Spring 2018

School Based Mental Health Literacy

Effectively Addressing the Need with Evidence Based Resources

Mental Health and Mental Health Literacy

Mental health and mental illness in young people (12-25 years of age) are a topic of substantial interest in Canadian schools. Available data show that, worldwide, approximately 1/3 of the burden of illness in young people can be attributed to mental illness [1-4]. Untreated mental illness may lead to student’s exhibiting current and long-term difficulties in schools, at home and in the community. Mental illnesses are further associated with many chronic physical conditions, such as heart disease, stroke, cancer, diabetes mellitus, hypertension, asthma, etc. [5]. On the other hand, good mental health in young people is a significant enabler for academic, social and vocational success [6].  

Increasing understanding of the importance of mental health has resulted in the delivery of numerous public campaigns (such as Bell’s “Lets Talk”).  These have been directed primarily to increasing mental health awareness in the public domain.  However, this enthusiasm has not yet extended to the development of mental health literacy, which is the necessary foundation for mental health promotion, prevention and care. [7-8].   

Knowing about something is not the same as knowing something and mental health literacy goes beyond mental health awareness to provide individuals and populations with the knowledge, competencies and capacities needed to enhance all aspects of mental health and effectively address mental illness. It consists of four interrelated components: understanding how to obtain and maintain good mental health; understanding mental disorders and their treatments; decreasing stigma related to mental disorders, and enhancing help-seeking efficacy (knowing when and where to seek help and developing competencies designed to improve one’s mental health care and self-management capabilities) [7]. With good mental health literacy, we learn how to take better care of ourselves, our loved ones and our communities. We are empowered and provided with the skills that we need to help us build better lives, better systems of care and a better society.

Schools are ideally placed to help individuals and communities develop good mental health literacy.  Not only can students be easily and frugally reached through schools but teachers, parents, caregivers and others involved in helping young people grow and develop can participate in school based mental health literacy interventions and thus enhance their own mental health literacy. 

However, available Canadian data illustrates that schools are not well prepared to address mental health literacy and other mental health related concerns.  Surveys conducted by the Canadian Teachers Federation and the School Based Mental Health and Substance Abuse Consortium show that about 80% of school administrators are concerned or very concerned about student mental health and substance abuse and approximately 90% of teachers reported that they didn’t have adequate knowledge required to address student mental health needs. [9].  While there is a plethora of mental health resources available for use by educators, only one has undergone the rigorous research needed to determine its effective and sustainable impact [10]. Recent research evaluating mental health literacy in Canadian educators has shown very low levels of mental health related knowledge but generally positive attitudes (low stigma). [11-12]   These findings raise concerns about the quality of resources used and the capability of teachers to effectively address mental health in the classroom.  Education administrators are thus faced with a challenge to provide their teachers and students with best available evidence supported mental health literacy resources that can readily be applied in the classroom setting.

Evidence-Based Mental Health Literacy Resources in Canada

While Canadian schools have been implementing a wide range of mental health programs addressing promotion, prevention, and intervention and care in youth, there have been very few, if any, mental health literacy resources applied, researched and evaluated for evidence of effectiveness. The Mental Health & High School Curriculum Guide (the Guide) (http://teenmentalhealth.org/curriculum/) is a modular classroom ready resource currently being applied in many junior high and secondary schools across numerous provinces that has the necessary scientific evidence needed to support its scale-up across Canada.   

The Guide was created as an integral component of the School-Based Pathway through Care Model (http://teenmentalhealth.org/pathwaythroughcare/) that blueprints how to unify cross-sector collaborations between education and health systems to address youth mental health needs in Canadian schools [8]. Since its inception and launch in 2009, the Guide has gone through three revisions based on national and international feedback from students, educators, parents and mental health professionals, and its content integrates the most recent scientific information provided in developmental context. It is designed for use by classroom teachers (grades 7-10) who receive either face-to-face or online professional development (available through the University of British Columbia Faculty of Education continuing education certification course: (http://pdce.educ.ubc.ca/MentalHealth/) in its use. The current version (2017) consists of 6 modules: the stigma of mental illness; understanding mental health and wellness; information about specific mental illnesses; experiences of mental illness; seeking help and finding support; and the importance of positive mental health. Taken together, these modules cover all aspects of mental health literacy as these apply to students from ages 13 – 16.

Teachers can use the freely available online version (http://teenmentalhealth.org/curriculum/) or the hard copy of the Guide steered by lesson plans in each module, featuring PowerPoint presentations, video clips, games and discussions, and other classroom friendly activities. Additionally, teacher self-evaluation and self-study resources are built into the Guide.  Unlike stand-alone mental health programs, the Guide is delivered using teacher familiar pedagogic approaches, in a frugal, sustainable and system strengthening manner.  This approach mirrors how teachers teach, and focuses on the fidelity of the content, but not the delivery format since no two teachers teach the same subject in the same manner. Thus, it builds on educator’s already existing professional skills.  Further, the Guide was developed to be easily embedded into the current existing school curricula so that it can be sustained through the school year and in the long term as well.     

The Guide has been/is being studied for its impact and effectiveness across Canada and in other countries, such as Malawi, Tanzania, Nicaragua, China, Portugal, Finland, Bangladesh, Australia, the United States, and the United Kingdom. In every location in which the Guide has been implemented and its outcomes studied the data show that its impact is significant, substantial and sustainable over time.  Regardless of socio-economic, geographic or cultural context, research and evaluation findings show similar outcomes: improved knowledge, reduced stigma, enhanced help-seeking efficacy, and reduced perceived stress in both students and teachers [13-18].  To our knowledge, this is the only global MHL resource that has been so well demonstrated to improve both student and teacher mental health with the same frugal intervention.  Recently, application of a one-day exposure to the use of the Guide resource has demonstrated similar outcomes in pre-service teachers as well [19].

As the companion program to the Guide, the Go-To Educator Training (GTET) is designed to improve mental health literacy and capacity for early identification, referral and support of students that may be at risk of mental health problems or mental disorders among educators whom students often gravitate towards for help and support. These educators can be anyone working in the school setting, such as classroom teachers, guidance counsellors, school nurses, psychologists, or school administration staff. Providing them with GTET will offer strong support for classroom teachers who deliver the Guide and facilitate intra-school communication to better address student mental health needs in a collaborative and systematic manner.

GTET is an existing one-day professional development resource, currently delivered face-to-face, that is designed to integrate the following key elements: defining roles of Go-To educators; differentiating different states of mental health and understanding stress; basic etiology and epidemiology of mental illness; brain growth and development; common mental illnesses during adolescence; identification keys, assessment tools and referral strategies for educators; communicating with parents/care givers about student mental health. It facilitates communications not only in the school setting and between the school and students’ caregivers; but also between the education and health systems. This approach has also demonstrated solid evidence in improving meaningful mental health literacy outcomes as well as early identification and referral of young people with mental health care needs and improved access to specialty mental health care for youth that require it [20-21].  Although preliminary in its findings, a recent evaluation of GTET on educators in Nova Scotia has demonstrated substantial positive self-reported outcomes on school culture and on a variety of additional mental health measures for educators and their families, suggesting a possible horizontal diffusion of the impact of this intervention as well [22].

Conclusions

While school-based mental health has received considerable attention and educators across Canada have demonstrated a strong interest in helping their students develop good mental health outcomes, it is essential that schools begin to apply mental health literacy resources that: have been clearly shown to demonstrate robust best available evidence for effectiveness; will be competency enhancing for educators and will be sustainable. Also of importance is frugal implementation that is based on existing pedagogic principles, not needing additional human resources for application and not making significant additional calls on schools already dealing with multiple competing demands. Combined as a mental health literacy package, the Guide and GTET program are timely responses to such a need with solid evidence for improving youth mental health outcomes for both students and teachers alike and are now ready for implementation and scale-up in Canadian junior high and secondary schools.

For more information about where you can access the Guide and GTET resources, see teenmentalhealth.org/schoolmhl

References
1. Whiteford HA1, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, Charlson FJ, Norman RE, Flaxman AD, Johns N, Burstein R, Murray CJ, Vos T. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet. 2013; 382(9904):1575-86.
2. Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry. 2015 Mar;56(3):345-65. doi:10.1111/jcpp.12381.
3. World Health Organization. (2011) Global burden of mental disorders and the need for a comprehensive, coordinated response from health and social sectors at the country level. 2011. Available from: http://apps.who.int/gb/ebwha/pdf_files/EB130/B130_9-en.pdf. [Accessed 6th March, 2018].
4. Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, Feigl AB, Gaziano T, Mowafi M, Pandya A, Prettner K, Rosenberg L, Seligman B, Stein AZ, &Weinstein C. The global economic burden of noncommunicable diseases. Geneva: World Economic Forum, 2011. Available from: http://www3.weforum.org/docs/WEF_Harvard_HE_GlobalEconomicBurdenNonCommunicableDiseases_2011.pdf. [Accessed 6th March, 2018].
5. Scott KM, Lim C, Al-Hamzawi A, Alonso J, Bruffaerts R, Caldas-de-Almeida JM, Florescu S, de Girolamo G, Hu C, de Jonge P, Kawakami N, Medina-Mora ME, Moskalewicz J, Navarro-Mateu F, O’Neill S, Piazza M, Posada-Villa J, Torres Y, Kessler RC. Association of mental disorders with subsequent chronic physical conditions: world mental health surveys from 17 countries. JAMA Psychiatry. 2016; 73(2): 150-158. doi: 10.1001/jamapsychiatry.2015.2688.
6. Canadian Council on Learning. A barrier to learning: mental health disorders among Canadian youth. 2009. Available from: http://en.copian.ca/library/research/ccl/lessons_learning/barrier_to_learning/barrier_to_learning.pdf. [Accessed 6th March, 2018]
7. Kutcher S, Wei Y, & Coniglio C. Mental Health Literacy: Past, Present and Future. Can J Psychiatry. 2016; 61(3): 154-158.
8. Wei Y, Kutcher S, & Szumilas M. Comprehensive school mental health: an integrated “School-Based Pathway to Care” model for Canadian secondary schools. McGill Journal of Education. 2011; 46(2): 213-230.
9. School-Based Mental Health and Substance Abuse Consortium. School based mental health in Canada: a final report. Mental Health Commission of Canada; 2013 [cited 2017 August 29]. Available from: https://www.mentalhealthcommission.ca/sites/default/files/ChildYouth_School_Based_Mental_Health_Canada_Final_Report_ENG_0.pdf
10. Kutcher S, & Wei Y. School mental health literacy: a national curriculum guide shows promising results. Education Canada. 2014; 54 (2): 22-25
11. Wei Y, Kutcher S. Understanding Mental Health Literacy of Educators in Canadian Secondary Schools: A Cross-Sectional Survey. Canadian Journal of Psychiatry. Submitted.
12. Wei Y, Faber S, Kutcher S. Mental health literacy in Newfoundland educators; knowledge, stigma, and help-seeking in a student services providers sample. Canadian Journal of Community Mental Health. Submitted.
13. Ravindran A, Herrera A, da Silva T, Henderson J, Castrillo M, Kutcher S. Evaluating the benefits of a youth mental health curriculum for students in Nicaragua: a parallel group, controlled pilot investigation. Global Mental Health. 2018; 5: 4e. https://doi.org/10.1017/gmh.2017.27
14. Kutcher S, Wei Y, Gilberds H, Brown A, Ubuguyu O, Njau T, Sabuni N, Magimba A, & Perkins K. The African guide: one year impact and outcomes from the implementation of a school mental health literacy curriculum resource in Tanzania. Journal of Education and Training Studies. 2017; 5(4). doi:10.11114/jets.v5i4.2049
15. Milin R, Kutcher S, Lewis S, Walker S, Wei Y, Ferrill N, Armstrong M. Impact of a mental health curriculum on knowledge and stigma among high school students: a randomized controlled trial. Journal of American Academy of Child and Adolescent Psychiatry. 2016; 55(5): 383-391. DOI: 10.1016/j.jaac.2016.02.018
16. Kutcher S, Wei Y, Gilberds H, Ubuguyu O, Njau T, Brown A, Sabuni N, Magimba A, & Perkins K. A school mental health literacy curriculum resource training approach: effects on Tanzanian teachers’ mental health knowledge, stigma and help-seeking efficacy. International Journal of Mental Health Systems. 2016;10(1). DOI: 10.1186/s13033-016-0082-6
17. Kutcher S, Wei Y, & Morgan C. Successful application of a Canadian mental health curriculum resource by usual classroom teachers in significantly and sustainably improving student mental health literacy. Canadian Journal of Psychiatry. 2015; 60(12): 580-586.
18. McLuckie A, Kutcher S, Wei Y, & Weaver C. Sustained improvements in students’ mental health literacy with use of a mental health curriculum in Canadian schools. BMC Psychiatry. 2014; 14(1):1694.
19. Carr W, Wei Y, Kutcher S, Heffernan A. Mental health literacy in pre-service teachers. Canadian Journal of School Psychology. 2017. DOI: 10.1177/0829573516688596.
20. Wei Y, & Kutcher S. Innovations in practice: “go-to” educator training on the mental health competencies of educators in the secondary school setting: a program evaluation. Child and Adolescent Mental Health. 2014; 19 (3), 219-222
21. Kutcher S, Wei, Y, Baxter A, Milin R, Cawthorpe D. (2016). School mental health literacy: early identification & seamless pathways to care. Session presented at the 22nd International Association for Child and Adolescent Psychiatry and Allied Professions World Congress; 2016 September 18-22; Canada, Calgary.
22. Teen Mental Health. Go-To educator training: identification of mental disorders in the secondary school setting. 2014. Available from: http://teenmentalhealth.org/wp-content/uploads/2014/08/GoToTeacherTraining_InterimReportforNovaScotia-2.pdf [Accessed 8th March, 2018].
AUTHOR BIO:
Dr. Stan Kutcher ONS, MD, FRCPC, FCAHS, Sun Life Financial Chair in Adolescent Mental Health at Dalhousie University and IWK Health Centre, is an international expert in adolescent mental health and leader in mental health research, advocacy, training, policy, and services innovation and has been involved in mental health work in over 25 countries.

Dr. Yifeng Wei, MA, PhD holds an Interdisciplinary PhD degree in school mental health with Dalhousie University and was awarded the Canadian Institute of Health Research Doctoral Research Award in 2011. She has worked as a researcher and school mental health lead with the Sun Life Financial Chair in Adolescent Mental Health team since 2008.