Mental health first aid training for high school teachers: a cluster randomized trial

The Building Educators' Skills in Adolescent Mental Health Training Program for Secondary School Educators: Protocol for a Cluster Randomized Controlled Trial

Background

In Australia, secondary school educators are well positioned to recognize mental illness among students and provide support. However, many report that they lack the knowledge and confidence to do so, and few mental health training programs available for educators are evidence based. To address this gap, the Black Dog Institute (BDI) developed a web-based training program (Building Educators’ Skills in Adolescent Mental Health [BEAM]) that aims to improve mental health knowledge, confidence, and helping behaviors among secondary school educators in leadership positions. A pilot study of the training program found it to be positively associated with increased confidence and helping behaviors among educators and reduced personal psychological distress. An adequately powered randomized controlled trial (RCT) is needed.

Objective

The primary objective of this cluster RCT is to evaluate the effectiveness of the BEAM program for improving educators’ confidence in managing student mental health. The trial will also evaluate the effect of the BEAM program in increasing educators’ frequency of providing help to students and improving their mental health knowledge and reducing educators’ psychological distress and stigma toward students with mental health issues.

Methods

The target sample size is 234 educators from 47 secondary schools across New South Wales, Australia. Four waves of recruitment and enrollment into the trial are planned. Schools will participate in one wave only and will be randomized to the intervention or waitlist control conditions. Participants from the same school will be assigned to the same condition. Assessments will be conducted at baseline, posttest (10 weeks after baseline), and follow-up (22 weeks after baseline) using the BDI eHealth research platform. Intervention participants will receive access to the BEAM program for 10 weeks upon completion of baseline, and the control condition will receive access for 10 weeks upon completion of the follow-up assessment.

Results

Recruitment for this trial began on July 21, 2020, with the first baseline assessments occurring on August 17, 2020. To date, 295 participants from 71 schools have completed baseline. Due to the unexpected success of recruitment in the first 3 waves, the final fourth wave has been abandoned. Intervention participants are currently receiving the program, with follow-up due for completion in March 2021.

Conclusions

This is one of the first RCTs to examine the effectiveness of a web-based adolescent mental health training program for Australian secondary school educators in leadership positions. If found to be effective, this training program will offer a sustainable and scalable delivery method for upskilling educators in caring for students’ mental health.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12620000876998; https://covid-19.cochrane.org/studies/crs-14669208

International Registered Report Identifier (IRRID)

DERR1-10.2196/25870

Review of Australian initiatives to reduce stigma towards people with complex mental illness: what exists and what works?

Background

Australian national mental health policy outlines the need for a nationally coordinated strategy to address stigma and discrimination, particularly towards people with complex mental illness that is poorly understood in the community. To inform implementation of this policy, this review aimed to identify and examine the effectiveness of existing Australian programs or initiatives that aim to reduce stigma and discrimination.

Method

Programs were identified via a search of academic databases and grey literature, and an online survey of key stakeholder organisations. Eligible programs aimed to reduce stigma towards people with complex mental illness, defined as schizophrenia, psychosis, personality disorder, or bipolar disorder; or they focused on nonspecific ‘mental illness’ but were conducted in settings relevant to individuals with the above diagnoses, or they included the above diagnoses in program content. Key relevant data from programs identified from the literature search and survey were extracted and synthesized descriptively.

Results

We identified 61 programs or initiatives currently available in Australia. These included face-to-face programs (n = 29), online resources (n = 19), awareness campaigns (n = 8), and advocacy work (n = 5). The primary target audiences for these initiatives were professionals (health or emergency), people with mental illness, family or carers of people with mental illness, and members of the general population. Most commonly, programs tended to focus on stigma towards people with non-specific mental illness rather than on particular diagnostic labels. Evidence for effectiveness was generally lacking. Face-to-face programs were the most well-evaluated, but only two used a randomised controlled trial design.

Conclusions

This study identified areas of strength and weakness in current Australian practice for the reduction of stigma towards people with complex mental illness. Most programs have significant input from people with lived experience, and programs involving education and contact with a person with mental illness are a particular strength. Nevertheless, best-practice programs are not widely implemented, and we identified few programs targeting stigma for people with mental illness and their families, or for culturally and linguistically diverse communities, Aboriginal and Torres Strait Islander communities and LGBTIQ people. These can inform stakeholder consultations on effective options for a national stigma and discrimination reduction strategy.

Psychotherapy and youth suicide prevention: An interpretative phenomenological analysis of specialist clinicians' experiences

The study explored psychologists' experiences in delivering short-term psychotherapy for suicidal adolescents and sought to clarify how these experiences fit with empirically supported interventions and the interpersonal psychological theory of suicide. Semistructured interviews were conducted with 12 psychologists' who provided short-term psychotherapy in a suicide prevention programme for youth (12- to 25-year-olds). Interview transcripts were analysed using interpretative phenomenological analysis. Three superordinate themes were identified: (i) understand the experience and context of the suicidality and the importance of a formulation-based approach to engagement and individualized treatment planning; (ii) involve broad support systems, and in particular families, to help the young person reduce feelings of burdensomeness and increase safety, connectedness and belonging; and (iii) improve affect regulation and reflective functioning, important not only for the young person but also for the support system to maximize the positive impact of supports via emotional coregulation and effective problem-solving. Interventions and approaches as well as the potential underlying processes of change being targeted are discussed in light of these findings. As an example, the development of a suicide safety plan was an intervention that traversed these themes. When used as a process tool, it helped foster a collaborative, formulation, dimensional and biopsychosocial approach to treat psychopathology and suicidality and extended beyond the therapist-client dyad. Moreover, treatment needs to be extended beyond the therapist-client dyad to allow therapists to facilitate a systemic treatment response, as this was seen as a major component of interventions for suicidal youth.

Beliefs about students’ mental health issues among teachers at elementary and high schools, Hail Governorate, Saudi Arabia

Background

Teachers’ awareness about and attitude towards students’ with mental health issues are often affecting their practical role in proper care of students with mental health problems. This is a cross-sectional study carried out among teachers in elementary (primary and middle) and secondary schools in Hail Governorate, Kingdom of Saudi Arabia (KSA). The objective of the study was to assess teachers’ awareness about and attitude towards student’s mental health issues through a response to a pretested constructed, semi-structured, anonymous self-administered questionnaire included 38 items.

Results

Consenting teachers returned 2398 completed questionnaires with response rate of 60.0%. Majority of respondents possessed favorable attitudes towards students with mental health issues attained 74.7% attitude score on a scale of maximum 55 points but revealed less awareness with students’ mental health issues; they just attained 55.1% awareness score.

Teachers acknowledged the importance of providing training programs regarding mental health issues for teachers (73.7%) and for other school staff (76.2%), availability of psychologist in schools (81.1%), providing schools with educational materials regarding students’ mental health (78.1%), providing telephone hotline to support dealing with students’ with mental health issues (78.5%), and promoting general media to increase community awareness with mental health (84.4%).

Conclusion

The current study gives insight to policy makers about teachers’ awareness and attitude they have towards mental health issues in schools. Training programs in mental health appear to be crucial for teachers. Providing enough resources for schools to support their roles in mental health will advance healthy development in children.

An Assessment of the Utility of the Youth Mental Health First Aid Training: Effectiveness, Satisfaction, and Universality

Youth Mental Health First Aid (YMHFA) is a training program developed to educate child-serving professionals on how to properly identify and respond to mental health needs among children and adolescents. The current study tested the utility of the training by examining the effectiveness, satisfaction, and universality across child-serving occupations. Data collected from 893 child-serving professionals was used to compare training effectiveness and training experiences across four different occupational settings (child welfare, education, support services, and the justice system). Using a pretest/posttest survey design, strong support for the effectiveness of YMHFA (i.e. knowledge, confidence, preparedness, and intentions to intervene), satisfaction with the training program, and universality of effectiveness and satisfaction across the occupational groups was found. Results highlight the utility of YMHFA across different sectors of child-serving agencies and support its sustainability.

Long-term effects of Youth Mental Health First Aid training: randomized controlled trial with 3-year follow-up

BACKGROUND

Mental Health First Aid (MHFA) training teaches community members how to provide initial support to someone with a mental health problem. Key gaps in the evidence base supporting the training are the longevity of effects beyond 6 months, effects on mental health first aid behavior, and the impact of support on the recipient of aid. This study aimed to evaluate the effect of the Youth MHFA course 3 years after training.

METHODS

384 Australian parents of an adolescent aged 12-15 were randomized to receive either the 14-h Youth MHFA course or the 15-h Australian Red Cross Provide First Aid course. This paper reports outcomes at baseline and 3 years later. Primary outcomes were cases of adolescent mental health problems, and parental support towards their adolescent if they developed a mental health problem, rated by the parent and adolescent. Secondary outcomes included parent knowledge about youth mental health problems, intentions and confidence in supporting a young person, stigmatizing attitudes, and help-seeking for mental health problems. Data were analyzed with mixed-effects models with group by measurement occasion interactions.

RESULTS

3-year follow-up data was obtained from 149 parents and 118 adolescents, who were aged 16.5 years on average. Between baseline and 3-year follow-up, there was a non-significant reduction in adolescent cases of mental health problems relative to the control group (odds ratios (OR) 0.16-0.17), a non-significant improvement in parental support reported by adolescents with a mental health problem (OR 2.80-4.31), and a non-significant improvement in the quality of support that parents reported providing to their adolescents with a mental health problem (d = 0.38). Secondary outcomes that showed significant improvements relative to the control group were parental knowledge about youth mental health problems (d = 0.31) and adolescent perceptions of general social support from their parents (d = 0.35).

CONCLUSIONS

This paper reports on the longest follow-up of Mental Health First Aid training in a controlled trial. Three years after training, participants had maintained their improved knowledge about mental health problems. There were some indications of other positive effects, but the study was underpowered to clearly show benefits to mental health first aid skills and recipients of aid.

TRIAL REGISTRATION

ACTRN 12612000390886 , registered retrospectively 5/4/2012, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=347502.

Mental Health Literacy Intervention on Help-Seeking in Athletes: A Systematic Review

Mental health literacy (MHL) is recognised as a major factor in whether athletes seek help when they experience mental health difficulties. Therefore, the current study aimed to provide a systematic review of the effectiveness of MHL training programmes in improving mental health knowledge and help-seeking and reducing stigma among athletes. To identify intervention studies of MHL programmes, five electronic databases were systematically searched for articles published before May 2020. The selection procedure was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All kinds of study designs were included. Effect sizes were calculated for mental health knowledge, stigma reduction and help-seeking attitudes, intentions and behaviours. Risk of bias was assessed for each study using the Cochrane tool and the Newcastle–Ottawa quality assessment scale. Five studies (1239 participants in total) were selected for review. Overall, either small or medium effects were found for mental health knowledge, stigma reduction, help-seeking attitudes, and intentions for post- and follow-up interventions, whereas a null effect was found in help-seeking behaviours for both post- and follow-up interventions. Furthermore, three studies had a low risk of bias, and two had a high risk of bias. MHL interventions can enhance help-seeking attitudes and intentions and mental health knowledge and reduce stigma but do not increase help-seeking behaviours for now. Further studies should evaluate interventions to enhance help-seeking behaviours. Furthermore, the methodological quality of studies, including randomized controlled trials and other designs, should be improved in future research.

Delivery of a Mental Health First Aid training package and staff peer support service in secondary schools: a process evaluation of uptake and fidelity of the WISE intervention

BACKGROUND

Improving children and young people's provision for mental health is a current health priority in England. Secondary school teachers have worse mental health outcomes than the general working population, which the Wellbeing in Secondary Education (WISE) cluster randomised controlled trial aimed to improve. The WISE intervention comprised a Mental Health First Aid (MHFA) training package delivered to at least 16% of staff, a short mental health awareness session to all teachers and development of a staff peer support service. Twenty-five schools were randomised to intervention or control arms. This paper reports findings regarding the extent of uptake and fidelity of the intervention.

METHODS

Mixed methods data collection comprised researcher observations of training delivery, training participant evaluation forms, trainer and peer supporter interviews, peer supporter feedback meetings, logs of support provided, and teacher questionnaires. Quantitative data were summarised descriptively, while thematic analysis was applied to the qualitative data.

RESULTS

In the 12 schools assigned to the intervention arm, 113 (8.6%) staff completed the 2-day standard MHFA training course, and a further 146 (11.1%) staff completed the 1-day MHFA for schools and colleges training. In seven (58.3%) schools, the required 8% of staff completed the MHFA training packages. A 1-h mental health awareness-raising session was attended by 666 (54.5%) staff. Delivery of the MHFA training package was achieved with high levels of fidelity and quality across schools. All schools set up the peer support service following training, with a majority adhering to most of the operational guidelines developed from the pilot study at the outset. Teachers reported limited use of the peer support service during follow-up. At the 1-year follow-up, only three (25.0%) schools indicated they had re-advertised the service and there was evidence of a reduction in support from senior leadership.

CONCLUSION

The MHFA training package was delivered with reasonably high fidelity, and a staff peer support service was established with general, but not complete, adherence to guidelines. In some schools, insufficient staff received MHFA training and levels of delivery of the peer support service compromised intervention dose and reach.

TRIAL REGISTRATION

ISRCTN 95909211 . Registered on 15 January 2016.

Evaluation of Mental Health First Aid from the Perspective Of Workplace End UseRs-EMPOWER: protocol of cluster randomised trial phase

Background

Mental Health First Aid (MHFA) is a mental health intervention that teaches people how to identify, understand and help someone who may be experiencing a mental health issue. Reviews of the implementation of MHFA found between 68 and 88% of trained Mental Health First Aiders had used their skills when in contact with someone experiencing mental health difficulties. Reviews evaluating the impact of MHFA suggest positive outcomes. However, to date, there has been no systematic, rigorous evaluation of the impact of MHFA on recipients of the intervention, the organisations providing it and the cost-effectiveness of MHFA overall. This trial will evaluate the effectiveness and cost-effectiveness of MHFA.

Methods

The study is a multi-centred, two-arm clustered randomised controlled trial. Organisations will be randomly allocated to the control or intervention (estimated sample size 800 recipients). The intervention is the standard MHFA intervention provided by Mental Health First Aid England (MHFAE). The control condition will be organisations having a brief consultation from MHFAE on promoting mental health and well-being in the workplace. The primary outcome is health seeking behaviour, measured using the Actual Help Seeking Questionnaire, at 6 months’ follow-up. Data collection will be undertaken at baseline (T0), post-intervention—up to 3 months (T1), at 6 months (T2), 12 months (T3) and 24 months (T4). The primary analysis will be conducted on those participants who receive MHFA, a per protocol analysis.

Discussion

The study is the first to evaluate the effect of MHFA in the workplace on employees with direct and indirect experience of the intervention, when compared with usual practice. Being also the first to assess, systematically, the social impact of MHFA and investigate its cost-effectiveness adds to the originality of the study. The study promises to yield important data, as yet unknown, regarding the effectiveness, cost-effectiveness, implementation issues, and the sustainability of MHFA in the workplace.

Trial registration

Clinicaltrials.govNCT04311203. Registered on 17 March 2020.

ThriveNYC: Delivering on Mental Health

Promoting population mental health and meeting the burdens of mental illness is a priority public health challenge of the 21st century. But too little attention has been placed on how to design and sustain the scope of strategies and commitments that credibly live up to the full breadth of that challenge. ThriveNYC is an effort by New York City to fill that gap, through a public health approach backed by investment in resources and leadership. ThriveNYC can by example help mobilize a larger community of investigators and policymakers to consider how to meet this challenge, to get to consensus on key elements for effective action and implementation, to reimagine who and what the mental health "system" includes, and, in doing so, to strengthen the social contract that underlies well-being.

Confidence and motivation to help those with a mental health problem: experiences from a study of nursing students completing mental health first aid (MHFA) training

BACKGROUND

Those studying nursing are at greater risk for developing mental health problems than other tertiary students. Mental Health First Aid (MHFA) training may assist students to support peers and build mental health literacy. Understanding motivation to participate in training can identify factors influencing uptake and completion. This paper explores motivators for university nursing students to participate in MHFA training and uses previous experience and confidence in assisting someone with a mental health problem to triangulate data.

METHOD

A randomised controlled trial was employed to measure the impact of the course for nursing students at a large Western Australian university. An online survey was administered prior to MHFA training with undergraduate nursing students (n = 140). Thematic analysis of open-ended questions explores motivators to participate and help provided to an individual. Baseline frequencies describe demographics, confidence in helping and exposure to someone with a mental health problem. A Chi Square test compared confidence in helping and exposure to someone with a mental health problem.

RESULTS

More than half of participants reported contact with individuals experiencing mental health problems (55%; n = 77); approximately a third (35.8%) reported limited confidence to assist. Those in previous contact with someone with a mental health problem (71.5%; n = 55) were significantly more likely to feel confident in helping (p = 0.044). Mental health literacy, helping others, career and experiences were described as training motivators.

CONCLUSION

Exploiting motivators, both intrinsic and extrinsic may increase MHFA training uptake and completion. Tertiary institutions would benefit from policy to embed MHFA training into nursing degrees. The training may have utility for university degrees more broadly.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry; ACTRN12614000861651. Registered 11 August 2014 (retrospectively registered).

Mental Health First Aid training and assessment among university students: A systematic review

OBJECTIVE

To explore the literature describing the delivery and assessment of Mental Health First Aid (MHFA) training among university students.

DATA SOURCES

The databases MEDLINE, PreMEDLINE, CINAHL, EMBASE, ERIC, and PsycINFO were searched to identify publications describing MHFA training and assessment among university students since 2000.

STUDY SELECTION

All studies, regardless of design, that described the delivery and assessment of MHFA training among university students, at any level, were included in this systematic review.

DATA EXTRACTION

The discipline and level of students; the version, length, and integration of MHFA training; and the constructs used to assess students post-MHFA training were extracted from each study.

RESULTS

Of the initial 1662 records, 12 were included. Eight studies were conducted in Australia, 3 in the United States, and 1 in the United Kingdom. Most students were enrolled in health care or social work degree programs across all years of their program with 4 studies involving pharmacy students. Three studies described integrating compulsory MHFA training for university students. Most studies reported on the delivery of the Standard or Adult version of MHFA training; no study reported on MHFA for Tertiary Students. Post-MHFA training, students were assessed on mental health knowledge, literacy, intentions, confidence, stigma, and skills application. Only 2 studies described assessment methods involving direct observation of behaviors, whereas the rest relied on self-reported measurements.

CONCLUSION

Despite the spread of MHFA to over 25 countries and the availability of tertiary student-specific training, the studies included in this systematic review were conducted in only 3 countries and mainly involved Standard and Adult MHFA training. Most assessments relied on self-reported measures. Future studies involving different versions of MHFA training, and the exploration of novel competency-based assessment methods among a diverse range of students from different countries are warranted.

Mental health first aid for the UK Armed Forces

Education programmes in mental health literacy can address stigma and misunderstanding of mental health. This study investigated self-rated differences in knowledge, attitudes and confidence around mental health issues following participation in a bespoke Mental Health First Aid (MHFA) training course for the Armed Forces. The mixed methods approach comprised quantitative surveys and qualitative interviews. A survey, administered immediately post-training (n = 602) and again at 10-months post-attendance (n = 120), asked participants to rate their knowledge, attitudes and confidence around mental health issues pre- and post-training. Quantitative findings revealed a significant increase in knowledge, positive attitudes and confidence from the post-training survey which was sustained at 10-months follow-up.Semi-structured telephone interviews (n = 13) were conducted at follow-up, 6-months post-attendance. Qualitative findings revealed that participation facilitated an ‘ambassador’ type role for participants. This study is the first to have investigated the effect of MHFA in an Armed Forces community. Findings show participants perceived the training to increase knowledge regarding mental health and to enhance confidence and aptitude for identifying and supporting people with mental health problems. Results suggest that such an intervention can provide support for personnel, veterans and their families, regarding mental health in Armed Forces communities.

Mental health literacy programs for school teachers: A systematic review and narrative synthesis

AIM

The prevalence of mental disorders increases sharply during adolescence. Therefore, school teachers are in a good position to provide initial assistance to students with mental health problems. Although effects of a number of mental health literacy programs aimed at teachers have been reported, they have not yet been reviewed in a systematic manner. This study conducted a systematic review of the effectiveness of mental health literacy programs for teachers.

METHODS

PubMed, PsycINFO, CINAHL, ERIC, Web of Science and reference lists of included studies were searched in September 2018. Studies that quantitatively measured at least one of the main components of mental health literacy, including (a) knowledge of mental illnesses, (b) stigma towards mental illnesses, (c) confidence in helping students, and (d) behaviour of helping students, were included regardless of study design. Risk of bias was rated for each included study according to the Cochrane tool for randomized studies and the Cochrane tool, for raondomized studies, and the Risk of Bias Assessment Tool for Nonrandomized Studies (RoBANS), for nonrandomized studies.

RESULTS

Sixteen studies met the inclusion criteria, including 1 randomized controlled trial (RCT), 2 cluster RCTs, 1 controlled before-and-after study and 12 case series. Most of the studies claimed significant improvement of knowledge, attitudes, behaviour and/or confidence. However, the overall quality for all outcomes was relatively low; 15 studies had high/unclear risk of bias due to lack of allocation concealment, not controlling for confounders, and/or inadequate analysis for attrition.

CONCLUSIONS

More high quality evidence is required before the effectiveness of mental health literacy programs for teachers can be established.

Twelve-month outcomes of MAKINGtheLINK: A cluster randomized controlled trial of a school-based program to facilitate help-seeking for substance use and mental health problems

BACKGROUND

Young people experiencing mental health problems are often reluctant to seek help, particularly from professionals (i.e., doctors or mental health workers). MAKINGtheLINK is a school-based intervention that aims to help adolescents overcome barriers to seeking professional help for mental health and substance use problems.

METHODS

A cluster randomised controlled trial was conducted to evaluate the 12-month outcomes of MAKINGtheLINK among 2447 participants (Mean age=14.9 years, SD=0.5 years, 50% male). Randomisation resulted in 1130 students from 11 schools allocated to receive the intervention, and 1317 students from 10 schools allocated to the wait-list control group. After the baseline assessment, follow-ups were conducted at 6-weeks (n = 2045), 6-months (n = 1874), and 12-months (n = 1827). The primary outcome measure was help-seeking behaviour, from both formal (e.g., health professionals) and informal (e.g., friends, family members) sources. The trial was registered with the Australia and New Zealand Clinical Trials Register (ANZCTR) on the 27th of February 2013 (registration number ACTRN12613000235707).

FINDINGS

The intervention was not associated with overall help-seeking at the 12-month follow-up (p = 0.99, odds ratio [OR]=1.00, 95% CI for OR = 0.70-1.42), or help-seeking for depression (p = 0.28, OR = 1.21, 95%CI =0.86-1.69), stress and anxiety (p = 0.73, OR = 1.04, 95%CI = 0.74-1.47), or alcohol/other drugs (p = 0.84, OR=1.12, CI=0.37-3.37). However, the intervention was associated with increased help-seeking from formal sources (compared to informal sources) both overall (p = 0.005, OR = 1.81, 95%CI = 1.19-2.75), as well as for depression (p = 0.01, OR=2.09, 95%CI=1.19-3.67), and stress and anxiety (p < 0.006, OR = 1.72, 95%CI = 1.17-2.54).

INTERPRETATION

Rates of help-seeking remained unchanged following the intervention. However, MAKINGtheLINK effectively improved the quality of adolescent help-seeking behaviour by increasing help-seeking from formal sources. As prompt treatment is essential in reducing the long-term impact of early onset mental health problems, MAKINGtheLINK has the potential to make a significant contribution to existing early intervention and prevention efforts.

FUNDING

National Health and Medical Research Council (APP1047492).

A Randomized Controlled Trial Evaluating the Effectiveness of Face-to-Face and Digital Training in Improving Child Mental Health Literacy Rates in Frontline Pediatric Hospital Staff

Background: Children with chronic physical health conditions are up to six times more likely to develop a mental health condition than their physically well peers. Frontline pediatric hospital staff are in a good position to identify mental health problems and facilitate appropriate support for patients. To date, no evaluation of mental health literacy training has taken place with this professional group to enable early identification of difficulties. It is also not known whether face-to-face or digital training is more effective or preferable in this setting. To improve the skills of frontline hospital staff, a face-to-face and digital mental health literacy training course was delivered using MindEd content and evaluated in a randomized controlled trial. Method: Two-hundred and three frontline staff across different professions from a tertiary pediatric hospital were randomized to a face-to-face (n = 64), digital (n = 71), or waitlist control group (n = 68). Face-to-face training was two and a half hours and digital training took ~1 h. The effects of training were evaluated pre- and post-training and at two-week follow-up. Questionnaires assessed mental health knowledge, stigma, confidence in recognizing concerns and knowing what to do, actual helping behavior, as well as training delivery preference, completion rate, and satisfaction. Results: Both face-to-face and digital training increased mental health knowledge, confidence in recognizing mental health problems and knowing what to do compared to waitlist controls. Digital training increased actual helping behavior relative to the waitlist controls and stigma decreased across all groups. Staff were satisfied with both delivery methods but preferred face-to-face training. Conclusions: The results provide promising findings that digital content is an effective way of improving mental health literacy in frontline pediatric hospital staff. Providing digital training could be a time-efficient way of upskilling non-mental health professionals to identify mental health needs in a pediatric population and facilitate access to appropriate care.

Interventions to improve children's access to mental health care: a systematic review and meta-analysis

AIMS

Mental disorders in children are a significant and growing cause of morbidity worldwide. Although interventions to help overcome barriers along the pathway to accessing health care for children with mental disorders exist, there is no overview of randomised controlled trials (RCTs) on these interventions as yet. This study aimed to systematically identify RCTs of interventions to improve access to mental health care for children and synthesise them using a conceptual framework of access to health care.

METHODS

This systematic review was performed following a predefined protocol registered with PROSPERO (ID: CRD42018081714). We searched the databases MEDLINE, EMBASE, PsycINFO and CENTRAL for RCTs up to 15 May 2019 using terms related to the concepts 'young people,' 'mental disorders' and 'help-seeking interventions' and scanned reference lists from relevant studies. Two reviewers independently screened all identified articles in a two-stage process, extracted results on outcomes of interest (knowledge, attitudes, intentions, help-seeking, accessing care, mental health outcomes and satisfaction), assessed the risk of bias and conducted meta-analyses where deemed appropriate.

RESULTS

After screening 5641 identified articles, 34 RCTs were eligible for inclusion. Eighty per cent of universal school-based interventions measuring knowledge (n = 5) and 67% measuring attitudes (n = 6) reported significantly better results compared with controls on those outcomes, whereas 20% measuring access to care (n = 5) and none measuring mental health outcomes (n = 7) did. In contrast, 71% of interventions targeting at-risk individuals (n = 21) reported better access to care compared with controls, while just 33% (n = 6) did for mental health outcomes. For satisfaction with care, this proportion was 80% (n = 5). Meta-analyses of interventions measuring initial appointment attendance yielded combined odds ratios of 3.11 (2.07-4.67) for appointment reminder interventions and 3.51 (2.02-6.11) for treatment engagement interventions. The outcomes for universal school-based interventions were heterogeneous and could not be summarised quantitatively through meta-analysis.

CONCLUSIONS

To have a population-level effect on improving children's access to mental health care, two-stage interventions that identify those in need and then engage them in the health-care system may be necessary. We need more evidence on interventions to target contextual factors such as affordability and infrastructural barriers.

Knowledge and Attitudes of Young People toward Mental Illness: A Cross Sectional Study

The aim of the study was to investigate young Jordanians' knowledge and attitudes toward people who have a mental illness. A cross sectional design was utilized. A convenient sample of 858 participants aged between 15-24 years old completed a survey. Participants under 19 years were accessed through their schools and those 19 years and above were accessed through universities. Results showed that although the majority of university and school students' responses were generally consistent, they disagreed on 11 items on the survey; for example, 186 (39.3%) of university students agreed that mental illness has a biological origin compared with only 119 (30%) of school students. The majority of young people 737 (85.9%) were willing to learn and 792 (92.3%) felt that they have to help people with mental illness, which make them willing to learn. In conclusion, the findings provide insights for decision makers and researchers in Jordan about young peoples' knowledge and attitudes toward mental illness. Increasing young adults' literacy through introducing educational programs such as mental health first aid courses will enrich their knowledge; help change attitudes and reduce stigma toward people living with mental illness.

The effects of educational interventions on suicide: A systematic review and meta-analysis

BACKGROUND

Suicide is a major public health problem. Educational interventions for preventing suicidal behaviour are widely used, although little is known regarding the collective effectiveness of these interventions.

AIM

We evaluated the existing evidence for the effectiveness of education interventions in the prevention of suicidal behaviour.

METHODS

In this systematic review and meta-analysis, we searched multiple databases using terms related to suicide prevention. The articles were reviewed by two independent reviewers, and the quality of evidence was rated according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Data from individual studies were combined in meta-analyses.

RESULTS

We identified 41 studies evaluating two different types of interventions: school-based education interventions and gatekeeper training. Education interventions showed significant gains in terms of knowledge and attitudes, though the effects seem to vary depending on subjects' personal characteristics. School-based education interventions significantly reduced suicidal ideation and suicide attempts in youths. Gatekeeper training showed no significant effect on suicide attempts or gatekeeper skills, though the quality of evidence for the estimate, according to GRADE criteria, was rated as very low.

CONCLUSION

The results of this study indicate that school-based education interventions are effective in preventing suicidal ideation and suicide attempts. In clinical practice, as well as in research, the development and implementation of educational interventions should focus on participants' individual characteristics.

Teacher Mental Health Literacy is Associated with Student Literacy in the Adolescent Depression Awareness Program

The Adolescent Depression Awareness Program, developed by psychiatrists and psychiatric nurses at the Johns Hopkins University School of Medicine, is a depression literacy program delivered to high school students by teachers. This mode of delivery represents an effective and sustainable way to increase awareness of mental health, reduce stigma, improve early detection, and facilitate help-seeking behavior among adolescents. The present study explores the depression literacy and stigma of teachers and their students. Survey responses of 66 teachers and 6679 high school students about depression literacy and stigma pre- and post-education intervention were analyzed using a multilevel model fit in Mplus. Teacher depression literacy was significantly associated with student depression literacy [β = 0.199, SE = 0.095, p = 0.035, 95% CI (0.044, 0.355)] at the post-assessment, but was not associated with student stigma. Teacher stigma was not significantly related to student depression literacy or stigma in the post-assessment. These findings highlight the importance of optimizing teacher depression literacy in order to maximize student depression literacy while also diminishing concerns about the transmission of stigmatized beliefs from teachers to students.

A multi-faceted community intervention is associated with knowledge and standards of workplace mental health: the Superior Mental Wellness @ Work study

BACKGROUND

Poor psychosocial work environments, such as those with low psychological support and high demands, can be harmful to the mental health of workers. In Canada, the National Standard for Psychological Health and Safety in the Workplace (the Standard) provides a comprehensive framework for organizations to identify hazards that may contribute to the psychological harm of employees. This study examines the association between a multi-faceted community intervention, the Superior Mental Wellness @ Work program designed to increase awareness of mental health and the National Standard, and outcomes assessing increased awareness and response to the Standard. These outcomes included the 1) prioritization of workplace mental health; 2) familiarity with the Standard; and 3) knowledge of mental health.

METHODS

A quasi-experimental design was used to assess the associations of interest. Surveys were sent to two random samples of employer representatives pre-and post-intervention. Intervention participants were also compared to non-participants at the post-intervention stage. T-tests and chi-square tests were used to compare differences between pre- and post-intervention outcomes and also between intervention participants and non-participants identified at the post-intervention survey.

RESULTS

The multi-faceted community intervention was associated with increased familiarity of the Standard, and increased knowledge of mental health challenges, mental health promotion, and existing resources at a community-level. When comparing those companies who participated in the intervention versus those who did not, participants were more likely to prioritize mental health in the workplace. Participants reported a greater need for support to address workplace mental health, poorer perceived mental health of employees, and greater stigma than non-participants. However, participants were more likely to be familiar with the Standard, have an action plan to implement the Standard, and be prepared to champion mental health in the workplace. Participants also had greater knowledge of workplace mental health in general compared to non-participants.

CONCLUSIONS

The multi-faceted community intervention, the Superior Mental Wellness @ Work project, was associated with increased familiarity of the Standard, and increased knowledge of mental health challenges, mental health promotion, and existing resources at a community-level. Such a multi-faceted intervention has the capacity to improve mental health literacy and awareness of the Standard.

A national child mental health literacy initiative is needed to reduce childhood mental health disorders

Half of all lifetime mental health disorders emerge in childhood, so intervening in the childhood years is critical to prevent chronic trajectories of mental health disorders. The prevalence of child mental health disorders is not decreasing despite the increased availability of evidence-based interventions. One key reason for the high prevalence and low treatment uptake may be low levels of child mental health literacy in the general community. Mental health literacy refers to knowledge and beliefs about mental health disorders that aid in their recognition, prevention and management. There is emerging evidence of poor recognition of child mental health problems in the community and low levels of parental knowledge about how to seek help, along with high levels of stigmatising attitudes. Although Australia has been a world leader in research and practice in improving mental health literacy for adolescent and adult mental health disorders, particularly depression and anxiety, mental health literacy for childhood disorders has been largely overlooked. In order to improve knowledge of child mental health disorders, reduce stigma, improve appropriate help-seeking and impact on the prevalence of child mental health disorders, we argue that a national initiative focussing on increasing mental health literacy for childhood disorders is urgently needed.

Suicidal ideation, suicidal behaviors, and attitudes towards suicide of adolescents enrolled in the Alternative Learning System in Manila, Philippines-a mixed methods study

BACKGROUND

Globally, suicide is a significant cause of death among adolescents. Previous studies conducted in high-income countries suggest that students in alternative schools are more likely to engage in suicidal behaviors than those in formal schools. This study aimed to document suicidal ideation and behaviors among adolescent learners enrolled in the Alternative Learning System (ALS) in Manila, Philippines.

METHODS

A mixed methods study was conducted in 24 ALS centers in the city of Manila. ALS centers were stratified according to congressional district and selected using probability proportionate sampling. A cross-sectional survey to determine attitudes towards suicide and prevalence of suicidal ideation and behaviors was administered to 171 learners aged 13 to 17 years old. In-depth interviews with 18 teachers and 12 learners were conducted to explore the school psychosocial environment's role on learners' suicidal ideation and behaviors. Exploratory factor analysis was used to extract attitude factors. Fisher's exact test and Student's t-test were used to identify differences in sociodemographic characteristics and attitudes towards suicide between learners with or without suicidal ideation or behaviors. Qualitative data were analyzed using thematic analysis.

RESULTS

Non-specific active thoughts were the most common type of lifetime suicidal ideation (40.9%) while passive ideation was the most common in the past month (13.5%). Aborted suicide attempt was the most frequent behavior in both lifetime (16.4%) and in the past month (4.7%). Non-fatal suicide attempt in the past month was 2.3%, reaching 12.9% for the entire lifetime. Age, sex, education, and attitudes towards suicide were significantly associated with suicidal ideation or behavior. Thematic analysis showed five themes: (1) fostering belongingness, (2) securing learners' safety, (3) teaching philosophy, (4) teacher and learner beliefs towards suicidal behavior, and (5) availability of school-offered and community-based services.

CONCLUSION

Suicidal ideation and behaviors are prevalent among adolescent ALS learners. This study also showed a significant difference in attitudes towards suicide and sociodemographic characteristics between learners with and without suicidal ideation behaviors. It also suggests that the school psychosocial environment, through social norms and learner-teacher interactions, can potentially prevent progression of suicidal ideation to behavior, influence help-seeking, and promote mental health among learners.

Does Mental Health First Aid training improve the mental health of aid recipients? The training for parents of teenagers randomised controlled trial

BACKGROUND

There is well-established evidence that Mental Health First Aid (MHFA) training improves knowledge about how to support someone developing a mental health problem, but less evidence that this support improves the mental health of the recipient of aid. This randomised controlled trial aimed to assess the long-term effects of MHFA training of parents on the mental health of their adolescent children.

METHODS

384 Australian parents of an adolescent aged 12-15 were randomised to receive either the 14-h Youth MHFA course or the 15-h Australian Red Cross Provide First Aid course. Outcomes were assessed at baseline, 1-year, and 2-year follow-up in both parents and adolescents. Primary outcomes were cases of adolescent mental health problems, and parental support towards their adolescent if they developed a mental health problem, rated by the parent and adolescent. Secondary outcomes included parent knowledge about mental health problems, intentions and confidence in supporting a young person, stigmatizing attitudes, and help-seeking for mental health problems.

RESULTS

Parent and adolescent reports showed no significant difference between training groups in the proportion of cases of adolescents with a mental health problem over time (ps > .05). There was also no significant difference between training groups in the quality of parental support provided to their adolescent at 1- or 2-year follow-up (ps > .05). In contrast, some secondary outcomes showed benefits from the Youth MHFA training relative to the control, with increased parental knowledge about mental health problems at 1-year (d = 0.43) and 2-year follow-up (d = 0.26), and increased confidence to help a young person (d = 0.26) and intentions to provide effective support (d = 0.22) at 1-year follow-up.

CONCLUSIONS

The study showed some improvements in mental health literacy in training recipients, but could not detect changes in the mental health of adolescents and the support provided to them by their parents if they had a mental health problem. However, there was a lack of power to detect primary outcome effects and therefore the question of whether MHFA training leads to better outcomes in the recipients of aid remains to be further explored.

TRIAL REGISTRATION

ACTRN12612000390886 , registered retrospectively 5/4/2012.

"Be creative and you will reach more people": youth's experiences participating in an arts-based social action group aimed at mental health stigma reduction

Background: Starting in 2013, the Mental Health Youth Action Board, made up of 15 teens ages 15-18, was created to advise a large children's hospital on improvements in mental health care and produce social action projects to impact community perceptions of mental health.Methods: This participatory qualitative case study explored the experiences of 14 young people who participated in the Mental Health Youth Action Board between 2013 and 2016.Results: There were two higher order themes: process and outcomes. Process-related themes included how this was a unique leadership experience, the importance of the arts-based approach, and value of the intentionally constructed storytelling process. These processes led to youth growing as advocates for mental health.Conclusions: Arts-based approaches to social action that allow youth to share personal experiences of stigmatized topics can promote healing and support their growth as leaders.

'The challenges of sharing information when a young person is experiencing severe emotional difficulties': implications for schools and CAMHS

BACKGROUND

Supporting the education of children and young people with complex emotional mental health difficulties requires schools to have knowledge of their needs. Exchanging information about less visible mental health difficulties is, however, known to be complex. Exploring the perceptions of young people experiencing problems can explicate some of this complexity and identify solutions. Yet their views are rarely given credence in this context.

METHODS

The findings were derived from a broader qualitative study exploring the school experiences of young people, aged 14-16 years, identified by CAMHS as having severe emotional difficulties. Their parents' and teachers' perceptions were also explored. Data were collected via semistructured interviews and analysed using thematic analysis.

RESULTS

Findings demonstrated that young people experiencing emotional difficulties need to feel safe about exchanging private information pertaining to their mental health. Teachers having a basic knowledge of mental health promoted their safety as this ensured confidentiality. Participants reported that CAMHS practitioners needed to be more proactive regarding the practicalities of exchanging information.

CONCLUSIONS

Arguably, teachers need to have basic knowledge of mental health and schools need clearer mental health confidentiality guidance. CAMHS also have responsibility in identifying more information exchange mechanisms and young service users and parents can play a part in this.

Teaching mental health first aid in the school setting: a novel approach to improving outcomes for common adolescent mental disorders

PURPOSE OF REVIEW

Common adolescent mental disorders, such as depression, often go untreated and severely impact health and educational outcomes. The purpose of this review is to describe what is currently known about school-based mental health interventions and to describe a new intervention, Mental Health First Aid training.

RECENT FINDINGS

Universal and selective prevention and treatment programmes have been widely evaluated, though population-level dissemination remains elusive. A novel approach is to train adolescents in how to recognise early signs of mental disorder onset, decrease stigmatising beliefs and barriers to help-seeking, and to use appropriate first aid strategies for assisting peers in mental health crisis, such as those with depression and suicidal ideation.

SUMMARY

Teaching adolescents the skills necessary to recognise and respond to mental health problems and mental health crises may provide life-long skills that prompt lower stigmatising beliefs, greater support of peers and appropriate, timely help-seeking.

Strengthening College Students' Mental Health Knowledge, Awareness, and Helping Behaviors: The Impact of Active Minds, a Peer Mental Health Organization

OBJECTIVE

To examine the relationship between college students' familiarity with and involvement in Active Minds, a student peer organization focused on increasing mental health awareness, decreasing stigma, and affecting mental health knowledge, attitudes, and behaviors.

METHOD

Students (N = 1,129) across 12 California colleges completed three waves of a web-based survey during the 2016-2017 academic year to assess familiarity with and involvement in Active Minds and mental health attitudes, behaviors, and perceived knowledge. Fixed-effects models assessed relations between changes in organization familiarity and involvement and changes in mental health-related outcomes over time overall and stratified by students' baseline engagement (ie, familiarity/involvement) with Active Minds.

RESULTS

Overall, increased familiarity with Active Minds was associated with increases in perceived knowledge (0.40; p < .001) and decreases in stigma over time (-0.33; p < .001). Increased involvement was associated with increases in perceived knowledge (0.40; p < .001) and a range of helping behaviors. Associations differed by students' baseline engagement with Active Minds. For students with low engagement, increased familiarity with Active Minds was associated with decreased stigma and improved perceived knowledge. For students with moderate baseline engagement, increasing involvement with Active Minds was associated with increases in helping behaviors (eg, providing emotional support, connecting others to services) over time.

CONCLUSION

Student peer organizations' activities can improve college student mental health attitudes and perceived knowledge and significantly increase helping behaviors. Such organizations can complement more traditional programs and play an important role in improving the campus climate with respect to mental health.

Helping adolescents to better support their peers with a mental health problem: A cluster-randomised crossover trial of teen Mental Health First Aid

BACKGROUND

teen Mental Health First Aid (tMHFA) is a classroom-based training programme for students aged 15-18 years to improve supportive behaviours towards peers, increase mental health literacy and reduce stigma. This research evaluated tMHFA by comparing it to a matched emergency Physical First Aid (PFA) training programme.

METHODS

A cluster-randomised crossover trial matched four public schools in two pairs and then randomised each to first receive tMHFA or PFA for all Year 10 students. In the subsequent calendar year, the new Year 10 cohort received the opposite intervention, giving eight cohorts. Online surveys were administered at baseline and 1 week post-training, measuring quality of first aid intentions, mental health literacy, problem recognition and stigmatising beliefs, towards fictional adolescents with depression and suicidality (John) and social anxiety (Jeanie).

RESULTS

A total of 1942 students were randomised (979 received tMHFA, 948 received PFA), 1605 (84%) analysed for the John vignette at baseline and 1116 (69% of baseline) provided post-training data. The primary outcomes, 'helpful first aid intentions' towards John/Jeanie, showed significant group-by-time interactions with medium effect sizes favouring tMHFA ( ds = 0.50-0.58). Compared to PFA, tMHFA students also reported significantly greater improvements in confidence supporting a peer ( ds = 0.22-0.37) and number of adults rated as helpful ( ds = 0.45-0.46) and greater reductions in stigmatising beliefs ( ds = 0.12-0.40) and 'harmful first aid intentions' towards John/Jeanie ( ds = 0.15-0.41).

CONCLUSIONS

tMHFA is an effective and feasible programme for increasing supportive first aid intentions and mental health literacy in adolescents in the short term. tMHFA could be widely disseminated to positively impact on help seeking for adolescent mental illness.

Systematic review and meta-analysis of Mental Health First Aid training: Effects on knowledge, stigma, and helping behaviour

OBJECTIVE

To provide an up-to-date assessment of the effectiveness of the Mental Health First Aid (MHFA) training program on improving mental health knowledge, stigma and helping behaviour.

DESIGN

Systematic review and meta-analysis.

METHODS

A systematic search of electronic databases was conducted in October 2017 to identify randomised controlled trials or controlled trials of the MHFA program. Eligible trials were in adults, used any comparison condition, and assessed one or more of the following outcomes: mental health first aid knowledge; recognition of mental disorders; treatment knowledge; stigma and social distance; confidence in or intentions to provide mental health first aid; provision of mental health first aid; mental health of trainees or recipients of mental health first aid. Risk of bias was assessed and effect sizes (Cohen's d) were pooled using a random effects model. Separate meta-analyses examined effects at post-training, up to 6 months post-training, and greater than 6 months post-training.

RESULTS

A total of 18 trials (5936 participants) were included. Overall, effects were generally small-to-moderate post-training and up to 6 months later, with effects up to 12-months later unclear. MHFA training led to improved mental health first aid knowledge (ds 0.31-0.72), recognition of mental disorders (ds 0.22-0.52) and beliefs about effective treatments (ds 0.19-0.45). There were also small reductions in stigma (ds 0.08-0.14). Improvements were also observed in confidence in helping a person with a mental health problem (ds 0.21-0.58) and intentions to provide first aid (ds 0.26-0.75). There were small improvements in the amount of help provided to a person with a mental health problem at follow-up (d = 0.23) but changes in the quality of behaviours offered were unclear.

CONCLUSION

This review supports the effectiveness of MHFA training in improving mental health literacy and appropriate support for those with mental health problems up to 6 months after training.

TRIAL REGISTRATION

PROSPERO (CRD42017060596).

World Health Organization "School Mental Health Manual"-based training for school teachers in Urban Lahore, Pakistan: study protocol for a randomized controlled trial

Background

The teacher’s role in school mental health initiatives cannot be overemphasized. Despite global evidence of educational interventions in improving teachers’ knowledge and attitudes regarding mental health, this area remains under researched in Pakistan. This paper presents a study protocol of a pilot randomized controlled trial to examine the effectiveness of a teacher training intervention for improving mental health literacy and self-efficacy among school teachers in urban Lahore, Pakistan.

Methods

The randomized controlled trial will follow the CONSORT guidelines. Participants will be allocated to the Intervention group (receiving the World Health Organization, Eastern Mediterranean Region (WHO-EMRO) School Mental Health Manual-based intervention in three 6-h, face-to-face sessions) or a waitlist control group (not receiving training during the study period). Participants will be teachers of private schools with similar broad demographic characteristics in an inner city area of Lahore. The primary outcome measures for the trial is teachers’ mental health literacy. It will be assessed by using the previously applied (during WHO training of Master Trainers) self-administered questionnaire in both groups pre and post training and at 3 months’ follow-up. Secondary outcomes include: for teachers: Teachers’ self-efficacy (assessed by the Teachers’ Sense of Self Efficacy Scale (TSES) short form.); for students (11–16 years): socio-emotional skills and psychological problems measured by the Strengths and Difficulties Questionnaire (assessed at baseline and 3 months post intervention); for schools: the WHO School Psychosocial Profile Questionnaire (baseline and 3 months post intervention).

Discussion

Given the high prevalence of child mental health problems, stigma and lack of services, it is important to consider alternate avenues for promoting positive mental health among youth. This pilot study should establish the effectiveness of the WHO-EMRO School Mental Health Manual-based Intervention improving teacher’s mental health literacy and helping them to learn practical steps that can be implemented at low cost in school settings. It will also provide information regarding intervention implementation and sustainability.

Trial registration

ClinicalTrials.gov, ID: NCT02937714. Registered on 18 October 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2679-3) contains supplementary material, which is available to authorized users.

A cluster randomised controlled trial of the Wellbeing in Secondary Education (WISE) Project - an intervention to improve the mental health support and training available to secondary school teachers: protocol for an integrated process evaluation

BACKGROUND

Secondary school teachers have low levels of wellbeing and high levels of depression compared with the general population. Teachers are in a key position to support students, but poor mental health may be a barrier to doing so effectively. The Wellbeing in Secondary Education (WISE) project is a cluster randomised controlled trial (RCT) of an intervention to improve the mental health support and training available to secondary school teachers through delivery of the training package Mental Health First Aid and a staff peer support service. We will conduct a process evaluation as part of the WISE trial to support the interpretation of trial outcomes and refine intervention theory. The domains assessed will be: the extent to which the hypothesised mechanisms of change are activated; system level influences on these mechanisms; programme differentiation and usual practice; intervention implementation, including any adaptations; intervention acceptability; and intervention sustainability.

METHODS

Research questions will be addressed via quantitative and qualitative methods. All study schools (n = 25) will provide process evaluation data, with more detailed focus group, interview and observation data being collected from a subsample of case study schools (4 intervention and 4 control). Mechanisms of change, as outlined in a logic model, will be measured via teacher and student surveys and focus groups. School context will be explored via audits of school practice that relate to mental health and wellbeing, combined with stakeholder interviews and focus groups. Implementation of the training and peer support service will be assessed via training observations, training participant evaluation forms, focus groups with participants, interviews with trainers and peer support service users, and peer supporter logs recording help provided. Acceptability and sustainability will be examined via interviews with funders, head teachers, trainers and peer support services users, and focus groups with training participants.

DISCUSSION

The process evaluation embedded within the WISE cluster RCT will illuminate how and why the intervention was effective, ineffective or conferred iatrogenic effects. It will contribute to the refinement of the theory underpinning the intervention, and will help to inform any future implementation.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number: ISRCTN95909211 registered on 24 March 2016.

Effect of unaffordable medical need on distress level of family member: analyses of 1997-2013 United States National Health Interview Surveys

BACKGROUND

Reduced funding to public health care systems during economic downturns is a common phenomenon around the world. The effect of health care cost on family members of the patients has not been established. This paper aims to explore the relationship between affordability of health care and vulnerability of family members to distress levels.

METHODS

Data of a total of 262,843 participants were obtained from 17 waves (1997-2013) of the United States National Health Interview Survey. Multinomial logistic regression was used to investigate psychological distress level as a result of having family members who experienced unmet medical needs due to cost.

RESULTS

Among participants without family members who experienced unmet needs for medical care due to cost, risks of having 'moderate' (score of 5-12) or 'serious' (score of 13 or above) level of psychological distress were 1.0% and 11.5%, respectively. Risks of having 'moderate' or 'serious' level of psychological distress were 3.1% and 23.4%, respectively among participants with family members who experienced unmet needs. The adjusted relative risk ratio of 'moderate' and 'serious', as compared to 'normal' level of psychological distress, were 1.58 (95% confidence interval: 1.47-1.69) and 2.09 (95% confidence interval: 1.78-2.45) if one's family members experienced unmet medical needs.

CONCLUSIONS

Unmet medical needs due to cost increases risk of distress levels experienced by family members. Careful planning and adequate funding to public health care system could be implemented to prevent any unnecessary detrimental effect on mental health among family members of the unwell and any further increment of the prevalence of mental illnesses. This recommendation aligns with the World Health Organization Mental Health Action Plan 2013-2020.

Development and Evaluation of Digital Game-Based Training for Managers to Promote Employee Mental Health and Reduce Mental Illness Stigma at Work: Quasi-Experimental Study of Program Effectiveness

BACKGROUND

To counteract the negative impact of mental health problems on business, organizations are increasingly investing in mental health intervention measures. However, those services are often underused, which, to a great extent, can be attributed to fear of stigmatization. Nevertheless, so far only a few workplace interventions have specifically targeted stigma, and evidence on their effectiveness is limited.

OBJECTIVE

The objective of this study was to develop and evaluate a digital game-based training program for managers to promote employee mental health and reduce mental illness stigma at work.

METHODS

We describe the empirical development of Leadership Training in Mental Health Promotion (LMHP), a digital game-based training program for leaders. A 1-group pre-post design and a 3-month follow-up were used for training evaluation. We applied multilevel growth models to investigate change over time in the dependent variables knowledge, attitudes, self-efficacy, and intentions to promote employee mental health in 48 managers of a global enterprise in the United Kingdom. Participants were mainly male (44/48, 92%) and ranged in age from 32 to 58 (mean 46.0, SD 7.2) years.

RESULTS

We found a positive impact of the Web-based training program on managers' knowledge of mental health and mental illness (P<.001), on attitudes toward people with mental health problems (P<.01), and on their self-efficacy to deal with mental health situations at work (P<.001), with the exception of intentions to promote employee mental health, which was initially high.

CONCLUSIONS

Results provide first evidence of the effectiveness of LMHP to positively affect managers' skills to promote employee mental health at work. Furthermore, the high rate of participation in LMHP (48/54, 89%) supports the use of digital game-based interventions to increase user engagement and user experience in mental health programs at work.

The Association of School Climate, Depression Literacy, and Mental Health Stigma Among High School Students

BACKGROUND

Although school climate is linked with youth educational, socioemotional, behavioral, and health outcomes, there has been limited research on the association between school climate and mental health education efforts. We explored whether school climate was associated with students' depression literacy and mental health stigma beliefs.

METHODS

Data were combined from 2 studies: the Maryland Safe Supportive Schools Project and a randomized controlled trial of the Adolescent Depression Awareness Program. Five high schools participated in both studies, allowing examination of depression literacy and stigma measures from 500 9th and 10th graders. Multilevel models examined the relationship between school-level school climate characteristics and student-level depression literacy and mental health stigma scores.

RESULTS

Overall school climate was positively associated with depression literacy (odds ratio [OR] = 2.78, p < .001) and negatively associated with stigma (Est. = -3.822, p = .001). Subscales of engagement (OR = 5.30, p < .001) and environment were positively associated with depression literacy (OR = 2.01, p < .001) and negatively associated with stigma (Est. = -6.610, p < .001), (Est. = -2.742, p < .001).

CONCLUSIONS

Positive school climate was associated with greater odds of depression literacy and endorsement of fewer stigmatizing beliefs among students. Our findings raise awareness regarding aspects of the school environment that may facilitate or inhibit students' recognition of depression and subsequent treatment-seeking.

Beliefs and Prejudices Versus Knowledge and Awareness: How to Cope Stigma Against Mental Illness. A College Staff E-survey

The aims of this study were to collect information about attitudes toward mental illness from the staff of Brescia University, and to detect predictors of issues regarding mental disorders and evaluate their relationship with public stigma. The study involved 1079 people and each participant received a letter explaining the purpose of the e-research. Four hundred and eighty-six people completed the questionnaires. The results showed that those who had a higher level of education, a personal life experience with mental disorders and a higher professional role were more likely to develop behaviours of acceptance toward the mentally ill. Factor analysis of the CAMI showed three main factors: Social distance and isolation, Social integration, Social responsibility and tolerance. Through the structural equation model it was found that the latent construct stigma was mainly defined by the first factor. From this study it emerged that education and personal contact were protective factors against public stigma.