 6019 sample conducted over 16 years in 3 time period: 1995, 2003/4 and 2011 demonstrated a reduction of nominating families/ friends, counsellors, psychiatrists and medications as potential help, with an increase in the election of psychiatrist, telephone counsellors and general practitioner as the better help, in depression (Reavley & Jorm, 2012). In depression with suicidal ideations, early and chronic schizophrenia, there was an increased recognition of in the usefulness of psychiatrists, GPs, psychologists. In social phobia and post-traumatic stress disorder, counselling was deemed more useful. Medications such as anti-depressants, antipsychotics were increasingly deemed as useful interventions (50%), rather than harmful (Reavley & Jorm, 2012). However, there were equal endorsement for minerals and vitamins (up to 49.3%). Despite overall MHL increment, the research concluded that MHL in Australia could still appreciate, especially for schizophrenia, anxiety disorders and their treatments. The MHL improvements in Australia demonstrated that public campaigns would make a significant difference in public's MHL. In a longitudinal study in Germany, conducted in 1993, then 2001, there was an increase in endorsement of seeking professional help, and reduction in seeking help from confidant or priest for schizophrenia (Angermeyer et al., 2009). There was also an increase in endorsement of anti-psychotics (from 36.3% to 50.6%). Despite that, psychotherapy was still regarded as the best treatment by public (81.5%) for schizophrenia, contrary to evidenced based practice which affirms pharmacological treatments over non-pharmacological treatments in psychosis. For depression, the public rather seek a confidant, than seek professional help, although, like schizophrenia, there was an increase in endorsement of psychotropic drugs (from 29.5% to 38.7%). Only 56.8% to 88.2% of the Europeans would be likely to seek professional assistance, when experiencing psychiatric symptoms. Furthermore, 30% of the Europeans deemed professional help as equal as or worse than no help (ten Have et al., 2010). Although stigma is not a considerable problem in European countries, Europeans lacked faith in the mental health professionals. Japanese tended to prefer seeing psychiatrists over general practitioner, and endorsed several medications (sleeping pills, antipsychotics and tranquilizers; 22.6%–38.4%) more than Australians did (Jorm, Nakane, et al., 2005). Unfortunately, with electroconvulsive therapy, only 5.9%–6.4% of Australians and 1.4%–2.2% of Japanese are agreeable. Similarly, only 1.9%–7.2% of Swedish endorsed electroconvulsive therapy (Dahlberg et al., 2008). 3538 participants in Sweden preferred help from close families and friends (76.8%–90.5%) over help from general practitioners, psychiatrists or psychologists (49.5%–77.6%), although psychologist was most popular among the three. With medications, antidepressants were deemed most useful (47.6%–74.4%), followed by vitamins

(iv) Knowledge of self-help strategies available Since only 33% of the public seek professional help when experiencing mental health symptoms (World Health Organisation (WHO), 2001), proper self-help interventions are crucial. Self-help strategies equate interventions that such as informational booklets, website administering cognitive behavioural therapy. Self-help strategies are viewed much more positively than professional interventions. Among 3746 Australian students aged 12–25 years old and their parents, for the depression vignette, non-professional interventions that were endorsed were, support group (82%–86%), self-help book (62%–75%), information from website (56%–68%), and lastly, vitamins (46%–62%), In the psychotic vignette, non-professional interventions that were endorsed were support group (89%–92%), information from website (50%–67%), self-help (49%–73%), and vitamins (36%–44%) (Jorm & Wright, 2007). Similarly, in Sweden, among 3538 participants, only 61% - 68.8% acknowledged psychiatrist help and 6.7%–20% endorsed hospital admission. Non-professional interventions were far more popular: exercising (77.6%) and self-help books (72%) (Dahlberg et al., 2008). A population-based survey conducted among Australian adolescents, using a depression vignette, concluded that 67.7% intended to seek help, with majority preferring informal help from parents (57.1%). When come into contact with someone with depression, 65.7% of people would help. The most popular method to help was, active listening (87.9%), telling the person to get their act together (87.5%), cheer him up (71.3%) and 63.4% recommend professional help. However, only 22.7% would ask about suicidal thoughts, and just 1.9% yearned for help from service (Lam, 2014). Through stratified cluster sampling, 4938 Portuguese youths aged 14–24, deemed effective treatment as, in a chronological order, relaxation techniques (82.9%), getting professional therapy (74.8%), increased physical activity (66.2%), mediation (62.7%), seeking professional service (59.3%), joining support group (49.9%), self-help book (48.3%) or web-site (45.9%) about personal psychiatric symptoms 4

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(v) Knowledge of resources of mental health information

(Loureiro et al., 2013). In contrast, as for the schizophrenia vignette, professional help (79.3%–81.3%) was considered most useful, followed by relaxation (73.1%), exercising (67%), mediation (59.8%), support group (56.5%), reading up about condition (43.3%–45.3%), and lastly, getting sunlight, acupuncture (25.9%–35.3%) (Loureiro et al., 2015). Drinking alcohol and smoking were considered harmful in both vignettes. In the depression vignette, interventions deemed most effective to help others were, active listening, followed by, seeking professional help, and attempting to cheer her up. Ignoring her (84.5%), encouraging her to drink alcohol (87.5%) and asking if she is suicidal (52%) were considered harmful interventions (Loureiro et al., 2013). These results resembled the results from the schizophrenia vignette (Loureiro et al., 2015). Knowledge of preventing mental conditions is also part of self-help strategies of MHL. Among the 4938 Portuguese youths, all the interventions that were stated on the questionnaire were deemed useful to prevent mental health problems, except for (having a religion). Those interventions were: engaging with family and friends, avoiding stressful situations, avoid drugs and alcohol and finding time to relax (Loureiro et al., 2013; Loureiro et al., 2015). Between Australians and healthcare professionals, there was a gap in the beliefs of effectiveness of interventions. The healthcare professionals endorsed mental health services, and interventions from psychiatrists and pharmacological management. However, 968 Australian youngsters (12–25 years old) and 531 of their parents, preferred informal interventions by loved-ones (76%–92%), generic counselling and stress reduction interventions (Jorm, Morgan, & Wright, 2008). Other self-help strategies endorsed were, mediation (75%–80%), selfhelp book (73%), website information (72%), getting sunlight (71%). Between Australians and Japanese, Japanese endorsed counselling and talking with family or friends, as compared with Australians (Jorm, Nakane, et al., 2005). For similarities, more than half of Australians and Japanese endorsed exercising, reading about symptoms from books or websites, going out, emailing experts or contacting health educator, over professional treatment such as hospital admission, psychotherapy, relaxation training and hypnosis. In terms of differences, Japanese prefer more private information sources, such as from the internet or books, rather than seeking help from health educator/experts. In a cross cultural study between 440 British, Malaysians and Hong Kongers, professional help was endorsed most by the British and Hong Kongers, while Hong Kongers and Malaysians preferred informal help by loved ones more (Loo et al., 2012). Among 240 participants in India, for the depression vignette, informal help was preferred over hospital admission (64.6%). Informal helps equates providing affection (99.2%), active listening (96.3%), distraction (93.3%), exercising (87.5%) and special diet (71.7%). For the psychosis vignette, except for informal help, all other informal interventions were more welcome than hospital admission (81.7%). Interestingly, as a cultural belief, 10.1%–15% regarded arranged marriage as an effective intervention for psychosis (Kermode et al., 2009). The high prevalence of mental health problems meant that most public had experience mental health conditions, directly or indirectly. People with mental health conditions often seek help from their families, friends, colleagues, who are most usually not psychiatrictrained. Hence, how these lay-persons helped, would make a significance difference as to whether they seek professional treatment. Unfortunately, research demonstrated that the general public lack ability and knowledge to help those with psychiatric problems. As mentioned in the above, counselling, relaxation training, exercising, meditation, sunlight, massages, vitamins, acupuncture, are viewed more positively than mental health service (Jorm & Wright, 2007). Such informal self-help strategies were popular even in severe mental health conditions like schizophrenia, demonstrating the misconception that public has about professional mental health treatment.

Traditional media such as televisions, newspapers, and movies often degrade mental health patients and treatment, portraying them in a repugnant light. Mental health patients are often depicted as alone, with no family or social connections, and were unpredictable, violent, scary and murderous (Stuart, 2006). Mental health patients are not deemed as someone who can fully recover or become productive societal members. Furthermore, mental health treatment was often portrayed as forced or solitary confinement and treatments such as electro-convulsive therapy and psychosurgery were deemed horrifying. Such negative media depictions, of those experiencing from mental disorders, diminished their self-esteem, help-seeking actions, and medication compliance and impede overall recovery. Multiple personality disorders were heavily sensationalized, through books, movies and shows. Until now, the general public still mistaken schizophrenia with multiple personality disorder, and often cite schizophrenia patients as having ‘dual personality’, ‘changing personality’. However, there is a universal lack of research to quantify public's knowledge of resources of mental health information. Factors affecting MHL Age Among Americans, older adults were better at identifying depression and ADHD, although they resented the term mental disorder (Pescosolido et al., 2008). Conversely, in Australia, the younger groups are better at identifying schizophrenia and depression compared with the elderly (> 70 years old). However, young adults (aged 18 to 24 years old) often mistaken schizophrenia with depression (Farrer, Leach, Griffiths, Christensen, & Jorm, 2008). The elderly tend to attribute schizophrenia to individual weaknesses. All ages rated doctor consultation as the best help. Young adults were more likely to endorse friends, family, counselling and selfreading as being useful (Farrer et al., 2008). Gender A systematic review has detected gender differences in MHL. Females are more accepting, more helpful, less angry, but more fearful towards those with mental conditions (Holzinger, Floris, Schomerus, Carta, & Angermeyer, 2012). Females also believed psycho-social factors, rather than the person himself, is responsible for the mental disorders. Females were better at recognising mental disorders than males (Coles et al., 2016; Dahlberg et al., 2008; Furnham & Lousley, 2013; Pescosolido et al., 2008; Wang et al., 2007). Although there are no gender differences revolving informal help, females tend to recommend professional help more than males (Coles et al., 2016; Holzinger et al., 2012). In another research, however, concluded that females were more likely to seek help both informal and formal help (family members, general practitioners, psychologists and psychiatrists) (Furnham et al., 2014). Females also preferred psychological treatment. Males preferred individual help, such as, use of internet, and coping alone. With medications, there is conflicting evidence about gender differences. Females tended to endorsed minerals, vitamins or herbal remedies while males endorsed tranquilizers, sleeping medications or alcohol. In summary, females had higher MHL levels than males. Discussion MHL between mental health professionals and general public Despite the overall increase in literacy and qualifications around the 5

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Conclusion

world, there is an astonishing gap of the MHL between mental health professionals and the general public. This is because health care professionals possessed expert knowledge that is evidence-based, whereas the public's knowledge is adopted from media and personal experience and often the public's seemingly ignorance baffles professional. However, it is crucial to first understand the public's views, and then introduce to them the conventional treatment. Even the best treatment will never work, without the public's faith in evidence-based practice.

MHL levels are low in the public. MHL can be increased with specific interventions. Such interventions can be provided in the primary care or in mainstream or online media. Nurses have a great role to play in leading these public educations, and enhancing public health as a whole. Such public educations serve as primary prevention measures, and can potentially reduce stigma and increase early help-seeking behaviours, which will reduce morbidity, mortality and promote early recovery. Hence, nurses play an important role in preserving and enhancing healthy and happy nations worldwide.

Identification of knowledge gap ‘Mental health literacy’ surfaced in literature in 1990s, and since then, had been intensively explored in Australia. Subsequently some research revolving MHL had been conducted in Europe. However, most countries, especially those in Asia have yet to examine MHL in depth. Furthermore, existing MHL research predominantly targeted healthcare professionals; to elevate their knowledge and skills to care for mental health patients. Therefore, the mental health literacy of the public was neglected (Jorm, 2012). Overseas research that measured mental health literacy often only measured a few aspects of MHL, rather than its entire 6 domains. Most MHL research focused on the recognition of the illness, and preferred interventions, although there were a total of six components of MHL. Moreover, studies that were conducted, although in the same country, produced conflicting results and varying MHL levels. This might be attributed to the methodological limitations of the studies.

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Methodological limitations in literature Majority of current literature utilised vignettes in their data collection. However, the different presentations of vignettes of the same diagnosis, in the same country, produced varying results of recognition, implying that findings were likely non-replicable and unreliable (Furnham & Hamid, 2014). Furthermore, many vignettes were utilised in various cultures, when they are regarded as culture-bound. Hence, the generalizability of the research findings was in doubt. There is a need of well-structured, succinct vignettes. Additionally, many research studies lack theoretical framework or theories. Hypotheses were often not systematically tested and overall MHL literature seemed to be in the exploratory phase (Furnham & Hamid, 2014). Most utilise convenience, or opportunistic sampling, with inadequate sample size. Most research studies utilised vignettes and data analysis rarely use sophisticated analysis such as structural equation modelling. The modelling could be used to determine the experiences leading to specific beliefs, causal relationships among individual factors, and relationships between theories. There is a need for large samples, with huge range of disorders (Furnham & Hamid, 2014).

Recommendation for nursing practice Generally, psychiatric diagnosis puzzles the public. This poor MHL impairs early detection and treatment of the mental health problems, because general practitioners often under-diagnosed mental health problems. Existing literature established that public attributed mental disorders to psychosocial factors rather than biological factors. Public education that mental disorders are caused by biological factors will enhance help-seeking behaviours and treatment compliance. Hence, there is still much work to be done to enhance public's MHL. It is much easier, more cost-effective and less time-consuming for one healthcare professional to educate the entire public, than to let the misled, vulnerable person, who experiences psychiatric symptoms, to slip through the cracks, never get treated, and become decompensated forever. 6

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