10.1192/bjp.177.5.

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2000, 177:396-401. BJP
A. F. JORM
disorders
Mental health literacy: Public knowledge and beliefs about mental
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Background Background Althoughthe benefits of Althoughthe benefits of
public knowledge of physical diseases are public knowledge of physical diseases are
widelyaccepted, knowledge about mental widelyaccepted, knowledge about mental
disorders (mental healthliteracy) has been disorders (mental healthliteracy) hasbeen
comparativelyneglected. comparativelyneglected.
Aims Aims Tointroducethe concept of Tointroducethe concept of
mental healthliteracy to awider audience, mental healthliteracy to a wider audience,
to bring togetherdiverseresearch to bring together diverseresearch
relevanttothetopic andtoidentifygaps in relevanttothetopic andtoidentifygapsin
the area. the area.
Method Method Anarrativereviewwithin a Anarrativereview within a
conceptual framework. conceptual framework.
Results Results Manymembers of the public Manymembers of the public
cannot recognise specific disorders or cannot recognise specific disorders or
differenttypes of psychological distress. differenttypes of psychological distress.
Theydiffer frommental health experts in Theydiffer frommental health experts in
their beliefs aboutthe causes of mental their beliefs aboutthe causes of mental
disorders andthe most effective disorders andthe most effective
treatments. Attitudes whichhinder treatments. Attitudes whichhinder
recognition and appropriate help-seeking recognition and appropriate help-seeking
are common. Much of the mental health are common. Much of the mental health
informationmost readilyavailabletothe informationmost readilyavailabletothe
public is misleading.However, thereis public is misleading. However, thereis
some evidencethat mental healthliteracy some evidencethat mental healthliteracy
canbeimproved. canbeimproved.
Conclusions Conclusions If the public's mental If the public's mental
healthliteracyis not improved, this may healthliteracyis not improved, this may
hinder public acceptance of evidence- hinder public acceptance of evidence-
basedmental healthcare. Also, many basedmental healthcare. Also, many
people withcommonmental disorders people withcommonmental disorders
maybe denied effective self-help andmay maybe denied effective self-help andmay
not receive appropriate support from not receive appropriate support from
othersinthe community. othersinthe community.
Declaration of interest Declaration of interest None. None.
Health literacy has been defined as ``the Health literacy has been defined as ``the
ability to gain access to, understand, and ability to gain access to, understand, and
use information in ways which promote use information in ways which promote
and maintain good health'' (Nutbeam and maintain good health'' (Nutbeam et et
al al, 1993). In the area of physical health, , 1993). In the area of physical health,
examples of health literacy would include examples of health literacy would include
knowledge and use of a healthy diet, taking knowledge and use of a healthy diet, taking
actions to prevent skin cancer, performing actions to prevent skin cancer, performing
breast self-examination, having first aid breast self-examination, having first aid
skills and knowing how to look up health skills and knowing how to look up health
information in a library or on the internet. information in a library or on the internet.
While the importance of health literacy While the importance of health literacy
for physical health is widely acknowledged, for physical health is widely acknowledged,
the area of mental health literacy has been the area of mental health literacy has been
comparatively neglected. The purpose of comparatively neglected. The purpose of
this review is to introduce the concept to this review is to introduce the concept to
a wider audience, to bring together diverse a wider audience, to bring together diverse
research relevant to mental health literacy research relevant to mental health literacy
and to identify gaps in the area. and to identify gaps in the area.
DEFINITIONAND DEFINITIONAND
CONCEPTUAL FRAMEWORK CONCEPTUAL FRAMEWORK
Jorm Jorm et al et al (1997 (1997a a) introduced the term ) introduced the term
`mental health literacy' and have defined `mental health literacy' and have defined
it as ``knowledge and beliefs about mental it as ``knowledge and beliefs about mental
disorders which aid their recognition, disorders which aid their recognition,
management or prevention''. Mental health management or prevention''. Mental health
literacy consists of several components, literacy consists of several components,
including: (a) the ability to recognise including: (a) the ability to recognise
specific disorders or different types of specific disorders or different types of
psychological distress; (b) knowledge and psychological distress; (b) knowledge and
beliefs about risk factors and causes; (c) beliefs about risk factors and causes; (c)
knowledge and beliefs about self-help inter- knowledge and beliefs about self-help inter-
ventions; (d) knowledge and beliefs about ventions; (d) knowledge and beliefs about
professional help available; (e) attitudes professional help available; (e) attitudes
which facilitate recognition and appro- which facilitate recognition and appro-
priate help-seeking; and (f) knowledge of priate help-seeking; and (f) knowledge of
how to seek mental health information. how to seek mental health information.
If people experience disabling psycho- If people experience disabling psycho-
logical symptoms or have close contact logical symptoms or have close contact
with others who have such problems, they with others who have such problems, they
will attempt to manage those symptoms. will attempt to manage those symptoms.
People's symptom-management activities People's symptom-management activities
will be influenced by their mental health will be influenced by their mental health
literacy. If successful, these symptom- literacy. If successful, these symptom-
management activities may lead to a management activities may lead to a
reduction in disabling symptoms and also reduction in disabling symptoms and also
a change in mental health literacy. In this a change in mental health literacy. In this
framework, the person affected by the framework, the person affected by the
symptoms (either personally or through symptoms (either personally or through
close contact) is seen as the primary agent close contact) is seen as the primary agent
in symptom management, with professional in symptom management, with professional
help being one of a range of strategies he or help being one of a range of strategies he or
she might try. This perspective is important she might try. This perspective is important
because it leads to a greater emphasis on because it leads to a greater emphasis on
increasing public (rather than professional) increasing public (rather than professional)
knowledge and skills about mental health knowledge and skills about mental health
and on empowering the person ex- and on empowering the person ex-
periencing disabling symptoms. The need periencing disabling symptoms. The need
for the public to have greater mental health for the public to have greater mental health
literacy is highlighted by the high lifetime literacy is highlighted by the high lifetime
prevalence of mental disorders (up to prevalence of mental disorders (up to
50%, according to Kessler 50%, according to Kessler et al et al, 1994), , 1994),
which means that virtually everyone will which means that virtually everyone will
either develop a mental disorder or have either develop a mental disorder or have
close contact with someone who does. close contact with someone who does.
RECOGNITION RECOGNITION
OF MENTAL DISORDERS OF MENTAL DISORDERS
Many members of the public cannot Many members of the public cannot
correctly recognise mental disorders and correctly recognise mental disorders and
do not understand the meanings of psychi- do not understand the meanings of psychi-
atric terms. For example, when a represen- atric terms. For example, when a represen-
tative sample of the Australian public was tative sample of the Australian public was
shown vignettes of a person suffering from shown vignettes of a person suffering from
major depression or schizophrenia, most major depression or schizophrenia, most
recognised that there was some sort of recognised that there was some sort of
mental health problem but depression was mental health problem but depression was
correctly used as the label by only 39% correctly used as the label by only 39%
and schizophrenia by 27% (Jorm and schizophrenia by 27% (Jorm et al et al, ,
1997 1997a a). For the depression vignette, 11% ). For the depression vignette, 11%
thought the person had a physical disorder. thought the person had a physical disorder.
Similarly, European surveys have found Similarly, European surveys have found
lack of understanding of the terms schizo- lack of understanding of the terms schizo-
phrenia and mania to be common (Brandli, phrenia and mania to be common (Bra ndli,
1999; Hillert 1999; Hillert et al et al, 1999) and that `schizo- , 1999) and that `schizo-
phrenia' is commonly associated with a split phrenia' is commonly associated with a split
personality (Angermeyer & Matschinger, personality (Angermeyer & Matschinger,
1999). A US study found that the public 1999). A US study found that the public
are reasonably knowledgeable about the are reasonably knowledgeable about the
mood symptoms of depression, but less mood symptoms of depression, but less
likely to know about somatic changes likely to know about somatic changes
(Regier (Regier et al et al, 1988). , 1988).
Is the inability to use a correct psychi- Is the inability to use a correct psychi-
atric label and lack of knowledge of symp- atric label and lack of knowledge of symp-
tomatology of any significance? These tomatology of any significance? These
failures of mental health literacy may cause failures of mental health literacy may cause
problems of communication with health problems of communication with health
practitioners. It is well known that patients practitioners. It is well known that patients
with mental disorders are often missed by with mental disorders are often missed by
general practitioners (GPs). Aspects of the general practitioners (GPs). Aspects of the
GP interviewing style are known to be GP interviewing style are known to be
associated with rate of detection (Goldberg associated with rate of detection (Goldberg
& Huxley, 1992), but the patient's mode of & Huxley, 1992), but the patient's mode of
3 9 6 3 9 6
BRI TI S H J OURNAL OF P SYCHI ATRY BRI TI S H J OURNAL OF P SYCHI ATRY ( 2 0 0 0 ) , 17 7, 3 9 6 ^ 4 0 1 ( 2 0 0 0 ) , 1 7 7, 3 9 6 ^ 4 0 1 R E V I E W A R T I C L E R E V I E W A R T I C L E
Mental health literacy Mental health literacy
Public knowledge and beliefs about mental disorders Public knowledge and beliefs about mental disorders
A. F. JORM A. F. JORM
MENTAL HEALTH LI TER ACY MENTAL HEALTH LI TER ACY
interacting with the GP is also important. interacting with the GP is also important.
Detection of a mental disorder is greater if Detection of a mental disorder is greater if
the patient presents his or her symptoms the patient presents his or her symptoms
as reflecting a psychological problem as reflecting a psychological problem
(Herran (Herran et al et al, 1999; Kessler , 1999; Kessler et al et al, 1999) , 1999)
and explicitly raises the problem with the and explicitly raises the problem with the
GP (Bowers GP (Bowers et al et al, 1990; Jacob , 1990; Jacob et al et al, ,
1998). Although GP recognition may 1998). Although GP recognition may
not be sufficient in itself to benefit the not be sufficient in itself to benefit the
patient (Goldberg patient (Goldberg et al et al, 1998; Simon , 1998; Simon et et
al al, 1999), it is a first step towards effec- , 1999), it is a first step towards effec-
tive action. tive action.
KNOWLEDGE AND BELIEFS KNOWLEDGE AND BELIEFS
ABOUTCAUSES ABOUTCAUSES
In Western countries depression and In Western countries depression and
schizophrenia are most often seen by the schizophrenia are most often seen by the
public as caused by the social environ- public as caused by the social environ-
ment, particularly recent stressors ment, particularly recent stressors
(McKeon & Carrick, 1991; Matschinger (McKeon & Carrick, 1991; Matschinger
& Angermeyer, 1996; Priest & Angermeyer, 1996; Priest et al et al, 1996; , 1996;
Jorm Jorm et al et al, 1997 , 1997b b; Link ; Link et al et al, 1999). , 1999).
While psychiatric epidemiologists would While psychiatric epidemiologists would
concur about the importance of stressful concur about the importance of stressful
life events in depression, in schizophrenia life events in depression, in schizophrenia
life events are more of a trigger than a life events are more of a trigger than a
cause. Biological factors are seen by the cause. Biological factors are seen by the
public as less important than environ- public as less important than environ-
mental ones (McKeon & Carrick, 1991; mental ones (McKeon & Carrick, 1991;
Matschinger & Angermeyer, 1996; Wolff Matschinger & Angermeyer, 1996; Wolff
et al et al, 1996; Jorm , 1996; Jorm et al et al, 1997 , 1997b b; Link ; Link et et
al al, 1999), although relatives of people , 1999), although relatives of people
with schizophrenia are more likely to see with schizophrenia are more likely to see
biological factors as important (Anger- biological factors as important (Anger-
meyer & Matschinger, 1996 meyer & Matschinger, 1996a a). Providing ). Providing
the label `schizophrenia' to a vignette the label `schizophrenia' to a vignette
has also been found to increase the likeli- has also been found to increase the likeli-
hood that biological rather than psycho- hood that biological rather than psycho-
social causes are seen as responsible social causes are seen as responsible
(Angermeyer & Matschinger, 1996 (Angermeyer & Matschinger, 1996b b). In ). In
some non-Western cultures, supernatural some non-Western cultures, supernatural
phenomena, such as witchcraft and phenomena, such as witchcraft and
possession by evil spirits, are seen as possession by evil spirits, are seen as
important causes of mental disorders important causes of mental disorders
(Razali (Razali et al et al, 1996), although this is un- , 1996), although this is un-
common in the West (Angermeyer & common in the West (Angermeyer &
Matschinger, 1999; Brandli, 1999). Matschinger, 1999; Bra ndli, 1999).
Beliefs about causes may alter patterns Beliefs about causes may alter patterns
of help-seeking and response to treatment. of help-seeking and response to treatment.
For example, in Malaysia belief by psychi- For example, in Malaysia belief by psychi-
atric patients in supernatural causes was atric patients in supernatural causes was
associated with greater use of traditional associated with greater use of traditional
healers and poorer compliance with medi- healers and poorer compliance with medi-
cation (Razali cation (Razali et al et al, 1996). In a US con- , 1996). In a US con-
trolled trial of psychotherapy for de- trolled trial of psychotherapy for de-
pression, belief in relationship causes was pression, belief in relationship causes was
associated with a better outcome in behav- associated with a better outcome in behav-
ioural therapy, while belief in existential ioural therapy, while belief in existential
causes was associated with a better outcome causes was associated with a better outcome
in cognitive therapy (Addis & Jacobson, in cognitive therapy (Addis & Jacobson,
1996). 1996).
KNOWLEDGE AND BELIEFS KNOWLEDGE AND BELIEFS
ABOUT SELF-HELP ABOUT SELF-HELP
Given that only a minority of people who Given that only a minority of people who
meet diagnostic criteria for a mental dis- meet diagnostic criteria for a mental dis-
order seek professional help (Regier order seek professional help (Regier et al et al, ,
1993; Lin 1993; Lin et al et al, 1996; Andrews , 1996; Andrews et al et al, ,
1999), self-help skills are of great import- 1999), self-help skills are of great import-
ance. When the public were asked to rate ance. When the public were asked to rate
a range of interventions for likely helpful- a range of interventions for likely helpful-
ness, self-help interventions were found to ness, self-help interventions were found to
be at the top of the list in both Australia be at the top of the list in both Australia
and the UK (Rippere, 1979; Parker & and the UK (Rippere, 1979; Parker &
Brown, 1982; Jorm Brown, 1982; Jorm et al et al, 1997 , 1997a a). Among ). Among
the most popular self-help interventions the most popular self-help interventions
are seeking support from family and are seeking support from family and
friends, engaging in pleasurable activities, friends, engaging in pleasurable activities,
taking up new activities and physical exer- taking up new activities and physical exer-
cise. Unfortunately, there is much less cise. Unfortunately, there is much less
evidence on the effectiveness of self-help evidence on the effectiveness of self-help
interventions than on that of professional interventions than on that of professional
ones, making it difficult to say which are ones, making it difficult to say which are
likely to work. However, for milder states likely to work. However, for milder states
of depression, there is evidence for the of depression, there is evidence for the
effectiveness of social support (Goldberg effectiveness of social support (Goldberg
& Huxley, 1992), physical exercise & Huxley, 1992), physical exercise
(Martinsen, 1994), self-help books based (Martinsen, 1994), self-help books based
on cognitivebehavioural therapy (Cuij- on cognitivebehavioural therapy (Cuij-
pers, 1997) and for the herb St John's wort pers, 1997) and for the herb St John's wort
(Linde (Linde et al et al, 1996). , 1996). Rauwolfia serpentina Rauwolfia serpentina is is
a traditional herbal remedy known to have a traditional herbal remedy known to have
an antipsychotic effect (Bhatara an antipsychotic effect (Bhatara et al et al, ,
1997). There is a clear need for further 1997). There is a clear need for further
evaluation of self-help interventions, so that evaluation of self-help interventions, so that
the public can be given appropriate advice. the public can be given appropriate advice.
Knowledge of how to help others is a Knowledge of how to help others is a
related component of mental health related component of mental health
literacy. Very little research has been done literacy. Very little research has been done
on the topic, but a Swiss survey found that on the topic, but a Swiss survey found that
the public have difficulty in dealing with the public have difficulty in dealing with
mental disorders, saying they do not know mental disorders, saying they do not know
how to behave, are afraid of making how to behave, are afraid of making
mistakes and do not have sufficient know- mistakes and do not have sufficient know-
ledge (Brandli, 1999). ledge (Bra ndli, 1999).
KNOWLEDGE AND BELIEFS KNOWLEDGE AND BELIEFS
ABOUT PROFESSIONALHELP ABOUT PROFESSIONALHELP
A number of surveys have asked the public A number of surveys have asked the public
about various helping professions. General about various helping professions. General
practitioners are rated very highly in many practitioners are rated very highly in many
countries, particularly for depression (Priest countries, particularly for depression (Priest
et al et al, 1996; Wolff , 1996; Wolff et al et al, 1996; Jorm , 1996; Jorm et al et al, ,
1997 1997a a; Bradli, 1999). The strong endorse- ; Bra dli, 1999). The strong endorse-
ment of GPs is not, however, universal ment of GPs is not, however, universal
(McKeon & Carrick, 1991; Jorm (McKeon & Carrick, 1991; Jorm et al et al, ,
2000 2000a a). For depression, psychiatrists and ). For depression, psychiatrists and
psychologists are rated less highly than psychologists are rated less highly than
GPs, but are more likely to be seen as help- GPs, but are more likely to be seen as help-
ful for schizophrenia (Jorm ful for schizophrenia (Jorm et al et al, 1997 , 1997a a; ;
Angermeyer Angermeyer et al et al, 1999). These results , 1999). These results
come from developed countries. Beliefs come from developed countries. Beliefs
about professional help may be very differ- about professional help may be very differ-
ent in developing countries. For example, in ent in developing countries. For example, in
Ethiopia traditional sources of help, such as Ethiopia traditional sources of help, such as
witchcraft, holy water and herbalists, were witchcraft, holy water and herbalists, were
preferred over medical help for a range of preferred over medical help for a range of
mental health problems (Alem mental health problems (Alem et al et al, ,
1999). By contrast, medical help was over- 1999). By contrast, medical help was over-
whelmingly preferred for physical health whelmingly preferred for physical health
problems. problems.
When the public are asked about When the public are asked about
various therapies, a strikingly consistent various therapies, a strikingly consistent
finding across many countries is very finding across many countries is very
negative beliefs about medication for a negative beliefs about medication for a
range of mental disorders (Regier range of mental disorders (Regier et al et al, ,
1988; Angermeyer 1988; Angermeyer et al et al, 1993; Priest , 1993; Priest et al et al, ,
1996; Jorm 1996; Jorm et al et al, 1997 , 1997a a; Fischer ; Fischer et al et al, 1999; , 1999;
Hillert Hillert et al et al, 1999; Jorm , 1999; Jorm et al et al, 2000 , 2000a a). ).
The public's belief about medication is in The public's belief about medication is in
sharp contrast to both the evidence from sharp contrast to both the evidence from
randomised controlled trials and the views randomised controlled trials and the views
of mental health professionals that anti- of mental health professionals that anti-
depressant and antipsychotic medications depressant and antipsychotic medications
are effective (Jorm are effective (Jorm et al et al, 1997 , 1997c c; Caldwell ; Caldwell
& Jorm, 2000). The public's negative views & Jorm, 2000). The public's negative views
about psychotropic medication also con- about psychotropic medication also con-
trast with their own positive views about trast with their own positive views about
medication for common physical disorders medication for common physical disorders
(Hillert (Hillert et al et al, 1999). The reasons given by , 1999). The reasons given by
the public for their negative views of the public for their negative views of
psychotropic medication are perceived psychotropic medication are perceived
side-effects, such as dependence, lethargy side-effects, such as dependence, lethargy
or brain damage, and the belief that the or brain damage, and the belief that the
treatments deal only with the symptoms treatments deal only with the symptoms
and not the causes (Angermeyer and not the causes (Angermeyer et al et al, ,
1993; Priest 1993; Priest et al et al, 1996; Fishcher , 1996; Fishcher et al et al, ,
1999). One interpretation of these findings 1999). One interpretation of these findings
is that the negative attributes of benzo- is that the negative attributes of benzo-
diazepines have become generalised to diazepines have become generalised to
all types of psychotropic medication all types of psychotropic medication
(Angermeyer (Angermeyer et al et al, 1993). Indeed, the , 1993). Indeed, the
public do not seem to discriminate between public do not seem to discriminate between
different types of psychotropic medication, different types of psychotropic medication,
in contrast to mental health professionals in contrast to mental health professionals
who are quite specific in their recommenda- who are quite specific in their recommenda-
tions (Jorm tions (Jorm et al et al, 1997 , 1997c c). An Australian ). An Australian
survey found that other treatments specifi- survey found that other treatments specifi-
cally associated with psychiatrists, such as cally associated with psychiatrists, such as
electroconvulsive therapy (ECT) and admis- electroconvulsive therapy (ECT) and admis-
sion to a psychiatric ward, are also viewed sion to a psychiatric ward, are also viewed
very negatively by the public, with more very negatively by the public, with more
people believing they are harmful than help- people believing they are harmful than help-
ful (Jorm ful (Jorm et al et al, 1997 , 1997a a). Anecdotal evidence ). Anecdotal evidence
would support the conclusion that such would support the conclusion that such
3 9 7 3 9 7
J ORM J ORM
beliefs are widespread in other countries as beliefs are widespread in other countries as
well. well.
`Natural' remedies, such as vitamins `Natural' remedies, such as vitamins
and herbs, are viewed much more positively and herbs, are viewed much more positively
by the public (Angermeyer & Matschinger, by the public (Angermeyer & Matschinger,
1996 1996c c; Jorm ; Jorm et al et al, 1997 , 1997a a) and are not gen- ) and are not gen-
erally seen as sharing the negative attributes erally seen as sharing the negative attributes
of psychotropics (Fischer of psychotropics (Fischer et al et al, 1999). , 1999).
Another consistent finding across a Another consistent finding across a
range of countries is very positive views range of countries is very positive views
about psychological treatments such as about psychological treatments such as
counselling (McKeon & Carrick, 1991; counselling (McKeon & Carrick, 1991;
Priest Priest et al et al, 1996; Jorm , 1996; Jorm et al et al, 1997 , 1997a a, ,
2000 2000a a) and psychotherapy (Angermeyer ) and psychotherapy (Angermeyer
& Matschinger, 1996 & Matschinger, 1996c c; Hillert ; Hillert et al et al, ,
1999). Indeed, the public's views tend to 1999). Indeed, the public's views tend to
be more positive than those of professionals be more positive than those of professionals
(Furnham (Furnham et al et al, 1992; Jorm , 1992; Jorm et al et al, 1997 , 1997c c). ).
What is most surprising is that psycho- What is most surprising is that psycho-
logical interventions are seen by the public logical interventions are seen by the public
as highly effective for psychotic disorders as highly effective for psychotic disorders
(Angermeyer & Matschinger, 1996 (Angermeyer & Matschinger, 1996c c; Jorm ; Jorm
et al et al, 1997 , 1997c c, 2000 , 2000a a) and even, according ) and even, according
to an Austrian survey, for dementia (Jorm to an Austrian survey, for dementia (Jorm
et al et al, 2000 , 2000a a). ).
What are the consequences of the What are the consequences of the
public's beliefs about treatment? The most public's beliefs about treatment? The most
obvious is that negative beliefs about medi- obvious is that negative beliefs about medi-
cation may lead to failure to seek medical cation may lead to failure to seek medical
help and lack of compliance with any medi- help and lack of compliance with any medi-
cation recommended (Fischer cation recommended (Fischer et al et al, 1999). , 1999).
It has been proposed that greater account It has been proposed that greater account
should be taken of patients' views in nego- should be taken of patients' views in nego-
tiating the treatment approach. In this tiating the treatment approach. In this
regard, the term `concordance', which regard, the term `concordance', which
implies a two-way negotiation between implies a two-way negotiation between
doctor and patient, is more appropriate doctor and patient, is more appropriate
than `compliance' (Mullen, 1997). Public than `compliance' (Mullen, 1997). Public
beliefs about professional help may also beliefs about professional help may also
affect the help-seeking of others. It has been affect the help-seeking of others. It has been
found that professional help for depression found that professional help for depression
is more likely to occur when another person is more likely to occur when another person
recommends that help be sought (Dew recommends that help be sought (Dew et al et al, ,
1991), so the views of significant others 1991), so the views of significant others
about treatment may also be influential. about treatment may also be influential.
ATTITUDES THAT ATTITUDES THAT
FACILITATE RECOGNITION FACILITATE RECOGNITION
ANDHELP-SEEKING ANDHELP-SEEKING
There is a stigma associated with mental There is a stigma associated with mental
disorders and this may hinder seeking disorders and this may hinder seeking
help. For example, the German public help. For example, the German public
report much greater reluctance to discuss report much greater reluctance to discuss
mental disorders with relatives and friends mental disorders with relatives and friends
than to discuss physical disorders (Hillert than to discuss physical disorders (Hillert
et al et al, 1999), while in the USA many , 1999), while in the USA many
members of the public reported an unwill- members of the public reported an unwill-
ingness to seek treatment for depression ingness to seek treatment for depression
because they feared a negative impact on because they feared a negative impact on
their employment situation (Regier their employment situation (Regier et al et al, ,
1988). 1988). Stigmatising attitudes also extend Stigmatising attitudes also extend
to approaching professionals. In the UK, a to approaching professionals. In the UK, a
majority of the public reported that they majority of the public reported that they
would be embarrassed to consult a GP for would be embarrassed to consult a GP for
depression, primarily because the GP would depression, primarily because the GP would
see them as unbalanced or neurotic (Priest see them as unbalanced or neurotic (Priest
et al et al, 1996), and in India patients with , 1996), and in India patients with
stigmatising attitudes have been found to stigmatising attitudes have been found to
present their distress in somatic rather than present their distress in somatic rather than
psychological terms (Raguram psychological terms (Raguram et al et al, 1996). , 1996).
KNOWLEDGE OF HOW KNOWLEDGE OF HOW
TOSEEK MENTALHEALTH TOSEEK MENTALHEALTH
INFORMATION INFORMATION
We know very little about how people We know very little about how people
acquire knowledge and beliefs about acquire knowledge and beliefs about
mental health. It is likely that personal mental health. It is likely that personal
experiences and anecdotal evidence from experiences and anecdotal evidence from
family and friends are an important source. family and friends are an important source.
A UK study found that 33% of respondents A UK study found that 33% of respondents
cited personal experience of someone with cited personal experience of someone with
a mental disorder as their main source of a mental disorder as their main source of
information, while a further 10% cited information, while a further 10% cited
friends and relatives (Wolff friends and relatives (Wolff et al et al, 1996). , 1996).
Indeed, personal experience or contact has Indeed, personal experience or contact has
been found to be associated with beliefs been found to be associated with beliefs
about causes (Angermeyer & Matschinger, about causes (Angermeyer & Matschinger,
1996 1996b b), with more favourable attitudes ), with more favourable attitudes
(Angermeyer & Matschinger, 1996 (Angermeyer & Matschinger, 1996d d; Wolff ; Wolff
et al et al, 1996), with treatment preferences , 1996), with treatment preferences
(Angermeyer & Matschinger, 1996 (Angermeyer & Matschinger, 1996a a) and ) and
with greater understanding of the term with greater understanding of the term
schizophrenia (Hillert schizophrenia (Hillert et al et al, 1999). , 1999).
Other important influences are journal- Other important influences are journal-
ists' reports and television and cinema ists' reports and television and cinema
dramas depicting mental disorders. In the dramas depicting mental disorders. In the
UK, 32% cited the media as their main UK, 32% cited the media as their main
source of information (Wolff source of information (Wolff et al et al, 1996). , 1996).
Unfortunately, these media often tend to Unfortunately, these media often tend to
report on the negative aspects. In a survey report on the negative aspects. In a survey
of the German public, 64% said that they of the German public, 64% said that they
had read about a person with a mental ill- had read about a person with a mental ill-
ness who had committed a violent crime ness who had committed a violent crime
and 50% about someone who became and 50% about someone who became
addicted to prescribed drugs, but only addicted to prescribed drugs, but only
17% had read about persons with mental 17% had read about persons with mental
illnesses who became able to lead a normal illnesses who became able to lead a normal
life by taking their medication (Hillert life by taking their medication (Hillert et al et al, ,
1999). It is clear that such negative report- 1999). It is clear that such negative report-
ing has an impact. Another German study ing has an impact. Another German study
was able to show that two attempts on was able to show that two attempts on
the lives of prominent politicians by the lives of prominent politicians by
persons with a mental disorder led to a persons with a mental disorder led to a
marked increase in negative attitudes marked increase in negative attitudes
(Angermeyer & Matschinger, 1995). (Angermeyer & Matschinger, 1995).
People with mental disorders are also People with mental disorders are also
frequently portrayed as violent or having frequently portrayed as violent or having
other undesirable characteristics in fictional other undesirable characteristics in fictional
accounts in the cinema and on television accounts in the cinema and on television
(Hyler (Hyler et al et al, 1991; Wilson , 1991; Wilson et al et al, 1999). , 1999).
Although violence is a problem in a small Although violence is a problem in a small
proportion of people suffering from severe proportion of people suffering from severe
mental disorders (Torrey, 1994), the public mental disorders (Torrey, 1994), the public
clearly overestimate this risk, on the basis clearly overestimate this risk, on the basis
of media reports and dramatic portrayals of media reports and dramatic portrayals
(Wolff (Wolff et al et al, 1996; Link , 1996; Link et al et al, 1999). , 1999).
Finally, there are sources of knowledge, Finally, there are sources of knowledge,
such as books, libraries, the internet and such as books, libraries, the internet and
courses of study, available to those with courses of study, available to those with
better education and resources. While it is better education and resources. While it is
known that some self-help books are best- known that some self-help books are best-
sellers and that some mental health web- sellers and that some mental health web-
sites receive a large number of hits, the sites receive a large number of hits, the
overall impact of such sources on mental overall impact of such sources on mental
health literacy is unknown. There is a need health literacy is unknown. There is a need
for greater quality control of such sources for greater quality control of such sources
to ensure that the public gets accurate to ensure that the public gets accurate
information. For example, a recent study information. For example, a recent study
of the top 20 depression websites found of the top 20 depression websites found
the overall quality of the information was the overall quality of the information was
poor when evaluated against clinical poor when evaluated against clinical
practice guidelines (K. Griffiths, personal practice guidelines (K. Griffiths, personal
communication, 2000; further details avail- communication, 2000; further details avail-
able from the author upon request). able from the author upon request).
COGNITIVE ORGANISATION COGNITIVE ORGANISATION
OF MENTALHEALTH OF MENTALHEALTH
LITERACY LITERACY
There is a clear gulf between public and There is a clear gulf between public and
professional beliefs about mental disorders professional beliefs about mental disorders
(Jorm (Jorm et al et al, 1997 , 1997c c). One interpretation of ). One interpretation of
this finding is that there is a continuum of this finding is that there is a continuum of
mental health literacy running from lay mental health literacy running from lay
beliefs to professional knowledge. The pro- beliefs to professional knowledge. The pro-
fessionals have expert knowledge which is fessionals have expert knowledge which is
to a large extent based on scientific to a large extent based on scientific
evidence and expert consensus, while the evidence and expert consensus, while the
public have a range of beliefs based on public have a range of beliefs based on
personal experience, anecdotes, media personal experience, anecdotes, media
reports and more formal sources of know- reports and more formal sources of know-
ledge. However, factor analysis of public ledge. However, factor analysis of public
beliefs reveals not a general factor corres- beliefs reveals not a general factor corres-
ponding to mental health literacy, but a ponding to mental health literacy, but a
number of factors representing general number of factors representing general
belief systems that illness is best handled belief systems that illness is best handled
by medical, psychological or lifestyle inter- by medical, psychological or lifestyle inter-
ventions (Jorm ventions (Jorm et al et al, 1997 , 1997d d). It may be that ). It may be that
when people are confronted by a health when people are confronted by a health
problem they know little about, they fall problem they know little about, they fall
back on their general belief systems about back on their general belief systems about
health (Jorm health (Jorm et al et al, 2000 , 2000b b). For example, if ). For example, if
a person has no specific knowledge about a person has no specific knowledge about
depression, they might fall back on a depression, they might fall back on a
general belief system that health problems general belief system that health problems
3 9 8 3 9 8
MENTAL HEALTH LI TER ACY MENTAL HEALTH LI TER ACY
are caused by lifestyle and that the solution are caused by lifestyle and that the solution
is to be found in natural remedies and life- is to be found in natural remedies and life-
style changes. These general belief systems style changes. These general belief systems
then become a scaffold onto which specific then become a scaffold onto which specific
knowledge (mental health literacy) is knowledge (mental health literacy) is
grafted. grafted.
IMPROVINGMENTALHEALTH IMPROVINGMENTALHEALTH
LITERACY LITERACY
Efforts to improve public knowledge of Efforts to improve public knowledge of
mental disorders have been much less mental disorders have been much less
common than for cancer and heart disease. common than for cancer and heart disease.
Nevertheless, a number of approaches have Nevertheless, a number of approaches have
been tried. One is an information campaign been tried. One is an information campaign
targeted at the general population. In the targeted at the general population. In the
late 1980s, the Americans instituted the late 1980s, the Americans instituted the
Depression Awareness, Recognition and Depression Awareness, Recognition and
Treatment Program, which aimed to inform Treatment Program, which aimed to inform
both the public and health professionals both the public and health professionals
that depressive disorders are common, that depressive disorders are common,
serious and treatable (Regier serious and treatable (Regier et al et al, 1988). , 1988).
This campaign involved a broad range of This campaign involved a broad range of
educational materials, including television, educational materials, including television,
radio and print advertisements, bookmarks radio and print advertisements, bookmarks
and brochures. This national campaign and brochures. This national campaign
was coordinated with action in local was coordinated with action in local
communities. Its effects are unknown. communities. Its effects are unknown.
Another US campaign, begun in the early Another US campaign, begun in the early
1990s, is the National Depression Screening 1990s, is the National Depression Screening
Day (Jacobs, 1995). The aims of this day are Day (Jacobs, 1995). The aims of this day are
to call public attention to depression, to to call public attention to depression, to
educate the public about symptoms and educate the public about symptoms and
treatments and to identify individuals who treatments and to identify individuals who
may be unaware they are clinically may be unaware they are clinically
depressed. This day has resulted in wide- depressed. This day has resulted in wide-
spread media publicity and screening of a spread media publicity and screening of a
large number of people. large number of people.
In the UK there was the Defeat Depres- In the UK there was the Defeat Depres-
sion Campaign run by the Royal College of sion Campaign run by the Royal College of
Psychiatrists and the Royal College of Psychiatrists and the Royal College of
General Practitioners from 1992 to 1996 General Practitioners from 1992 to 1996
(Paykel (Paykel et al et al, 1998). This campaign aimed , 1998). This campaign aimed
to educate the public about depression to educate the public about depression
and its treatment, to encourage earlier and its treatment, to encourage earlier
treatment-seeking and to reduce the stigma treatment-seeking and to reduce the stigma
of depression. It included use of radio, tele- of depression. It included use of radio, tele-
vision and print media. National surveys vision and print media. National surveys
carried out at the beginning, middle and carried out at the beginning, middle and
end of the campaign showed small but end of the campaign showed small but
significant changes in the percentage of significant changes in the percentage of
the public who believe that antidepressants the public who believe that antidepressants
are effective and who would be willing to are effective and who would be willing to
seek professional help. It is impossible to seek professional help. It is impossible to
say whether these changes were solely due say whether these changes were solely due
to the campaign, but the results are to the campaign, but the results are
certainly encouraging. certainly encouraging.
In Norway, there has recently been a In Norway, there has recently been a
campaign in one county aimed at reducing campaign in one county aimed at reducing
the duration of untreated psychosis by the duration of untreated psychosis by
encouraging early help-seeking (Johannes- encouraging early help-seeking (Johannes-
sen, 1998). As well as targeting the public, sen, 1998). As well as targeting the public,
this campaign was aimed at health care this campaign was aimed at health care
providers, educators and treatment centres. providers, educators and treatment centres.
It involved radio, newspaper, cinema and It involved radio, newspaper, cinema and
television advertisements. Public surveys television advertisements. Public surveys
carried out before and after the campaign carried out before and after the campaign
showed a large increase in knowledge of showed a large increase in knowledge of
the terms psychosis and schizophrenia. the terms psychosis and schizophrenia.
There is alsoearly evidence that help-seeking There is also early evidence that help-seeking
behaviour has changed and that the duration behaviour has changed and that the duration
of untreated psychosis has decreased. of untreated psychosis has decreased.
Another approach is to target specific Another approach is to target specific
subgroups of the public. This approach is subgroups of the public. This approach is
exemplified by the work of Wolff exemplified by the work of Wolff et al et al
(1999), who educated the public in a neigh- (1999), who educated the public in a neigh-
bourhood where a group house for those bourhood where a group house for those
with mental illnesses was being established. with mental illnesses was being established.
In this study, one such neighbourhood In this study, one such neighbourhood
received an education campaign, while received an education campaign, while
another acted as a control. The campaign another acted as a control. The campaign
consisted of an educational package with consisted of an educational package with
information sheets and a video, social information sheets and a video, social
events to establish contact with the group events to establish contact with the group
house, a formal reception and informal dis- house, a formal reception and informal dis-
cussion sessions. Pre- and post-surveys in cussion sessions. Pre- and post-surveys in
the experimental and control neighbour- the experimental and control neighbour-
hoods showed only a small effect on public hoods showed only a small effect on public
knowledge, but revealed less fear and more knowledge, but revealed less fear and more
social contact with the group house social contact with the group house
residents in the experimental neighbour- residents in the experimental neighbour-
hood. Another targeted population sub- hood. Another targeted population sub-
group is high-school students. Fairly brief group is high-school students. Fairly brief
classroom instruction has been found to classroom instruction has been found to
improve willingness to seek professional improve willingness to seek professional
help (Battaglia help (Battaglia et al et al, 1990; Esters , 1990; Esters et al et al, ,
1998). 1998).
Finally, there are attempts to improve Finally, there are attempts to improve
the quality of information presented in the the quality of information presented in the
media through expert input. Although media through expert input. Although
mental health experts frequently make mental health experts frequently make
themselves available for media comment, themselves available for media comment,
there is virtually no research on the effects there is virtually no research on the effects
of doing so. However, in an analysis of four of doing so. However, in an analysis of four
media items derived from lay sources and media items derived from lay sources and
three from psychiatrists, Nairn (1999) found three from psychiatrists, Nairn (1999) found
that the psychiatrists presented mental dis- that the psychiatrists presented mental dis-
orders in a less negative manner, but the orders in a less negative manner, but the
journalists tended to undermine their journalists tended to undermine their
message to produce a more newsworthy message to produce a more newsworthy
story. story.
IMPLICATIONS FOR MENTAL IMPLICATIONS FOR MENTAL
HEALTHCARE HEALTHCARE
The evidence reviewed here makes it clear The evidence reviewed here makes it clear
that the public in many countries have poor that the public in many countries have poor
mental health literacy. There are a number mental health literacy. There are a number
of important consequences of this poor of important consequences of this poor
knowledge. First, it may place a limit on knowledge. First, it may place a limit on
the implementation of evidence-based the implementation of evidence-based
mental health care. Attempts to make mental health care. Attempts to make
clinical practice more evidence-based, such clinical practice more evidence-based, such
as the Cochrane Collaboration (Adams, as the Cochrane Collaboration (Adams,
1995), are founded on the assumption that 1995), are founded on the assumption that
meta-analyses of randomised controlled meta-analyses of randomised controlled
trials and the dissemination of clinical trials and the dissemination of clinical
practice guidelines are sufficient to improve practice guidelines are sufficient to improve
clinical practice. This approach is very much clinical practice. This approach is very much
a top-down one in which it is assumed that a top-down one in which it is assumed that
the benefits of research will be realised if the benefits of research will be realised if
clinicians can be won over to use evidence- clinicians can be won over to use evidence-
based treatments. However, this approach based treatments. However, this approach
fails to take account of the views of the fails to take account of the views of the
public, who are the potential consumers of public, who are the potential consumers of
services. If evidence-based treatments do services. If evidence-based treatments do
not accord with public views, people who not accord with public views, people who
develop mental disorders may be unwilling develop mental disorders may be unwilling
to seek those treatments or to adhere to to seek those treatments or to adhere to
advice given by clinicians (Jorm advice given by clinicians (Jorm et al et al, ,
2000 2000a a). Furthermore, they may burden the ). Furthermore, they may burden the
health care system by seeking inappropriate health care system by seeking inappropriate
services and unnecessary investigations. services and unnecessary investigations.
A second consequence of poor mental A second consequence of poor mental
health literacy is that the task of preventing health literacy is that the task of preventing
and helping mental disorders is largely and helping mental disorders is largely
confined to professionals. However, the confined to professionals. However, the
prevalence of mental disorders is so high that prevalence of mental disorders is so high that
the mental health workforce cannot help the mental health workforce cannot help
everyone affected and tends to focus on everyone affected and tends to focus on
those with more severe and chronic prob- those with more severe and chronic prob-
lems. If there are to be greater gains in pre- lems. If there are to be greater gains in pre-
vention, early intervention, self-help and vention, early intervention, self-help and
support of others in the community, then support of others in the community, then
we need a `mental health literate' society in we need a `mental health literate' society in
which basic knowledge and skills are more which basic knowledge and skills are more
widely distributed. widely distributed.
ACKNOWLEDGEMENTS ACKNOWLEDGEMENTS
Suggestions for improving the paper were provided Suggestions for improving the paper were provided
by Betty Kitchener,Kathy Griffiths, Scott Henderson, by Betty Kitchener,Kathy Griffiths, Scott Henderson,
Jo Medwayand Bryan Rodgers. Jo Medwayand Bryan Rodgers.
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4 0 0 4 0 0
CLINICAL IMPLICATIONS CLINICAL IMPLICATIONS
& &
The public does not share many of the core beliefs of clinicians with regard to The public does not share many of the core beliefs of clinicians with regard to
treatment and aetiology of mental disorders. treatment and aetiology of mental disorders.
& & Clinicians may have difficulty inimplementing evidence-basedmental health care if Clinicians may have difficulty inimplementing evidence-basedmental health care if
patients do not believe in the interventions offered. patients do not believe in the interventions offered.
& & Anincreasein mental health literacy in the populationmay assist prevention, early Anincreasein mental health literacy in the population may assist prevention, early
intervention, effective self-help and support of others in the community. intervention, effective self-help and support of others in the community.
LIMITATIONS LIMITATIONS
& &
The concept of mental health literacy assumes the superiority of expert The concept of mental health literacy assumes the superiority of expert
psychiatric knowledge over lay beliefs. psychiatric knowledge over lay beliefs.
& & The concept couldbe criticisedfor seeing the sufferer's interpretation of his or her The concept couldbe criticisedfor seeing the sufferer's interpretation of his or her
condition as less valid. condition as less valid.
A. F. JORM, DSc, Centre for Mental Research, The Australian National University, Canberra 0200, Australia A. F. JORM, DSc, Centre for Mental Research, The Australian National University, Canberra 0200, Australia
(First received 4 February 2000, final revision 12 May 2000, accepted15 May 2000) (First received 4 February 2000, final revision12 May 2000, accepted 15 May 2000)
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