Research

"Mental health literacy": a survey of the public's ability

to recognise mental disorders and their beliefs about the
effectiveness of treatment
Anthony F Jorm, Ailsa E Korten, Patricia A Jacomb, Helen Christensen, Bryan Rodgers and Penelope Pollitt

" H e a l t h literacy" has been Abstract

defined as the ability to gain
access to, understand, and Objectives: To assess the public's recognition of mental disorders and their beliefs
use information in ways which promote about the effectiveness of various treatments ("mental health literacy").
and maintain good health.' By exten- Design: A cross-sectional survey, in 1995, with structured interviews using vignettes
sion, we have coined the term "mental of a person with either depression or schizophrenia.
health literacy" to refer to knowledge
Participants: A representative national sample of 2031 individuals aged 18-74
and beliefs about mental disorders years; 1010 participants were questioned about the depression vignette and 1021
which aid their recognition, management about the schizophrenia vignette.
or prevention. Mental health literacy
includes the ability to recognise specific Results: Most of the participants recognised the presence of some sort of mental
disorders; knowing how to seek mental disorder: 72% for the depression vignette (correctly labelled as depression by 39%)
health information; knowledge of risk and 84% for the schizophrenia vignette (correctly labelled by 27%). When various
factors and causes, of self-treatments, people were rated as likely to be helpful or harmful for the person described in the
and of professional help available; and vignette for depression, general practitioners (83%) and counsellors (74%) were most
often rated as helpful, with psychiatrists (51%) and psychologists (49%) less so.
attitudes that promote recognition and
Corresponding data for the schizophrenia vignette were: counsellors (81%). GPs
appropriate help-seeking.
(74%), psychiatrists (71%) and psychologists (62%). Many standard psychiatric
The lifetime risk of developing a
treatments (antidepressants, antipsychotics, electroconvulsive therapy, admission to
mental disorder is so high (nearly 50%)2 a psychiatric ward) were more often rated as harmful than helpful, and some non-
that almost the whole population will at standard treatments were rated highly (increased physical or social activity, relaxation
some time have direct experience of and stress management, reading about people with similar problems). Vitamins and
such a disorder, either in themselves or special diets were more often rated as helpful than were antidepressants and
in someone close. A high public level of antipsychotics.
mental health literacy would make early
recognition of and appropriate inter- Conclusion: If mental disorders are to be recognised early in the community and
appropriate intervention sought, the level of mental health literacy needs to be raised.
vention in these disorders more likely.
Further, public understanding of psychiatric treatments can be considerably
Previous information on this topic is
improved.
limited and is derived from national sur-
veys on depression alone.>" or on MJA 1997; 166: 182-186
depression and schizophrenia." Although
these surveys found that most people report our findings on the ability of this Monitor." This is a household survey
believed depression to be treatable.>> population to recognise these disorders covering all private dwellings in urban
most respondents had negative views and their beliefs about the effectiveness and rural areas (excluding the sparsely
about the effectiveness of medication for of various treatments. settled areas) across all States and Ter-
mental disorders. In contrast, coun- ritories. Selected households were ini-
selling and psychotherapy were generally tially sent a letter explaining that their
viewed more favourably. 3,4,6 Methods dwelling had been selected for the
To assess the mental health literacy of Sample survey. The letters gave advance notice
the Australian population, we surveyed that an interviewer would call to make
a representative national sample of The survey was carried out by the Aus- an appointment. Interviewers made at
adults on their knowledge of and beliefs tralian Bureau of Statistics in August least three call-backs in rural areas and
about schizophrenia and depression. We 1995 as part of its Population Survey at least five in urban areas before a
dwelling was classified as "non-contact".
NHMRC Social Psychiatry Research Unit, The Australian National University,
Contact was made with a sample of
Canberra, ACT. 2531 households, with one person ran-
Anthony F Jorm, PhD, DSc, Deputy Director; Ailsa E Korten, BSc, Research Officer; domly sampled per household for a per-
Patricia A Jacomb, MSc, Research Assistant; Helen Christensen, PhD, Fellow; sonal interview; 2164 persons agreed to
Bryan Rodgers, PhD, Fellow; Penelope Pollitt, PhD, Research Fellow.
No reprints will be available. Correspondence: Dr A F jorm, NHMRC Social Psychiatry Research
participate (85%). Because a pilot study
Unit, The Australian National University, Canberra, ACT 0200. showed that people aged more than 75
E-mail: [email protected] years often had trouble understanding

182 MJA Vol 166 17 February 1997

 Research

Box 1: Depressio n vignette Box 2: Sch izop hrenia vignette

John is 30 years old . He has been feeling John is 24 and lives at home with his parents. He has had a few
unusually sad and miserable for the last few temporary jobs since finishing school but is now unemployed. Over
weeks. Even though he is tired all the tim e, the last six months he has stopped seeing his friend s and has begun
he has trouble sleeping nearl y every night . locking himself in his bedroom and refusing to eat with the family or
John doesn't feel like eating and has lost to have a bath . His parents also hear him walking about his bedroom
weight. He can't keep his mind on his work at night while they are in bed. Even though they know he is alone,
and puts off making decisions. Even they have heard him shouting and arguing as if someone else is there.
day-to -day tasks seem too mu ch for him. When they try to encourage him to do mor e things, he whispers that
This has come to the att ent ion of his boss, he won' t leave home because he is being spied upon by the neighbour.
who is con cern ed ab out John 's lowered They realise he is not taking drugs because he never sees anyone or
productiviry. goes anywhere.

the interview, this age group was • "What would you say, if anything, is Ethical approval
excluded, leaving a sample of 2031 wrong with John/Mary?" and Approval was obtained from the Ethics
respondents, aged 18-74. • "How do you think John/Mary could in Human Experimentation Committee
Fifty-six per cent of the sample was best be helped?" of the Australian National University.
female and 74% Australian-born. The
The rest of the interview consisted of
age distribution was: 21 % aged 18-29, Statistical analysis
questions to determine the respon-
25% aged 30-39, 22% aged 40-49,16%
dents' knowledge of and views about: Using the X2 test, all estimates were
aged 50-59, 11% aged 60-69 and 5%
• Various people who could help compared according to recognition of a
aged 70-74. The highest educational
(whether each category of person was mental health problem. Only differences
qualification was: secondary school cer-
likely to be helpful, harmful, or nei- significant at the 0.01 level (P:% 0.01)
tificate (51 %), trade certificate/appren-
are reported below.
ticeship (11 %), other certificate (17%), ther, for the person described);
associate or undergraduate diploma • A range of possible treatments
(7%), bachelor's degree or higher (13%), Results
(whether each treatment was likely to
still at school (1 %). Weights were pro- be helpful, harmful, or neither, for the Of the 2031 persons interviewed, 1010
vided for each respondent, based on were shown the depression vignette
person described);
complex ratio estimation procedures, to (508, John and 502, Mary) and 1021
• Knowledge of likely prognosis; were shown the schizophrenia vignette
adjust for probabilities of selection and
to reduce non-response bias.? Weighted • Knowledge of risk factors; and (514, John and 507, Mary).
percentages, which represent estimates • Beliefs associated with stigma and
of the whole of the Australian population discrimination. Recognition
aged 18-74, are presented here. Figure 1 summarises responses
Depression
to the question "What would
you say, if anything, is wrong
Interview
Schizophrenia with John/Mary?", and shows
The interview was based on a those categories mentioned by
vignette of a person suffering Mental problem at least 5% of the respondents
from a mental disorder. Half the (all responses were later cate-
Mental illness
sample were shown a vignette gorised by the researchers).
describing a person who met Emotiona l symptoms Multiple responses were
lCD-lOS and DSM-IV9 criteria
for major depression (Box 1)
and the others were shown a Self·esteem ==;:..... allowed, and 30% of respon-
dents gave at least two answers.
For the depression vignette,
vignette of a person who met
lCD-lOS and DSM-IV9 criteria
for schizophrenia (Box 2). The
sex of the person described was
randomly assigned to be male
Stress

Has a probfem

Physical condition
=:::'. • Depression vignette
39% correctly identified depres-
sion and 22% mentioned stress.
In all, 72% mentioned a cate-
gory that could be regarded as
being within the sphere of
• Schizophrenia vignette
(John) or female (Mary). Don't know mental health. Eleven per cent
After being shown the mentioned items that we cate-
o 5 10 15 20 25 30 35 40
gorised as physical disorders
vignette and having it read
out to them, respondents Figure 1: Percentage of respondents mentioning each category (e.g., viruses, nutritional defi-
to describe the problem shown in the vignette. ciencies, cancer), and half of
were asked two open-ended
questions: these respondents did not men-

MJA Vol 166 17 February 1997 183

Research

tion a mental problem. A further 17%

Harmful (%) Helpfu l (%)
gave only answers that were extremely
GP a: People who could help I variable, but which we grouped as "per-
sonal or employment-related problems",
Counsellor
. . Depression vignette "problems with not being active or
Close friend s
Schizophrenia vigne tte sociable enough", and "other". Seven per
cent of the sample responded with
Close family "don't know".
Phone counse lling
For the schizophrenia vignette,
although 84% mentioned at least one
Psychiatrist category in the sphere of mental health,
only 27% recognised schizophrenia and
Psvcho loqist a further 26% mentioned depression.
Social worke r
Physical disorders were the only sug-
gestion from 2% of the respondents,
Clergy while 13% gave responses that described
neither physical nor mental disorders
Naturopathlh erbalist (e.g., "has a problem"). There was less
Deal with it alone
uncertainty with the schizophrenia
vignette, however, in that only 4%
Chemist responded with "don't know".

Vitamins. minerals b: Medications I Choice and rating of available help

Antidepressants For the second open-ended question -

"How do you think John/Mary could
Sleeping pills best be helped?" - 34% of the respon-
dents (across both vignettes) made
Pain relievers
more than one suggestion.
Antibiotics
For the depression vignette, the most
frequent response was "see a doctor"
Tranquillisers (44%), followed by "see a counsellor"
(23%) and "talk over with family or
Antipsychotics
friends" (20%). A psychiatrist was men-
tioned by 8%, while 5% answered
Get out more c:Traalmenls I "don't know".
- - - - - - - - - - - - - - - _. ----------- - - --
Responses for the schizophrenia
Physical activity
vignette were: counsellor (31 %), psy-
- ---- ---- - - - - - - -- - - ----- --- - - - --
chiatrist (28%), doctor (27%), family or
learn relaxation
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- friends (20%) and "don't know" (4%).
Read about problem The respondents were given a list of
- - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - people who might potentially provide
Cut out alcoho l help and were asked to rate the various
helpers by saying whether each would be
Special diet
helpful or harmful (Figure 2a).
Occasional drink For the depression vignette, most of
the respondents regarded GPs (83%),
Psychotherapy counsellors (74%), close friends (73%)
and close family (70%) as helpful;
Hypnosis
around half the population rated tele-
phone counselling services (53%), psy-
Psychiatric ward
chiatrists (51 %) and psychologists
ECT
(49%) as helpful. Fewer than 10% felt
that any of the above groups would be
100 50 a 50 100 harmful, although 43% believed it would
Harmful (%) Helpfu l (%)
be harmful for someone with depression
Figure 2: Percentage of respondents rating each type of help as harmful or helpful for the to deal with it on their own. For the
person described in the vignette. ECT = electroconvulsive therapy. schizophrenia vignette, most respon-
dents regarded counsellors (81 %), GPs

184 MJA Vol 166 17 February 1997

 Research

(74%) and psychiatrists (71 %) as help- vary according to whether or not the res- Only half the respondents thought that
ful; a larger proportion of the population pondent thought the person in the a psychiatrist or psychologist would be
than for the depression vignette believed vignette had a mental health problem, helpful for the person in the depression
it would be harmful to try and deal with the respondents were divided accord- vignette, a proportion less than that
such problems alone (55%). ingly. The major difference in findings cited for GPs, counsellors, close friends,
was that those who did not perceive a family, and telephone counselling. While
mental health problem were more likely psychiatrists and psychologists were
RaUngofpharmacologicalueatments to rate treatments as "neither helpful nor rated as relatively more helpful for the
harmful" or to respond "don't know" . person in the schizophrenia vignette,
Respondents were given a list of phar-
However, the rank ordering of treat- they were nevertheless less likely to be
macological treatments (Figure 2b) to
ments in terms of helpfulness was gen- rated as helpful than counsellors or GPs.
rate as helpful or harmful. For the
erally similar. Spearman rank correlation This suggests that public perceptions of
depression vignette, more of the respon- mental health specialists need to be
coefficients for the depression vignette
dents regarded each of the medications changed.
were 0.82 (people), 0.90 (medicines)
as harmful than helpful. The exception Ratings given for the helpfulness of
and 0.98 (treatments), and for the
was the category vitamins, minerals, various treatments for depression are not
schizophrenia vignette they were 0.87
tonics or herbal medicines, which were (people), 0.71 (medicines) and 0.98 consistent with the evidence of con-
regarded as helpful by 57% of respon- (treatments). trolled trials, which have indicated that
dents, and as harmful by 3%. Antide- both antidepressant medication and
pressant medication was recognised as psychotherapy are effective treat-
helpful by 29% and as harmful by 42% Prognosis
ments.w-'! Antidepressants were rated as
of respondents. For the schizophrenia All respondents were asked to give their helpful by 29% of our sample and as
vignette, antidepressants were regarded views on prognosis with and without the harmful by 42%, while psychotherapy
as helpful by 38% of respondents, fol- professional help they thought most was rated as helpful by 34% and harm-
lowed by vitamins and minerals (34%) appropriate. For the depression vignette, ful by 13%. Both were regarded as less
and antipsychotics (23%). The greatest 80% thought that there would be full helpful than treatments such as vitamins
percentage of "don't know" responses recovery with help. If there was no help, and minerals and special diets. The
was for antipsychotics (about one-fifth 56% believed the person would get treatment with the highest negative
of the respondents for both vignettes). worse, and 5% that there would be full rating was ECT. Although the patient
recovery. For the schizophrenia vignette, described to the respondents could not
Rating of non-pharmacological 69% believed that help would result in be regarded as severely depressed
treatments full recovery; if there was no help, 75% enough to warrant ECT, II there is
believed that the person would get clearly a public perception that this
When respondents were asked to rate worse, and 3% that there would be full treatment is harmful. The treatments
non-pharmacological treatments (Figure recovery. that the public rated most highly were all
2c), most (for both the depression and non-standard in nature. These views
the schizophrenia vignettes) regarded may not be entirely misguided; there is
non-standard interventions (more phys- Discussion evidence (e.g., from controlled trials)
ical or social activity; learn relaxation that physical exercise may have a positive
[including stress management, medita- Recognition of the presence of a mental effect on depression.P
tion or yoga courses]; reading about disorder was high in our population The findings were similar for the
people with similar problems) as helpful sample, although only a minority gave schizophrenia vignette. Although con-
and not harmful. On the other hand, the correct psychiatric label to their trolled trials show that antipsychotic
most regarded admission to a psychiatric vignette. While it is not known whether medication is an effective treatment, 13
ward as harmful (depression, 62%; there is any benefit to the public in being this was rated as helpful by 23% of the
schizophrenia, 51 %) and most regarded able to apply the correct psychiatric respondents and harmful by 34%; 20%
having electroconvulsive therapy (ECT) label, misidentifying a mental disorder did not offer an opinion. Similarly,
as harmful (depression, 72%; schizo- as a physical one or as a problem unre- admission to a psychiatric ward, which
phrenia, 66%). For the depression lated to health may lead to inappropri- can be useful in the management of
vignette, psychotherapy was seen as ate use or avoidance of health services. schizophrenia,'> was rated as harmful by
helpful by 34% and harmful by 13%, The major limitation in recognition is half the respondents. As with depres-
compared with 55% helpful and 7% therefore seen in the 28% who thought sion, non-standard interventions were
harmful for the schizophrenia vignette. the person described in the depression the most likely to be rated as helpful.
The highest number of "don't know" vignette did not have a mental disorder Despite these negative opinions of, or
responses was elicited for psychotherapy and the 16% who had the same opinion ignorance about, the helpfulness of
(16% for depression, 15% for schizo- about the person in the schizophrenia many standard treatments, the public
phrenia) and for ECT (10% for depres- vignette. clearly sees the conditions described in
sion and 14% for schizophrenia) (data When respondents were asked about the vignettes as treatable. The predom-
not shown). the helpfulness of various people, GPs inant belief that mental disorders are
As opinions about treatment might were rated very highly for both vignettes. treatable has also been found in overseas

MJA Vol 166 17 February 1997 185

Research

surveys. v' although a United States health literacy in the population should 6. Ang ermeye r MC, Matschinger H. Publ ic attitude
survey found that most respondents be raised. There has been considerable towards psychiatric treatment. Acta Psychiatr Scand
1996; 94: 326-336.
believed it possible to get better through interest in trying to improve the recog- 7. Australian Bureau of Statistics. Population survey mon-
one's own efforts." nition and management of mental dis- itor, AuguSl1995 (No. 4103.0). Adelaide : ABS, 1995.
There were some marked differences orders in primary care, IO.14 but this 8. World Health Organization. The ICD-10 classification
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The Ramaciotti Medal Glaxo Wellcome Australia

The Ramaciotti Medal for excellence Medal
in biomedical research has been The 1996 Wellcome Australia Medal
awarded to Professor Max Bennett has been awarded to Dr Michael
(right, below), Professor of Physiology Berndt (left, above), Associate Direc-
at the University of Sydney, for his dis- tor at the Baker Medical Research
covery of non-adrenergic and non- Institute in Melbourne. Dr Berndt was
cholinergic neurotransmitters. awarded the Medal for identifying the
The award included a cash prize of structure and function of receptors that
$10000, with which Professor Bennett mediate platelet and neutrophil inter-
will endow an annual award for the actions with blood vessels.
best research paper by a PhD student The award included a grant of
at the recently formed Institute for $20000, expected to fund further
Biomedical Research at the University research.
of Sydney. The annual Glaxo Wellcome Medal
This is the second Ramaciotti and Award, inaugurated by Wellcome
Medal awarded since its inception; Australia in 1980, was renamed the
the inaugural Medal was awarded in Glaxo Wellcome Australia Medal in
1995 to Professor John Coghlan, 1996 , It is presented to a scientist, usu-
then Director of the Howard Florey ally younger than 45 years of age, who
Institute of Experimental Physiology is not a member of a commercial
and Medicine, in Melbourne, for his organisation. Previous winners of the
work in hybridisation histochemistry. award, which is made on the recom-
The Medal is awarded by the Clive mendation of representatives from the
and Vera Ramaciotti foundations that Australian Academy of Science, the
have distributed more than $25 mil- Australian Academy of Technological
lion for medical research since their Sciences and Engineering and Glaxo
inception in 1970; the foundations are Wellcome Australia Ltd., include Pro-
managed by Perpetual Trustees Aus- fessors Ian Gust, John Funder, Ian
tralia Limited. McCloskey and Susan Pond.

186 MJA Vol 166 17 February 1997