Long-term impact of a mental health literacy resource applied by regular classroom teachers in a Canadian school cohort.

Application of evidence-based mental health literacy (MHL) curriculum resources by classroom teachers has been demonstrated to significantly improve knowledge and decrease stigma in the short term. AIMS: To report results that extend these positive findings for a period of one year. METHOD: In a naturalistic cohort study, 332 grade 9 students (ages 14-15) in a Canadian school district learned from an evidence-based curriculum resource (the Guide) applied by classroom teachers who trained in its use. Evaluations of knowledge and stigma were conducted before the Guide, immediately following the Guide delivery and at one-year follow-up. RESULTS: Students showed significant (p < .001) and substantial (d = 0.68 and 0.67) short-term and significant (p < .001) and substantial (d = 0.44 and 0.58) long-term improvements in knowledge and reductions in stigma. Significant stigma reduction was found among female students than male students, but no gender differences on knowledge were found at long-term follow-up. Educators showed significant and substantial short-term improvements in knowledge (p < .001; d = 1.03) and reductions in stigma (p < .05; d = 0.35). CONCLUSIONS: The Guide resource delivered by trained classroom teachers may have value in enhancing MHL outcomes for young people.

School-based mental health literacy training shifts the quantity and quality of referrals to tertiary child and adolescent mental health services: A Western Canada regional study.

BACKGROUND: We aimed to improve mental health referral quality of young people by helping educators build capacity for early identification of youth at risk of mental illness and facilitate referrals between the education and health systems. METHODS: We applied the Go-To Educator mental health literacy training for early identification, triage and support in 208 schools in Calgary, Alberta between 2013 and 2016. Students presenting to mental health services during this time were compared on a number of clinical, system, and demographic variables, based on the training status of the school (untrained schools; before and after training schools), using retrospective cohort design. Based on clinical and system data, bivariate and multivariable logistic regression analysis were employed to compare the three school status domains. RESULTS: After training, referrals differed significantly from control and pre-training schools. Students presenting to services from these schools were younger, from single parent families; were referred more because of adjustment and learning/attention problems; had complex social/family issues; thought disturbances, and harmful behavior/thoughts towards others. While they waited longer to be admitted they stayed longer in services; had more provisional comorbid diagnoses and demonstrated positive treatment outcomes. CONCLUSIONS: The Go-To Educator training may be an effective intervention helping educators identify students at risk of mental disorders and in substantial need of mental health services, demonstrating improved linkages between education and health sectors.

Dos and Don'ts in Designing School-Based Awareness Programs for Suicide Prevention.

Background: Despite the promising evidence for the effectiveness of school-based awareness programs in decreasing the rates of suicidal thoughts and suicide attempts in young people, no guidelines on the targets and methods of safe and effective awareness programs exist. Aims: This study intends to distill recommendations for school-based suicide awareness and prevention programs from experts. Method: A three-stage Delphi survey was administered to an expert panel between November 2018 and March 2019. A total of 214 items obtained from open-ended questions and the literature were rated in two rounds. Consensus and stability were used as assessment criteria. Results: The panel consisted of 19 participants in the first and 13 in the third stage. Recommended targets included the reduction of suicide attempts, the enhancement of help-seeking and peer support, as well as the promotion of mental health literacy and life skills. Program evaluation, facilitating access to healthcare, and long-term action plans across multiple levels were among the best strategies for the prevention of adverse effects. Limitations: The study is based on opinions of a rather small number of experts. Conclusion: The promotion of help-seeking and peer support as well as facilitating access to mental health-care utilities appear pivotal for the success of school-based awareness programs.

The Impact of Transitions, a Mental Health Literacy Intervention With Embedded Life Skills for Postsecondary Students: Preliminary Findings From a Naturalistic Cohort Study.

OBJECTIVE: Mental illness is a common medical condition to onset during adolescence. Young people who leave for postsecondary life are at an especially challenging period of lifetime when many will leave home and familiar environments for prolonged periods of time. These new circumstances may put young people at risk of developing mental health problems or disorders or exacerbate existing mental disorders. Alternatively, some young people may misinterpret the normal negative emotional states occurring as a result of these new challenges as a mental disorder requiring professional intervention. We conducted a quasiexperimental cohort study to investigate the effectiveness of a mental health literacy intervention Transitions with blended life skills to address these challenges for first-year postsecondary students. METHODS: Students (n = 2,397) from five Canadian postsecondary institutions were assigned to the intervention or the control group and were administered a survey at baseline, postintervention, and at 2-month follow-up (September 2017 to February 2018). We applied generalized linear mixed effects (PROC Mixed procedure) to test the between-group difference in the post-pre/follow-up-pre and to determine the predicted least-square mean values. RESULTS: The findings showed that students who were exposed to the Transitions intervention significantly improved their mental health knowledge, decreased stigma against mental illness, improved help-seeking attitudes and behaviours, and decreased perceived stress when compared to students who had not been exposed to the intervention. However, we did not identify significant changes in general health. This may be due to the relatively short follow-up time (2 months) to determine participants' general health status. CONCLUSIONS: Transitions delivered to first-year postsecondary students may be a beneficial intervention to help young people adjust to their new postsecondary life and improve their mental health.

The program evaluation of 'Go-To Educator Training' on educators' knowledge about and stigma toward mental illness in six Canadian provinces.

AIM: Schools are well positioned to promote mental health literacy and assist in the early identification of students who may have a mental disorder. However, many educators are unprepared to effectively address these issues. Enhancing this capacity may improve mental health outcomes for students. This report describes the application of a gatekeeper-type program, the 'Go-To Educator Training' (GTET), targeting educators whom students naturally gravitate toward for support, designed to improve educators' mental health knowledge and early identification skills and decrease stigma. METHODS: GTET was conducted in six Canadian provinces (Ontario, Nova Scotia, New Brunswick, Newfoundland, Alberta and Manitoba) (2012-2015), with 949 secondary school educators involved. Pre- and postintervention mental health knowledge and stigma surveys were completed. Paired t-tests assessed change in knowledge and stigma. ANCOVA compared knowledge and stigma change across subgroups. Correlation measured the relationship between knowledge and stigma. RESULTS: Knowledge significantly improved (t[919] = 58.40, P < .001, d = 2.12) and stigma significantly decreased (t[872] = 4.52, P < .001, d = 0.14). Similar results were identified within each province/region. Knowledge and stigma were correlated before (N = 922, r = .18, P < .01) and after the training (N = 888, r = .22, P < .01). CONCLUSIONS: These results suggest GTET may be an effective school-based mental health related intervention. Further study is needed to measure its long-term impact and its role in addressing youth mental health care referrals.

Measurement invariance and psychometric analysis of Kutcher Adolescent Depression Scale across gender and marital status.

BACKGROUND: The Kutcher Adolescent Depression Scale (KADS) has been studied across Canada and some other countries during the past almost 15 years. The scale is a self-report tool to diagnose and monitor clinical depression in adolescents. A brief review of previous studies on KADS showed the lack of evaluation of KADS fairness/equivalence in measuring depression among identified groups. METHODS: To examine the psychometric properties and measurement invariance of the KADS, responses of 407 participants were analyzed using item response theory (IRT) and ordinal logistic regression (OLR). Relevant measures of effect size were utilized to interpret the results. RESULTS: Findings of the parallel factor analysis confirmed unidimensionality of the KADS and the partial credit IRT model found to be the best fitting model for analyzing the scale. OLR analysis detected three items across gender and one item across marital status to function differentially. An assessment of effect sizes implied negligible differences for practical considerations. LIMITATIONS: A note of caution is necessary with respect to interpreting results of measurement invariance across Gender. The sample analyzed in this study was predominantly female and this might have affected our findings. A similar analysis with a more balanced sample is recommended. CONCLUSIONS: This study was a significant step towards providing theoretical and practical information regarding the assessment of depression among adolescents by presenting adequate evidence regarding the psychometric properties of KADS-11. Future studies may look at different methods for assessing invariance and different groups for strengthening conclusions with respect to the KADS.

Establishment and validation of a mental health literacy measurement in Canadian educators.

We aim to create the first mental health literacy measure addressing mental health knowledge of educators and assess its psychometric properties. We developed a 30-item multiple choice measure, Mental Health Literacy Tool for Educators (MHL-ED), with experts in both mental health and education. We administered it to educators (n = 909) from 6 Canadian provinces. We analysed the factor structure, internal consistency reliability, construct validity and responsiveness to change of MHL-ED. Factor analysis resulted in 4 factors of MHL-ED addressing: general mental illness and related treatment; assessment and diagnostic tools and treatments; causes and risk factors of mental illness; and epidemiology of mental health and mental illness. MHL-ED demonstrated strong internal consistency reliability. The construct validity was established because the hypothesis was supported that school based mental health professionals scored significantly higher than classroom teachers and school administrators/school support staff; and further MHL-ED scores were positively related with stigma measures. We did not identify floor or ceiling effects of MHL-ED. MHL-ED is reliable and valid to evaluate mental health literacy levels among educators working in junior high and secondary school settings, and may be considered for use in future research in this field.

Evaluating the benefits of a youth mental health curriculum for students in Nicaragua: a parallel-group, controlled pilot investigation.

BACKGROUND: High rates of mental illness and addictions are well documented among youth in Nicaragua. Limited mental health services, poor mental health knowledge and stigma reduce help-seeking. The Mental Health Curriculum (MHC) is a Canadian school-based program that has shown a positive impact on such contributing factors. This pilot project evaluated the impact of the MHC on mental wellness and functioning among youth in Leon, Nicaragua. METHODS: High school and university students (aged 14-25 years) were assigned to intervention (12-week MHC; n  =  567) and control (wait-list; n  =  346) groups in a non-randomized design. Both groups completed measures of mental health knowledge, stigma and function at baseline and 12 weeks. Multivariate analyses and repeated measures analyses were used to compare group outcomes. RESULTS: At baseline, intervention students showed higher substance use (mean difference [MD]  =  0.24) and lower perceived stress (MD = -1.36) than controls (p  <  0.05); there were no other group differences in function. At 12 weeks, controlling for baseline differences, intervention students reported significantly higher mental health knowledge (MD  =  1.75), lower stigma (MD  =  1.78), more adaptive coping (MD  =  0.82), better lifestyle choices (MD  =  0.06) and lower perceived stress (MD = -1.63) (p  <  0.05) than controls. The clinical significance as measured by effect sizes was moderate for mental health knowledge, small to moderate for stigma and modest for the other variables. Substance use also decreased among intervention students to similar levels as controls (MD  =  0.03) (p > 0.05). CONCLUSIONS: This pilot investigation demonstrates the benefits of the MHC in a low-and-middle-income youth population. The findings replicate results found in Canadian student populations and support its cross-cultural applicability.

Measurement properties of mental health literacy tools measuring help-seeking: a systematic review.

BACKGROUND: Mental health literacy is important to improve help-seeking behaviors. However, the quality of mental health help-seeking tools remains unknown. AIMS: We conducted a systematic review to appraise the quality of such tools. METHODS: We searched databases for English publications addressing psychometrics of help-seeking tools. We included help-seeking tools addressing mental health in general and tools on four mental disorders: anxiety, depression, attention deficit hyperactivity disorder (ADHD) and schizophrenia. We determined the methodological quality of studies as "excellent", "good", "fair", or "indeterminate". We ranked the level of evidence of each measurement property as "strong", "moderate", "limited", "conflicting" or "unknown". RESULTS: We found 12 help-seeking tools in 24 studies that assessed related psychometrics. The methodological quality of included studies ranged from "poor" to "excellent" with four studies on the content validity, structural validity or internal consistency demonstrating "excellent" quality. Three tools demonstrated overall strong evidence (content or structural validity); eight tools demonstrated moderate evidence (internal consistency, structural or construct validity); and eight tools demonstrated limited evidence (reliability, construct validity or internal consistency). CONCLUSIONS: We recommend the application of tools with strong or moderate evidence for their psychometric properties. Future research may focus on the generalizability of the tools across diverse settings.

School- and Community-Based Youth Suicide Prevention Interventions: Hot Idea, Hot Air, or Sham?

Suicide in young people is a significant health concern, with numerous community- and school-based interventions promising to prevent suicide currently being applied across Canada. Before widespread application of any one of these, it is essential to determine its effectiveness and safety. We systematically reviewed the global literature on one of the most common community suicide prevention interventions in Canada and summarized data on 2 commonly applied school-based suicide prevention programmes. None of these has demonstrated effectiveness in preventing youth suicide or safety in application. Concurrently with their widespread distribution in Canada, the suicide rate in young women has increased-the first time in over 3 decades. Policy and regulatory implications of these findings are discussed.

Addressing Adolescent Depression in Tanzania: Positive Primary Care Workforce Outcomes Using a Training Cascade Model.

BACKGROUND: This is a report on the outcomes of a training program for community clinic healthcare providers in identification, diagnosis, and treatment of adolescent Depression in Tanzania using a training cascade model. METHODS: Lead trainers adapted a Canadian certified adolescent Depression program for use in Tanzania to train clinic healthcare providers in the identification, diagnosis, and treatment of Depression in young people. As part of this training program, the knowledge, attitudes, and a number of other outcomes pertaining to healthcare providers and healthcare practice were assessed. RESULTS: The program significantly, substantially, and sustainably improved provider knowledge and confidence. Further, healthcare providers' personal help-seeking efficacy also significantly increased as well as the clinicians' reported number of adolescent patients identified, diagnosed, and treated for Depression. CONCLUSION: To our knowledge, this is the first study reporting positive outcomes of a training program addressing adolescent Depression in Tanzanian community clinics. These results suggest that the application of this training cascade approach may be a feasible model for developing the capacity of healthcare providers to address youth Depression in a low-income, low-resource setting.

From personal crisis care to convenience shopping: an interpretive description of the experiences of people with mental illness and addictions in community pharmacies.

BACKGROUND: The role of community pharmacists is changing globally with pharmacists engaging in more clinically-oriented roles, including in mental health care. Pharmacists' interventions have been shown to improve mental health related outcomes but various barriers can limit pharmacists in their care of patients. We aimed to explore the experiences of people with lived experience of mental illness and addictions in community pharmacies to generate findings to inform practice improvements. METHODS: We used interpretive description methodology with analytic procedures of thematic analysis to explore the experiences of people with lived experience of mental illness and addictions with community pharmacy services. Participants were recruited through multiple mechanisms (e.g., paper and online advertisements), offered honorarium for their time, and given the option of a focus group or interview for participation in our study. Data were gathered during July to September of 2012. Interviews and focus groups were audio-recorded, transcribed verbatim, and analyzed by two researchers. RESULTS: We collected approximately nine hours of audio data from 18 individuals in two focus groups (n = 12) and six individual interviews. Fourteen participants were female and the average age was 41 years (range 24 to 57 years). Expectations, decision-making, and supports were identified as central themes underlying the community pharmacy experiences of people with lived experience of mental illness and addictions. Eight subthemes were identified including: relationships with pharmacy staff; patient's role in the pharmacist-patient relationship; crisis and triage; privacy and confidentiality; time; stigma and judgment; medication-related and other services; and transparency. CONCLUSIONS: People with lived experience of mental illness and addictions demonstrate a high regard and respect for pharmacist's knowledge and abilities but hold conservative expectations of pharmacy health services shaped by experience, observations, and assumptions. To some extent, expectation management occurs with the recognition of the demands on pharmacists and constraints inherent to community pharmacy practice. Relationships with pharmacy staff are critical to people with lived experience and influence their decision-making. Research in the area of pharmacists' roles in crises and triage, especially in the area of suicide assessment and mitigation, is needed urgently.

A school mental health literacy curriculum resource training approach: effects on Tanzanian teachers' mental health knowledge, stigma and help-seeking efficacy.

BACKGROUND: Mental health literacy (MHL) is foundational for mental health promotion, prevention, stigma reduction, and care; School supported information pertaining to MHL in sub-Saharan Africa is extremely limited, including in Tanzania. Successful application of a school MHL curriculum resource may be an effective way to increase teacher MHL and therefore help to improve mental health outcomes for students. METHODS: Secondary school teachers in Tanzania were trained on the African Guide (AG) a school MHL curriculum resource culturally adapted from a Canadian MHL resource (The Guide) for use in Africa. Teacher training workshops on the classroom application of the AG were used to evaluate its impact on mental health literacy in a sample of Tanzanian Secondary school teachers. Pre-post training assessment of participant knowledge and attitudes was conducted. Help-seeking efficacy for teachers themselves and their interventions for students, friends, family members and peers were determined. RESULTS: Paired t test (n = 37) results demonstrate highly significant improvements in teacher's overall knowledge (p < 0.001; d = 1.14), including mental health knowledge, (p < 0.001; d = 1.14) and curriculum specific knowledge (p < 0.01; d = 0.63). Teachers' stigma against mental illness decreased significantly following the training (p < 0.001; d = 0.61). Independent t tests comparing the paired sample against unpaired sample also demonstrated significant differences between the groups for teacher's overall knowledge (p < 0.001). Teachers also reported high rates (greater than ¾ of the sample) of positive help-seeking efficacy for themselves as well as for their students, friends, family members and peers. As a result of the training, the number of students teachers identified for potential mental health care totaled over 200. CONCLUSIONS: These positive results, when taken together with other research, suggest that the use of a classroom-based resource (the AG) that integrates MHL into existing school curriculum through training teachers may be an effective and sustainable way to increase the MHL (improved knowledge, decreased stigma and positive help-seeking efficacy) of teachers in Tanzania. As this study replicated the results of a previous intervention in Malawi, consideration could be given to scaling up this intervention in both countries and applying this resource and approach in other countries in East Africa.

Measurement properties of tools measuring mental health knowledge: a systematic review.

BACKGROUND: Mental health literacy has received great attention recently to improve mental health knowledge, decrease stigma and enhance help-seeking behaviors. We conducted a systematic review to critically appraise the qualities of studies evaluating the measurement properties of mental health knowledge tools and the quality of included measurement properties. METHODS: We searched PubMed, PsycINFO, EMBASE, CINAHL, the Cochrane Library, and ERIC for studies addressing psychometrics of mental health knowledge tools and published in English. We applied the COSMIN checklist to assess the methodological quality of each study as "excellent", "good", "fair", or "indeterminate". We ranked the level of evidence of the overall quality of each measurement property across studies as "strong", "moderate", "limited", "conflicting", or "unknown". RESULTS: We identified 16 mental health knowledge tools in 17 studies, addressing reliability, validity, responsiveness or measurement errors. The methodological quality of included studies ranged from "poor" to "excellent" including 6 studies addressing the content validity, internal consistency or structural validity demonstrating "excellent" quality. We found strong evidence of the content validity or internal consistency of 6 tools; moderate evidence of the internal consistency, the content validity or the reliability of 8 tools; and limited evidence of the reliability, the structural validity, the criterion validity, or the construct validity of 12 tools. CONCLUSIONS: Both the methodological qualities of included studies and the overall evidence of measurement properties are mixed. Based on the current evidence, we recommend that researchers consider using tools with measurement properties of strong or moderate evidence that also reached the threshold for positive ratings according to COSMIN checklist.