Enhancing mental health literacy in young people
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According to the World Health Organization (WHO), health literacy is key to improving health outcomes for both individuals and populations . Mental health literacy (MHL), a component of health literacy can be expected to have similar impacts . Our understanding of MHL has evolved from its early development as a tool to enhance the recognition of mental disorders  to a more complex consideration, consistent with the WHO’s construct of health literacy as a social determinant of health and an educationally driven intervention with demonstrated positive impact on the health outcomes of individuals and populations, as well as a vehicle that can be applied to help transform health inequities [1, 4]. As such, MHL has been conceptualized as comprising four distinct but related components: (1) understanding how to obtain and maintain good mental health; (2) understanding mental disorders and their treatments; (3) decreasing stigma related to mental disorders; (4) enhancing help-seeking efficacy (knowing when, where, and how to obtain good mental health care and developing competencies needed for self-care) [2, 5]. Thus, MHL provides the necessary foundation for mental health promotion, prevention, and care, and binds these essential components into a seamless construct focused on improving both mental health and mental health care outcomes rather than focusing singly on promotion of wellbeing [3, 6, 7].
It is now widely appreciated that about 70 % of mental disorders can be diagnosed prior to age 25 years and that they comprise the single largest component of disease burden during the second decade of the life span [8, 9]. To effectively address youth mental health, it is essential that MHL becomes a focus of mental health interventions for young people. Without a good MHL foundation, young people will not be well prepared to successfully travel the developmental pathway into adulthood and beyond. Recent evidence further demonstrates that improved mental health knowledge and decreased stigma are two essential components to facilitate help-seeking behaviors and early identification of mental disorders [10, 11]. Since most young people are enrolled in schools, schools have been recognized as an important venue to address student mental health  and recently with special focus on MHL in both Europe and Canada [13, 14, 15].
Recently, this importance of addressing school mental health has been further recognized by the European Commission  and European Joint Action on Mental Health and Wellbeing 2016 (mentalhealthandwellbeing.eu) . A great number of school-based mental health interventions have been applied in Europe. For example, Weare and Nind  identified and analyzed more than 500 school mental health interventions, including those in UK, Netherlands, Germany, Norway, and Belgium. Power and colleagues  also conducted a selective review of school mental health interventions in Ireland. While these interventions have demonstrated small to moderate effect sizes in improving student wellbeing, social and emotional learning, or safe and positive school environment, very few, if any, interventions have addressed full components of MHL. It is fundamental that schools not only promote positive mental health, but also enable students to differentiate normal mental distress from mental health problems/disorders, reduce stigma against mental illness, and promote help-seeking behaviors of students and mental health self-care if they need mental health care. The concept of MHL has been developed to fill this gap in the education system [2, 13]. Our literature search identified one school MHL intervention in Norway  that embedded MHL into schools that demonstrated impact on student knowledge for identification of certain mental disorders and attitude changes; however, these approaches have often been input into schools by external providers and, therefore, may not lead to sustained and enhanced MHL capacity embedded into educational systems. Nor, if external providers are used, do those interventions demonstrate the positive impact on teacher mental health literacy that is seen with curriculum resource approaches delivered by teachers such as those described below.
The systematic review by Weare and Nind  recommended that effective interventions should be sustainable and embedded in the already existing whole-school approach, which encompasses teacher capacity building and links with parents and the wider community. Further, WHO  stated that successful interventions should develop personal skills for both students and school staff and be implemented over a long period of time. These recommendations are in good alignment with a recent MHL approach that is based on existing classroom friendly pedagogical applications that can be easily and inexpensively delivered within existing educational systems and does not require extracurricular or outside-of-school inputs [2, 6]. When applied through enhancing capacity of classroom teachers to integrate evidence-based MHL curriculum resources (http://teenmentalhealth.org/curriculum/) into existing curriculum, as demonstrated by numerous Canadian studies, such interventions can concurrently result in positive MHL outcomes for both students and teachers alike [21, 22, 23, 24]. Additionally, this approach can facilitate the development of an horizontally integrated school-based pathway to youth mental health care that links education and health systems, enhances identification, and facilitates triage and referral of students with mental disorders to local mental health care providers, thus functionally integrating educational and health care delivery systems, even in the absence of specific policies designed to do so [13, 25].
Similar approaches have been recently field-tested in Europe with positive results. For example, in Portugal, a MHL project was recently applied in the Lisbon region . Results demonstrated substantial and significant improvements in MHL for teachers, student services providers (such as psychologists), and nurses. Referrals from schools to mental health providers increased, and participants reported high satisfaction with the intervention .
Building on this pilot, the ongoing WhySchool initiative of EUTIMIA (http://www.whyschool.eutimia.pt), a branch of the European Alliance Against Depression in Portugal (EAAD; www.eaad.eu), is applying an adapted version of the Canadian curriculum resource (www.teenmentalhealth.org/curriculum) to improve MHL for teachers and students. Additionally, and similar to Canadian experience , WhySchool is linking trained primary health care providers with schools to improve access to mental health care for young people who require it. This intervention has been enhanced by electronic-based self-care tools , training of psychologists working in primary care, and a media campaign. Over 600 teachers have been trained to date in a project supported by the University of Oslo through the EEA Grants program (www.eeagrants.org).
These findings taken together with the simplicity, sustainability, and system capacity enhancing features of this approach, coupled with its inexpensive application raises the opportunity for consideration of the widespread implementation of such an approach within Europe. Other MHL approaches, such as Mental Health First Aid, usually target the general community, and focus on symptom identification (e.g., depression, anxiety, and schizophrenia), and awareness of help-seeking resources. While these approaches may be effective for the general public in some aspects of MHL , they address a limited number of MHL components when applied in the school setting, with a lack of stigma-reduction strategies and absence of positive mental health approaches; without features for potential sustainability; and with a lack of capacity building component within educational systems, especially for teacher capacity building and links with the wider community.
In Europe, a number of organizations and agencies, such as ADOCARE (http://www.adocare.eu) and the European Joint Action on Mental Health and Wellbeing 2016 (http://mentalhealthandwellbeing.eu), have identified mental health in schools as a priority. With the rich experiences and success in promoting social and emotional wellbeing among students, and with the demonstrated effectiveness of available well-established school MHL interventions, now, it may be an ideal time to adapt and integrate such interventions as a potential universal mental health intervention within European schools. However, thorough adaptations of existing interventions for local contexts and subsequent research are needed to evaluate the effectiveness of this MHL approach in European school settings.
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