Psychiatry and Clinical Neurosciences 2015; 69:

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1 Psychiatry and Clinical Neurosciences 2015; 69: doi: /pcn Regular Article Effects of school-based mental health literacy education for secondary school students to be delivered by school teachers: A preliminary study Yasutaka Ojio, MSc, 1 Hiromi Yonehara, RN, 2 Setsuko Taneichi, MD, PhD, 1 Syudo Yamasaki, PhD, 3 Shuntaro Ando, MD, PhD, 3 Fumiharu Togo, PhD, 1 Atsushi Nishida, PhD 3 and Tsukasa Sasaki, MD, PhD 1 * 1 Department of Physical and Health Education, 2 Secondary School attached to the Faculty of Education, The University of Tokyo, and 3 Department of Psychiatry and Behavioral Science, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan Aims: Improving knowledge and beliefs about mental health (or mental health literacy [MHL]) may promote appropriate help-seeking by adolescents who are suffering from mental health problems. We developed a concise, school-staff-led MHL program and examined its effects. Methods: The participants comprised 118 grade-9 students (61 boys and 57 girls). The program consisted of two 50-min sessions, and was given by a schoolteacher. The effects of the program were evaluated before, immediately after and 3 months after the program, using a self-report questionnaire. Results: Knowledge of mental health/illnesses and desirable behavior for help-seeking were significantly improved immediately after (post-test, P < 0.001, and P < 0.001, respectively) and 3 months after the program (3-month follow up, P < and P < 0.001, respectively), compared with the test before the delivery of the program (pre-test, Wilcoxon signed rank test). Proportions of the correct diagnoses of vignette cases of major depression and schizophrenia were significantly (P < 0.001) elevated from 38.3% and 19.1% (pre-test) to 94.7% and 93.6% (post-test), and 91.5% and 86.2% (3-month follow up). Intentions to seek help and to provide peers with help with mental health problems were also significantly (P < 0.001) elevated at post-test and at 3 months compared with the pre-test. Conclusions: A concise, school-staff-led program may have a significant effect on the improvement of MHL in secondary school students. Key words: adolescent, health education, mental health, program evaluation, schools. MOST CASES OF mental illnesses begin prior to the age of 25 years. 1 3 It is therefore crucial for adolescents to have appropriate knowledge and beliefs about mental health and its problems *Correspondence: Tsukasa Sasaki, MD, PhD, Laboratory of Health Education, Graduate School of Education, The University of Tokyo, Hongo, Bunkyo-ku, Tokyo , Japan. sasaki@p.u-tokyo.ac.jp Received 29 January 2015; revised 13 April 2015; accepted 13 May (illnesses) that will help their recognition of, coping with and prevention of the problems (illnesses), and will promote appropriate help-seeking. Such knowledge and beliefs are referred to as mental health literacy (MHL). 4,5 Help-seeking requires a multistep decision that leads an affected individual to: (i) identify the problem; (ii) acknowledge the necessity of help and/or treatment of the problem; (iii) understand that mental illnesses are treatable; and (iv) be motivated to seek help and/or treatment. 6,7 MHL education is intended to help adolescents acquire the 572

2 Psychiatry and Clinical Neurosciences 2015; 69: In-school mental health literacy 573 knowledge and beliefs that are required for these steps. Schools may play an important role in the promotion of mental health care and the support of children and adolescents. In several countries, there are a number of MHL education programs to be given in school, however most of these programs take a number of hours (e.g., 5 10 h) to carry out In addition, the majority of them are to be given by mental health professionals from outside schools, not by school staff In most schools, the schedule is tight due to heavy demands of the regular curriculum and extra-curricular activities. 11,12 Schools therefore may not be able to employ an MHL program that requires a long time to carry out. Further, if the program has to be given by health professionals from outside school, its employment may be more difficult for schools, because finding an appropriate outside person to give the program can be a challenge for schools. It may be necessary for the program to be more concise and led by school staff to make it more usable in schools. For this reason, we recently developed a concise MHL program for secondary school students that can be taught by schoolteachers and consists of two 50-min sessions. In the present study, its effect on the students knowledge and beliefs about mental health/illnesses and on their intentions to seek appropriate help with problems are evaluated. METHODS Principles and contents of the program The MHL education program for secondary school students to be delivered by schoolteachers was developed by a collaborating team consisting of psychiatrists, public health nurses and teachers specializing in health care/check-up. These teachers are unique to the Japanese school system. Their role is similar to, but not the same as, a school nurse: giving health education to the students, in addition to taking care of and conducting regular check-ups on students physical/mental health. The School Health Act of the Japanese Government strictly requires every elementary and secondary school to employ one or two full-time health-care teachers, according to the number of students in the school. In this preliminary trial, the classes of the MHL program were given by one of the teachers (H.Y.) in the collaborating team. The teacher and two other team members (Y.O. and T.S.) discussed for several hours how to specifically deliver the program. The present MHL program consisted of two 50-min sessions (Lessons 1 and 2). Table 1 summarizes the contents of the program. The two sessions were given 1 week apart. Teaching methods included: (i) standard instruction using text and a blackboard; (ii) showing animations; and (iii) group discussion. The Table 1. Teaching methods and main contents of the program Lesson 1 (50 min) Lesson 2 (50 min) Goal of lesson 1 Goal of lesson 2 Instruction Animation Group discussion Explanation of mental illnesses (prevalence, onset age, risk factors, treatability and possibility of recovery, frequent symptoms in adolescence) and frequent misunderstandings about mental illnesses. Showing pictures of a psychiatric outpatient clinic to show that the clinic is not a place that creates an unusual or frightening impression. Showing typical symptoms of depression and schizophrenia. Sharing their ideas of solutions that help adolescents who are suffering from problems with mental health. Learning the signs and symptoms of mental problems and illnesses. Understanding that mental health problems and mental illnesses are not rare. Understanding how they should behave when they themselves or their peers are suffering from mental problems.

3 574 Y. Ojio et al. Psychiatry and Clinical Neurosciences 2015; 69: animations were on symptoms of several mental illnesses, including major depression and schizophrenia. They were downloaded from a website of the Ministry of Health, Labor and Welfare of Japan ( index.html). 13 Each animation takes approximately 4 min to show. The first 50-min session (Lesson 1) comprised general explanations of mental illnesses, including prevalence, onset age, risk factors, treatability and possibility of recovery, and their symptoms in adolescence. Typical symptoms of major depression and schizophrenia in their initial phases were shown using the animations. The goals of Lesson 1 were: (i) to have students learn about signs and symptoms of mental health problems, including illnesses; and (ii) to understand that mental illnesses are not rare in adolescents and may develop in them or their peers. Recognition of the signs/symptoms of mental health problems is the first step in seeking appropriate help and is essential to avoid any delay in help-seeking. 6,7 The second 50-min session (Lesson 2) comprised simple explanations of: (i) sources of help, such as psychiatric outpatient clinics, by showing pictures of these; (ii) methods of psychiatric diagnosis; and (iii) clinical examinations for it. At the end of the lesson, the students held group discussions for min. In the discussions, the students were asked to think about appropriate ways of finding solutions if they were suffering from mental health problems or illnesses. The goal of Lesson 2 was to have the students think about and understand how they can help themselves and their peers when they are suffering from mental health problems. Participants and procedure The participants comprised 118 grade-9 students (61 boys and 57 girls, aged years) in a secondary school in Tokyo, Japan. The two lessons were given once a week over a 2-week period in the health education class. Evaluation of the effects The students were asked to answer the same questions 1 week before the first session of the program (pre-test), at the end of the second session (post-test) and 3 months after the program (follow up) to evaluate the effects of the program. The first part of the test comprised six questions on general knowledge about mental health and illnesses and six questions about basic knowledge on the treatment of mental illnesses (Table 2). These questions were to be answered true or false. The second part of the test was about two case vignettes of major depression and schizophrenia (according to the DSM-IV criteria). Having read the vignettes, the students were asked the following: (i) to indicate whether the person in the vignette was suffering from no or any one of the mental illnesses, including major depression, schizophrenia, eating disorder and social phobia (Tables 3a,4a); and to select the most desirable behavior among the four options (ii) when the students suffered from major depression or schizophrenia (Tables 3b,4b, respectively); and (iii) when their peers had the problem (Tables 3c,4c, respectively). The vignettes were similar to those in the study by Jorm et al., 4 but were made more concise to make them easier to read. The effects of the program were evaluated by comparing proportions of the correct or appropriate answers to the questions in the post-test and the 3-month follow up with the proportions in the pre-test. Ethical aspects We clearly explained the aim and content of the program to the students and their parents using a written document, which stated that participation in the program, including the questionnaire, was not mandatory and that the students could stop participating when they felt any discomfort. The study was approved by the University of Tokyo Human Research Ethics Committee. Data analysis Non-parametric paired-samples tests (Wilcoxon signed rank test and McNemar s test) were conducted, considering the distribution of the data, to examine whether the knowledge of and beliefs about mental health/illnesses and the intention to seek help were significantly changed between pre- and posttests and pre- and follow-up tests. The level of significance was set at P < 0.05 (two-sided). The analyses were conducted using the Japanese version of SPSS 22.0 (IBM Japan, Tokyo, Japan). RESULTS Participants Of the 118 grade-9 students, 102 students (86.4%; 52 boys and 50 girls) participated fully in the program;

4 Psychiatry and Clinical Neurosciences 2015; 69: In-school mental health literacy 575 Table 2. Proportions of correct answers to the questions on knowledge of/beliefs about mental illnesses and their treatment (n = 94; 47 boys and 47 girls) Proportions % (n) of correct responses Pre-test Post-test Follow-up test General knowledge about mental health and mental illnesses Incidences of most mental illnesses sharply increase in T 69.1 (65) 100 (94)*** 93.6 (88)*** adolescence. Mental illnesses are caused by weakness or a bad personality. F 75.5 (71) 98.9 (93)*** 94.7 (89)*** Lifestyle, including sleep habits, has an effect on prevention and T 86.2 (81) 90.4 (85) 96.8 (91) recovery of mental illnesses. Somatic symptoms, including fatigue, abdominal pain and T 86.2 (81) 96.8 (91)* 97.9 (92)** nausea, may occur as early symptoms of mental illnesses. Most mental illnesses improve without treatment. F 92.6 (87) 96.8 (91) 100 (94)* People with mental illnesses cannot get a regular job. F 96.8 (91) 98.9 (93) 100 (94) Knowledge about treatment for mental illnesses Mental illnesses are treatable. T 95.7 (90) 100 (94) 100 (94) Early treatment may make a significant difference in the T 94.7 (89) 94.7 (89) 96.8 (91) prognosis of mental illnesses. Medical examinations, including blood tests, may be required for T 28.7 (27) 86.2 (81)*** 52.1 (49)*** diagnosis of mental illnesses. Medication improves many mental illnesses. T 29.8 (28) 91.5 (86)*** 76.6 (72)*** People who are undergoing psychiatric treatment cannot go to F 89.4 (84) 97.9 (92)* 95.7 (90) work or school. Most subjects with mental illnesses need to receive inpatient treatment. F 84 (79) 97.9 (92)** 89.4 (84) *P < 0.05, **P < 0.01, ***P < (comparison of post-test and follow-up test with pre-test). F, false; T, true. all of the 102 participated in both of the sessions. None of them withdrew during the sessions. Of the 102, 94 students (92.1%; 47 boys and 47 girls) completed the pre-, post-, and follow-up tests for the evaluation. Effects on knowledge and beliefs The proportions of correct answers to the six questions on general knowledge about mental health and illnesses were significantly elevated after the program had been given, with a mean/median number of correct answers of 5.8/6.0 in the post-test, and 5.8/ 6.0 in the follow up (after 3 months), compared with 5.1/5.0 in the pre-test (P < and P < 0.001, respectively). Similar results were found for the six questions about basic knowledge of the treatment of mental illnesses; 4.2/4.0 in the pre-test versus 5.7/6.0 in the post-test (P < 0.001) and 5.1/5.0 in the follow up (P < 0.001). The proportions of correct responses to each question were elevated in the post-test and the follow up compared with the pre-test for all questions, as shown in Table 2. Prior to the lessons, few students knew that medical examinations, including blood tests, were often required for the diagnosis of mental illnesses (28.7%), or that medication improved several mental illnesses (29.8%). In contrast, most of the students knew that mental illnesses might not improve without treatment (92.6%), people with mental illnesses might be able to have a regular job (96.8%), mental illnesses are treatable (95.7%), and the early start of treatment might make the prognosis better (94.7%). Recognition of mental health problems and selection of desirable behavior Tables 3a and 4a show the proportions of students who selected the correct diagnosis and the desirable

5 576 Y. Ojio et al. Psychiatry and Clinical Neurosciences 2015; 69: Table 3. Answers to the questions about vignette of a major depression case (n = 94; 47 boys and 47 girls) Proportion % (n) of the correct responses Pre Post Follow up a. Proportion of students who indicated the correct name of the 38.3 (36) 94.7 (89)*** 91.5 (86)*** illness b. Answers to the question, What would you do if you had the problem described? I would do nothing, because it s not a disease (15) 3.2 (3)** 1.1 (1)** I would wait and see for a while (26) 9.6 (9)** 22.3 (21) I would talk to someone who can be trusted (44) 87.2 (82)*** 74.5 (70)*** I would not know what to do. 9.6 (9) 0 (0)** 2.1 (2)** c. Answers to the question, What would you do if your peer had the problem described? I would do nothing, because it s not a disease. 5.3 (5) 0 (0) 1.1 (1) I would wait and see for a while (32) 18.1 (17)** 18.1 (17)** I would avoid conversation with him or her. 1.1 (1) 0 (0) 1.1 (1) I would advise him or her to change their behavior (10) 4.3 (4)* 3.2 (3) I would talk to someone who can be trusted (31) 74.5 (70)*** 72.3 (68)*** I would not know what to do (15) 3.2 (3)** 4.3 (4)* *P < 0.05, **P < 0.01, ***P < (comparison of post-test and follow-up test with pre-test). Table 4. Answers to the questions about vignette of a schizophrenia case (n = 94; 47 boys and 47 girls) Proportion % (n) of the correct responses Pre Post Follow up a. Proportion of students who indicated the correct name of the 19.1 (18) 93.6 (88)*** 86.2 (81)*** illness b. Answers to the question, What would you do if you had the problem described? I would do nothing, because it s not a disease. 4.3 (4) 2.1 (2) 0 (0) I would wait and see for a while. 7.4 (7) 4.3 (4) 13.8 (13) I would talk to someone who can be trusted (51) 88.3 (83)*** 76.6 (72)*** I would not know what to do (32) 5.3 (5)*** 9.6 (9)*** c. Answers to the question, What would you do if your peer had the problem described? I would do nothing, because it s not a disease. 2.1 (2) 0 (0) 0 (0) I would wait and see for a while. 9.6 (9) 9.6 (9) 9.6 (9) I would avoid conversation with him or her. 8.5 (8) 2.1 (2)* 4.3 (4) I would advise him or her to change their behavior. 7.4 (7) 0 (0) 3.2 (3) I would talk to someone who can be trusted (45) 86.2 (81)*** 74.5 (70)*** I would not know what to do (23) 2.1 (2)*** 8.5 (8)** *P < 0.05, ** P < 0.01, *** P < (comparison of post-test and follow-up test with pre-test).

6 Psychiatry and Clinical Neurosciences 2015; 69: In-school mental health literacy 577 solutions for the two vignette cases of major depression and schizophrenia, respectively. In the pre-test, proportions of the correct diagnosis were 38.3% and 19.1%, respectively. The proportions were significantly (P < 0.001) elevated in the post-test and the 3-month follow up (94.7% and 93.6% in the posttest and 91.5% and 86.2% in the 3-month follow up for the cases of major depression and schizophrenia, respectively). The proportions of students who selected the most desirable behavior ( I would talk to someone who can be trusted ) as the answer also increased significantly (P < 0.001) in the postand follow-up tests, compared with the pre-test (Tables 3b,4b). The proportions were 46.8% and 54.3% in the pre-test, 87.2% and 88.3% in the posttest and 74.5% and 76.6% in the follow-up test for major depression and schizophrenia, respectively. Intention of helping peers with mental health problems Tables 3c and 4c show the proportions of students who selected the desirable answer to the question about the actions they might take if their peers were suffering from mental health problems. The proportions of the students who answered that they would provide their peers with mental health problems with help ( I would talk to someone who can be trusted ) increased significantly (P < 0.001) after the lessons (Tables 3c,4c). The proportions were 33.0% and 47.9% in the pre-test, 74.5% and 86.2% in the posttest and 72.3% and 74.5% in the follow-up test for the cases of major depression and schizophrenia, respectively. DISCUSSION We developed a concise, school-staff-led MHL program for secondary school students and found significant effects. The effects were evaluated by comparing proportions of correct or desirable answers to a questionnaire immediately after and 3 months after the delivery of the program with the answers before the program. Knowledge and beliefs about mental health/illnesses and their treatment and also the intention to seek help and to support their peers with mental health problems were significantly elevated following the program. To our knowledge, this is the first MHL program for secondary school students that is to be taught by school staff and takes a short time of less than 2 h (two 50-min sessions). There have been a limited number of school-based MHL education programs of this short length for adolescents. Pinfold et al. 14 developed a concise school-based MHL program of two 60-min sessions for secondary school students, and examined its effect. The program was to teach about (deal with) knowledge of mental illnesses and their care/treatment, and stigma of mental illnesses, using a short video, lecture, and information leaflets. A talk with people with mental illnesses was also included in the program. The program had a significant positive effect on knowledge about and attitudes to people with mental illnesses, similar to the present study. Unlike our program, however, their program was delivered by mental health professionals from outside the school. A small number of school-staff-led programs have been developed, which showed significant effects on the student s knowledge and attitudes The present result may be consistent with these. However, a unique feature of our program is that it takes a substantially shorter time (two 50-min sessions) compared with those programs. For example, the program of Mcluckie et al. 15 consists of six modules that are delivered in h of class time. The program of Naylor et al. 16 comprises six 60-min sessions, taking 6 h. The program of Petchers et al. 17 includes six lessons. The program of Rahman et al. 18 takes 4 months to complete. A longer program might have greater effect, but may be less easily and less sustainably used in schools in most countries, including Japan. The balance between the expected effect and the usability should be well considered in the development of the program. MHL programs that are delivered by school staff (or teachers) may have advantages compared with programs delivered by persons outside schools. An advantage is that the teachers, who are regularly observing the students in schools, may be able to deliver the program with more careful consideration of the needs of students in each school than outside professionals. Another advantage is that the students given the program by teachers may be encouraged to seek help from school staff when they suffer from mental health problems. Another advantage is that the teachers, who are regularly observing the students in schools, may be able to deliver the program with more careful consideration of the students needs than outside professionals. The present program, however, has an issue to be solved. An appropriate training program for teachers needs to be developed

7 578 Y. Ojio et al. Psychiatry and Clinical Neurosciences 2015; 69: for spreading the education program. We are currently developing textbooks and audio-visual materials, which may enable schoolteachers to learn how to deliver the program in a several-hour session. Some previous studies have developed and evaluated educational programs for teachers to deliver the MHL program at schools. 19,20 These may help us develop the textbooks and materials. Several limitations may be noted in the present study and the program. First, the number of participants was small and they were all from one school in Tokyo. The effects of MHL programs may be associated with baseline characteristics of the students, such as intelligence, academic capacity, and socioeconomic status. Previous contact with individuals with mental health problems and previous exposure to such problems may also influence the effect of the program. 8 Generalization of the present results should therefore be with caution. Second, the effects of the program were examined without a control group. Third, to test the effects of the program, we used a brief self-report questionnaire, which was developed originally for this study and not validated with a large number of subjects. A limitation of penand-paper assessments, which suffer from potential social desirability bias, may also be noted. Another caution may be regarding the results for the intention to seek help. First, for the outcome measure, questions What would you do if you/your peers had the problem described in the vignette (major depression and schizophrenia, respectively)? were asked and the most desirable answer to select was I would talk to someone who can be trusted. This selection is considered the most desirable, because the behavior might lead to seeking appropriate help and/or treatment. The selection of this behavior, however, may not directly indicate that the students learned the most appropriate help seeking. Specifically, we did not include whom (e.g., physicians, other professionals or others) they should talk to in the sentences of the options for answer. This is partly due to a difference in the system of medical services between Japan and Western countries. There is no family doctor system in Japan and people, usually, directly (without an introduction by a family doctor) visit a psychiatrist for the treatment of mental difficulties when they or their family think they suffer. Another reason was that persons whom adolescents most frequently talk to about their mental difficulties are their families and peers. 21 We thought that these talks may also help and be encouraged, although mental health literacy needs to be elevated in peers and families to make the talks really helpful. Second, we evaluated the change in the intention to seek help, but not the actual behavior. The actual behavior may be influenced by stigma or feeling shy/ embarrassed. 22,23 A change in such feelings or stigma is an important focus of the MHL education program for adolescents. This issue must be considered in a revision of the program. Using videos of people who have experienced mental illnesses, for example, might be a helpful approach in reducing stigma In summary, a concise, school-staff-led program was effective in improving the MHL of secondary school students. The effects were maintained 3 months after the program was given. Studies using a larger number of students with a control group may be required for further evaluation of concise, schoolstaff-led MHL programs. ACKNOWLEDGMENTS This research was funded through grants from the Kitano Foundation of Lifelong Integrated Education, the Center for Excellence in School Education, The Mental Health Okamoto Memorial Foundation, The Toyota Foundation, and the Ministry of Education, Culture, Sports, Science and Technology of Japan, Scientific Research Grant on Innovative Area ( ; Adolescent Mind & Self-Regulation). We are grateful also to research assistants, in particular Mr Junichi Katori, for his cooperation with this study. The authors declare no conflicts of interest. The authors are solely responsible for the content and writing of the paper. REFERENCES 1. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch. Gen. Psychiatry 2005; 62: Patel V, Fisher AJ, Hetrick S, McGorry P. Mental health of young people: A global public health challenge. Lancet 2007; 369: Jones PB. Adult mental health disorders and their age at onset. Br. J. Psychiatry 2013; 202: Jorm AF, Korten AE, Jacomb PA, Christensen H, Rodgers B, Pollitt P. Mental health literacy : A survey of the public s ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Med. J. Aust. 1997; 166:

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