Mental health first aid training for the public: evaluation of effects on knowledge, attitudes and helping behavior

Description of the program

This nine hour course is usually delivered as three sessions of three hours each across three consecutive weeks. Each participant receives an accompanying course manual [5]. The content covers helping people in mental health crises and / or in the early stages of mental health problems. The crisis situations covered include suicidal thoughts and behaviour, acute stress reaction, panic attacks and acute psychotic behaviour. The mental health problems discussed include depressive, anxiety and psychotic disorders. The co-morbidity with substance use disorders is also covered. Participants learn the symptoms of these disorders, possible risk factors, where and how to get help and evidenced-based effective help.

Five basic steps have been devised as an action plan for carrying out Mental Health First Aid (see Figure 1). This action plan is applied to each of the problem areas covered.

The same instructor (BAK) taught all the courses. Mental Health First Aid courses have been conducted in two settings: with members of the public who respond individually to publicity and do courses in the evenings at the Centre for Mental Health Research, and with workplaces which request courses during working hours.

Evaluation method

The evaluation reported here was carried out with the first 210 participants in the public courses. These participants were given questionnaires to self-complete at the beginning of the first session of the course (pre-test), at the end of the last session (post-test) and were mailed a questionnaire 6 months after completing the course (follow-up). The questionnaires had an ID number but no name.

The pre-test questionnaire began by asking about the sociodemographic characteristics of the participant and whether they had ever experienced a mental health problem themselves or whether someone in their family had. Participants were next asked "How confident do you feel in helping someone with a mental health problem?" (1. Not at all, 2. A little bit, 3. Moderately, 4. Quite a bit, 5. Extremely). This was followed by: "In the last 6 months have you had contact with anyone with a mental health problem?" (Yes/ No/ Don't know). If the participant said "yes", they were asked "How many people?" and "Have you offered any help" (1. Not at all, 2 A little, 3. Some, 4. A lot) and "What type of help?" (blank lines were provided for a description). The next section of the questionnaire was taken from the National Survey of Mental Health Literacy [6]. Participants were presented with a vignette of a person who had either major depression ("Mary") or schizophrenia ("John"). Because it would have been too time consuming for participants to answer questions about both vignettes, they were randomly assigned to receive one or the other and were given this same vignette at each assessment. They were asked "From the information given, what, if anything is wrong with Mary/John" (open-ended question) and "Do you think Mary/John needs professional help?" (yes/ no). Then followed a list of people, treatments and actions that the person in the vignette might use and participants were asked to rate each of these as likely to be helpful, harmful or neither. The list was: a typical GP or family doctor; a chemist or pharmacist; a counselor; a social worker; telephone counseling services, e.g. Lifeline; a psychiatrist; a clinical psychologist; help from her/his close family; help from some close friends; a naturopath or a herbalist; the clergy, a minister or a priest; Mary/John tries to deal with her/his problem on her/his own; vitamins and minerals; St John's wort; pain relievers such as aspirin, codeine or panadol; antidepressants; antibiotics; sleeping pills; anti-psychotics; tranquillisers such as valium; becoming more physically active such as playing more sport, or doing a lot more walking or gardening; read about people with similar problems and how they have dealt with them; getting out and about more; courses on relaxation, stress management, meditation or yoga; cutting out alcohol altogether; counseling; cognitive-behavior therapy; psychotherapy; hypnosis; admission to the psychiatric ward of a hospital; electroconvulsive therapy (ECT); having an occasional alcoholic drink to relax; a special diet or avoiding certain foods. To score these items, scales were created showing the extent to which participants agreed with health professionals about which interventions would be useful. For depression, there is a professional consensus that GPs, psychiatrists, clinical psychologists, antidepressants, counseling and cognitive-behavior therapy are helpful, while for schizophrenia there is a professional consensus that GPs, psychiatrists, clinical psychologists, antipsychotics and admission to a ward are helpful [7]. Thus, for the depression vignette participants received a score from 0 to 6 according to the number of these interventions endorsed as helpful, while for the schizophrenia vignette they scored from 0 to 5. To equalize the range of scores for the two vignettes, they were then converted to percentages. The questionnaire next assessed stigmatizing attitudes using a social distance scale [8]. Social distance was measured by asking how willing the participant would be to: Move next door to Mary/John; Spend an evening socializing with Mary/John; Make friends with Mary/John; Have Mary/John start working closely with you on a job; Have Mary/John marry into your family. Each question was rated on the following scale: 1. Definitely willing, 2. Probably willing, 3. Probably unwilling, 4. Definitely unwilling. Responses were summed to give a score ranging from 5 to 20. Finally, the questionnaire asked "Have you ever had a problem similar to Mary's/John's?" and "Has anyone in your family or close circle of friend ever had a problem similar to Mary's/John's?".

Post-test and follow-up questionnaires involved the same vignette that was randomly assigned at pre-test. However, the post-test questionnaire excluded the sociodemographic questions and questions related to personal or family mental health problems, confidence in providing help and actual help provided. The latter questions were excluded because it was believed that 6 months were required in order to see the effects of the course in daily life. The follow-up questionnaire was the same as the pre-test one except that the socio-demographic questions were excluded.

Ethics

The Chair of the Australian National University Human Research Ethics Committee advised that the evaluation work fell under the definition of quality assurance and therefore did not require formal approval by the Committee. The methods of evaluation conformed to the Helsinki Declaration.

Statistical analysis

Scale scores were analyzed by analysis of variance in which time of measurement (pre, post, follow-up) was a repeated measures factor and type of vignette (depression or schizophrenia) was an independent groups factor. Dichotomous variables were analyzed using the McNemar test when two time points had to be compared (pre, follow-up) and Cochran's Q test when three time points had to be compared (pre, post, follow-up).

The analysis was carried out according to intention-to-treat principles, so that all persons who completed a pre-test questionnaire were included, even if they subsequently dropped out. In such cases, the pre-test score was substituted for the missing value, so that no improvement was assumed.

Participants' characteristics

Of the 210 participants who began the course, 190 attended all three sessions, 14 attended two sessions and 6 attended one session. Some participants who completed the course chose not to return a questionnaire at post-test or follow-up. Consequently, questionnaires were available from all participants at pre-test, 168 at post-test and 166 at follow-up.

Perception of mental health problem in self or family

Participants were asked at pretest and follow-up about whether they themselves had ever experienced a mental health problem or whether anyone in their family had. The percentage reporting these increased from 41.4% to 47.4% for self (P = .050, 2-tailed McNemar exact test) and from 73.4% to 79.0% for family (P = .052).

Recognition of disorder in vignette

Beliefs about treatments

Social distance

Table 4 also shows the mean score on the social distance scale. As would be expected, those who received the schizophrenia vignette expressed greater social distance than those who received the depression vignette. However, social distance decreased over occasions for both groups (significant linear trend in analysis of variance), with some increase again at follow-up (significant quadratic trend).

Help provided to others