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Early Intervention in Psychiatry 2013; 7: 109–121 doi:10.1111/eip.12010

Review Article
The effectiveness of school mental health literacy
programs to address knowledge, attitudes and
help seeking among youth
Yifeng Wei, Jill A. Hayden, Stan Kutcher, Austin Zygmunt and Patrick McGrath

Abstract knowledge, attitudes and help-

Maritime Psychiatry, IWK Health Centre
and Dalhousie University, Halifax, Nova
Scotia, Canada
Corresponding author: Ms Yifeng Wei,
Maritime Psychiatry, IWK Health Centre
and Dalhousie University, 5850 University
Avenue, PO Box 9700, Halifax, NS,
Canada B3K 6R8. Email:
Yifeng.wei@iwk.nshealth.ca
Aim: Conduct a systematic review for
the effectiveness of school mental
health literacy programs to enhance
knowledge, reduce stigmatizing
attitudes and improve help-seeking
behaviours among youth (12–25 years
of age).
Methods: Reviewers independen-
tly searched PubMed, PsycINFO,
Cochrane Library, CINAHL, ERIC,
grey literature and reference lists of
included studies. They reached a con-
sensus on the included studies, and
rated the risk of bias of each study.
Studies that reported three outcomes:
knowledge acquisition, stigmatizing
attitudes and help-seeking behav-
iours; and were randomized con-
trolled trials (RCTs), cluster RCTs,
quasi-experimental studies, and
controlled-before-and-after studies,
were eligible.
Results: This review resulted in
27 articles including 5 RCTs, 13
quasi-experimental studies, and
9 controlled-before-and-after studies.
Whereas most included studies
claimed school-based mental
health literacy programs improve
seeking behaviour, 17 studies met cri-
teria for high risk of bias, 10 studies
for moderate risk of bias, and no
studies for low risk of bias. Common
limitations included the lack of rand-
omization, control for confounding
factors, validated measures and
report on attrition in most studies.
The overall quality of the evidence for
knowledge and help-seeking behav-
iour outcomes was very low, and low
for the attitude outcome.
Conclusions: Research into school-
based mental health literacy is still in
its infancy and there is insufficient
evidence to claim for positive impact
of school mental health literacy pro-
grams on knowledge improvement,
attitudinal change or help-seeking
behaviour. Future research should
focus on methods to appropriately
determine the evidence of effective-
ness on school-based mental health
literacy programs, considering the
values of both RCTs and other
research designs in this approach.
Educators should consider the
strengths and weaknesses of current
mental health literacy programs to
inform decisions regarding possible
implementation.

Received 22 July 2012; accepted 30 Key words: adolescents, attitudes towards mental illness, help-seeking
September 2012 behaviours, program effectiveness, school mental health literacy.

INTRODUCTION orders affect approximately 20% of children and

Mental health problems and mental disorders in
young people are a major public health concern.
Most mental disorders initially manifest between
the age of 12 and 25 years.1,2 Worldwide mental dis-
youth.2,3 Despite the great burden of disability due
to these disorders, the majority of individuals who
require care are unable to secure needed services.4–6
This need for care gap is larger in middle and lower
income countries.3 Untreated mental disorders may

© 2013 Wiley Publishing Asia Pty Ltd 109

Effectiveness of school mental health literacy programs
lead to substantial negative personal, family and
social outcomes,7 and increased health-care utiliza-
tion.8 Epidemiological data highlight adolescence as
a significant period of risk for mental disorders and
stress the need to address mental health concerns in
adolescents.9,10
Mental health literacy encompasses knowledge
and skills that address the biological, psychological
and social aspects of mental health to increase the
understanding of mental health and mental disor-
ders, reduce stigma, help recognize and prevent
mental disorders, and facilitate help-seeking behav-
iours in youth along the pathway to mental health
care. Mental health literacy programs are differenti-
ated from mental health interventions such as iden-
tification and treatment of specific mental disorders
or substantive emotional symptoms, or the applica-
tion of interventions designed to prevent negative
social behaviours. It has been proposed that mental
health literacy programs may play an important role
in facilitating access to care among young people
with mental health problems.11,12 Educators, health
professionals and policy makers have recognized
the important role of schools in addressing the
mental health needs of young people and have
endorsed the implementation of school mental
health programs.11,12
Current school-based mental health literacy pro-
grams fall into two categories: those that address
mental health and mental disorders in general, and
those that focus on specific mental disorders.
However, there are few systematic reviews available
investigating effectiveness of school-based mental
health literacy programs. Most available systematic
reviews focus on prevention strategies addressing
symptomatic youth or promotional activities
addressing self-concept, self-esteem or social and
coping skills, some of which have taken literacy as
one subcomponent for discussion, with none focus-
ing solely on mental health literacy. Educational
approaches addressing stigma are well known, but to
our knowledge only one systematic review13 has
evaluated the effects of school interventions on stig-
matization. Schachter et al.13 noted that conclusions
about benefits or harms of these interventions could
not be determined due to serious methodological
limitations of included studies. Kelly et al.14 have
provided a narrative overview of mental health lit-
eracy interventions for youth; however, this overview
only summarized intervention characteristics and
level of evidence defined by the Australian National
Health and Medical Research Council. It did not criti-
cally appraise the quality of studies they reviewed,
and some of the interventions included did not have
results available at the time of publication.
110
To our knowledge, no reviews have investigated
the effectiveness of school-based mental health lit-
eracy programs in a systematic manner. Our review
addresses this gap by evaluating the evidence of
effectiveness of school-based mental health literacy
programs in comparative studies to enhance knowl-
edge, reduce stigmatizing attitudes towards mental
illness and improve help-seeking behaviours among
youth between the ages of 12 and 25 years.
METHODS
Inclusion criteria
We included studies targeting youth who were
between 12 and 25 years old and were enrolled in an
educational institution. This age range is based on
the fact that most disorders have their manifesta-
tion prior to the age of 25.1,2
Studies of school-based mental health literacy
programs, either condition-based programs or
general mental health education, were eligible. We
included mental health literacy programs encom-
passing at least one of the following domains: (i)
addressing basic concepts about mental health (e.g.
biological, psychological and social aspects of
mental health); (ii) providing resources/strategies
for help-seeking behaviours; or (iii) including
activity/strategies for stigma reduction towards
mental illness. Therefore, included studies should
report at least one of the following outcomes:
knowledge acquisition, stigmatizing attitudes
towards mental illness and help-seeking behav-
iours. Delivery formats, models of intervention,
socio-geographic locations, evaluation criteria and
duration of interventions were not used to select
studies.
We included randomized controlled trials (RCTs),
cluster RCTs, quasi-experimental studies, and
controlled-before-and-after studies that described
within-group comparison.
Exclusion criteria
We excluded programs that primarily addressed
social and emotional well-being, such as stress
management, social skills, self-esteem, empathy
and self-concept. We excluded studies of profes-
sional development programs for medical school
students and educators; and studies evaluating
the prevention of substance abuse and conduct
problems.
Search methods
Two reviewers independently searched PubMed,
PsycINFO, the Cochrane Library, CINAHL and ERIC,
© 2013 Wiley Publishing Asia Pty Ltd

using five sets of search terms that reflect the char-
acteristics of the study participants, interventions
and settings to identify studies of school-based
mental health literacy programs. These five sets of
search terms were combined using the AND Boolean
operator, with each individual term connected with
the OR Boolean operator within each set of terms. No
restrictions were applied for publication status and
date. Key search terms were: mental health, mental
disorders/illness, health education, health literacy,
health promotion, prevention, youth, adolescents,
schools, program evaluation and effectiveness. The
two reviewers further independently reviewed refer-
ence lists of included studies for relevant studies.
They also reviewed grey literature using the GREY
MATTERS tool15 and searched all the relevant
sites listed on GREY MATTERS. They finally searched
the Campbell Collaboration (http://www.campbell
collaboration.org/library.php) using the five sets of
search terms mentioned. Further details regarding
search strategies can be found in the Appendix.
Study selection and data extraction
Two reviewers independently selected relevant
studies for inclusion and imported selected studies
into the RefWorks 2.016 database, with duplicates
removed. The two reviewers then screened the titles
and abstracts and excluded studies that were not
relevant to the topic of interest. They independently
reviewed full-text articles for final selection of
included studies; they negotiated and reached con-
sensus in situations where there was not initial
agreement of selection. The third reviewer was
invited to resolve any disagreements between
reviewers.
A data extraction form, developed a priori, cap-
tured the following information: identifying infor-
mation, study eligibility, study characteristics
(baseline characteristics, location, timing, methods,
and intervention type and duration), outcome
measures and data.
Critical appraisal method
To determine the internal validity of the included
studies, the reviewers modified the Risk of Bias
(ROB) assessment tool based on the six Cochrane
ROB domains: sequence generation, allocation
concealment, blinding, incomplete outcome data,
selective reporting and other topic-specific biases,17
with incorporated components from the Quality in
Prognosis Studies (QUIPS) tool18 that provides
detailed interpretation of individual quality items to
© 2013 Wiley Publishing Asia Pty Ltd
Y. Wei et al.
inform reviewers’ assessment of potential bias. As a
result, all included studies were assessed for poten-
tial biases in five domains: selection bias (e.g.
randomized sequence generation and allocation
concealment), attrition bias (loss to follow-up), con-
founding (definition and control of important
confounders), outcome measurement (valid and
reliable measurement of outcome) and reporting
bias (selective reporting or underreport of unex-
pected results).
The internal validity of included studies was
scored independently by two reviewers; each
domain was ranked as low, moderate or high ROB.
Then the two reviewers reached consensus through
discussion on the overall ROB of each study.
Synthesis of results
This review compared the difference of mean scores
or percentages of correct answers for each study
before and after the intervention. This review also
intended to pool outcome data for meta-analysis.
We first grouped studies by outcome, following
which we excluded high ROB studies. Remaining
studies were classified by research design, type of
educational institution and type of intervention.
Overall quality of evidence
We rated the overall quality of the available evidence
using the Grades of Recommendation, Assessment,
Development and Evaluation (GRADE) frame-
work.17,19 GRADE assesses five domains to determine
the evidence level: study design/conduct limitation,
generalizability/relevance, heterogeneity of results,
imprecision of results and publication bias. The
overall quality of the evidence for each outcome was
rated as high, moderate, low and very low.
RESULTS
Study characteristics
Figure 1 describes the flow of studies through the
review. Twenty-seven studies that investigated 25
different interventions were included, with 6 non-
English publications excluded due to the lack of
translation services. Studies in this review included
17 643 participants: 13 798 secondary students and
3845 post-secondary students. Table 1 presents a
comprehensive description of study characteristics
of all included studies.
Of the 27 included studies, 16 addressed mental
health literacy in general20–35 and 11 focused on
depression, schizophrenia, psychosis, eating disor-
111
Effectiveness of school mental health literacy programs

FIGURE 1. Flow chart of included studies.

Databases searched: Hand searches and grey literature:

Pubmed,PsycINFO, ERIC, Cochrane Library, CINAHL Reference lists of identified studies;
key websites from GREY MATTERS tool

Potentially relevant publications for screening Duplications removed

(n=11,025) (n=1438)

Publications included Publications included

Total publications for screening Excluded by screening titles:
for data extraction for data extraction
(n=10,587) Not the topic of interest (n=4763)
from hand searches from grey literature
(n=9) (n=0)

Total publications for screening Excluded by screening titles:

(n=5824) Not the intervention (n=5508)

Papers excluded by screening the

Publications excluded:
Publications for more detailed evaluation title and abstract or brief scan of Not English (n=3)
(n=316) complete publication (n=275): Not the intervention (n=1)
Not the population (n=45) Duplication (n=1)
Not the outcome (n=106)
Not the desired design (n=114)
Not the school setting(n=6)
Not English (n=3)
Duplicates (n=1)

Papers excluded by screening

Publications included for date extraction
and reading the full paper (n=18):
(n=41)
Not the outcome (n=5)
Not the intervention (n=11)
Not the population (n=1)

Studies from hand searches (4)

Studies from databases (23)

Included studies: 27

ders and anxiety disorders.36–46 Fifteen studies were
delivered to students through classroom lectures or
presentations, or video discussions by recipients of
mental health services.24,26–33,35,37,38,43–46 Additional
teaching methods included group discussion,
posters, role playing, drama, games and Internet
searching. Nineteen studies were not administered
by teachers, but by either mental health profession-
als only, recipients of mental health services only,
or mental health professionals and recipients of
mental health services together.20,23–26,28–38,41,44,46 Only
three interventions were led by teachers27,40,42; two
involved students self-studying the information
provided22,39; and three did not specify who was
in charge of the delivery of content.21,43,45 Twenty-
one studies were conducted in secondary
schools20,21,24,26–34,36–38,40–43,45,46 and six in post-
secondary schools.22,23,25,35,39,44 Fourteen studies took
place in the USA,21–23,25,27,29,31–36,40,46 five in the
UK,20,28,39,41,44 two in Germany,38,43 two in China,24,37
two in Canada,41,45 one in Serbia,26 one in Australia30
and one in Pakistan.42 Twenty-one studies reported
duration of interventions, ranging from a single
20-min session to multiple 40-min sessions for 10
weeks20,21,23,24,26,29–34,36–41,43–46; six studies did not report
intervention duration.22,25,27,28,35,42
All studies reported at least one of the outcomes
and no studies reported adverse events. Fifteen
studies reported knowledge acquisition as an
outcome.20,27–30,33–35,37,39–42,45,46 Twenty-one studies
reported attitudes towards mental illness as an
outcome,20–26,28–35,37,38,41,43–45 and eight studies
reported help-seeking behaviours or attitudes
towards help-seeking behaviours as an out-
come.21,22,25,30,31,36,38,44 Fourteen studies followed up
participants from 1 to 7 months post interven-
tion,21–24,26,28,29,33,37,38,40,42–44,46 and the rest of the studies
reported outcomes only immediately following the
intervention.20,25,27,30–32,34–36,39,41,42,45
Five of the studies were RCTs,35,37,39,42,44 13 were
quasi-experimental,21,22,24,25,27,29–31,33,36,38,40,43 and 9
were controlled-before-and-after.20,23,26,28,32,34,41,45,46
Experimental intervention groups were
compared with either no-intervention
groups21,22,24,25,27,29,30,33,36,38–40,42,43,46 or other-
intervention groups.31,35,37,44

112 © 2013 Wiley Publishing Asia Pty Ltd

 TABLE 1. Study characteristics

Study/Author Sample Country Population Design Focus of intervention Comparison Duration Follow-up Outcome Risk of bias
size
Knowledge Attitudes Help seeking

Battaglia et al. 1662 US Secondary Quasi Presentations about psychiatry, No 1 week Post NA NA ↑ High
(1990)36 depression, drugs and alcohol, and intervention

© 2013 Wiley Publishing Asia Pty Ltd

helping strategies
Chan et al. 255 China Secondary RCT Education on schizophrenia through Other 45 min Post; 1 ↑ ↑ NA Moderate
(2009)37 anti-stigma lecture and video intervention month
watching
Conrad et al. 210 Germany Secondary Quasi Intervention through contacting people No 1 day Post; 3 NA ↑ ↑ Moderate
(2009)38 with mental illness; education on intervention months
schizophrenia, depression and bipolar
disorder, and learning about the help
system
Essler et al. 104 UK Secondary CBA Intervention involving general mental No 1 week Post ↑ ↑/↓ NA High
(2006)20 health education and experience comparison
through quiz, drama and games
Esters et al. 40 US Secondary Quasi A unit of instruction to change No 3 classes Post; 12 NA ↑ NA High
(1998)21 conceptions of mental illness and intervention weeks
attitudes about seeking professional
help
Gonzalez et al. 167 US College Quasi Education on mental disorders, No 15 min Post; 4 NA ↑ NA Moderate
(2002)22 treatment and the need for help intervention weeks
through students’ self-study
Merritt et al. 3313 UK College Cluster Education on depression, such as No 1 week Post ↑/↓ NA NA High
(2007)39 RCT symptoms, treatments and intervention
help-seeking strategies through
sending posters, and postcards
Morrison et al. 38 US College CBA Demythologizing approach to mental No 2h Post; 5 NA ↑ NA High
(1979)23 illness comparison weeks
Naylor et al. 416 US Secondary Quasi Education on stress, depression, No 6 weeks Post ↑/↓ NA NA Moderate
(2009)40 suicide/self-harm, eating disorders, intervention
bullying, intellectual disability
Ng and Chan 219 China Secondary Quasi A four-phase intervention that includes No 40 min over 10 Post; 7 NA ↑/↓ NA High
(2002)24 mental health education, a mental intervention weeks months
health promotion day, talks and
exhibits, and direct contact with
mental patients
Owusu (2002)25 90 US College Quasi A videotape presentation about mental No Unknown Post NA ↑/↓ NA Moderate
illness and psychological services that intervention
are culturally specific to Black people
Pejović-Milovančević, 63 Serbia Secondary CBA Anti-stigma program that raises the level No 6 weeks Post; 6 NA ↑/↓ NA High
et al. (2009)26 of awareness through education, comparison months
placing the accent on acquainting the
students with mental health-related
problems of the young
Petchers et al. 102 US Secondary Quasi A video-based program with a No Unknown Post ↑ NA NA High
(1988)27 curriculum supplement, addressing intervention
basic concepts on mental health, and
experiences with the mentally ill
Pinfold et al. 472 UK Secondary CBA A two-phase educational program with No Unknown Post; 6 ↑ ↑ NA High
(2003)28 phase 1 focusing on mental health comparison months
literacy and phase 2 on reducing
stigma through contact with the
mentally ill

113
Y. Wei et al.
 TABLE 1. (continued)

114
Study/Author Sample Country Population Design Focus of intervention Comparison Duration Follow-up Outcome Risk of bias
size
Knowledge Attitudes Help seeking

Pinfold et al. 2136 Canada/UK Secondary CBA An education program on general No 2 sessions Post ↑ ↑ NA High
(2005)41 mental health literacy and stigma comparison
reduction in UK and it focuses on
schizophrenia in Canada
Pinto-Foltz 156 US Secondary Quasi A narrative storytelling of anti-stigma No 1h Post; 1 (-) (-) NA Moderate
(2009)29 program that includes mental health intervention week; 4
education delivered by mentally ill weeks; 8
individuals weeks
Rahman et al. 100 Pakistan Secondary RCT Education on depression epilepsy, No Unknown Post ↑ NA NA High
(1998)42 psychosis, drug, smoking, and mental intervention
retardation through classroom lectures
and school posters
Rickwood et al. 457 Australia Secondary Quasi Presentation on stigma, myths about No 90 min Post ↑ ↑ ↑ High
(2004)30 mental illness, and general mental intervention
health information
Saporito (2009)31 156 US Secondary Quasi A presentation on information about Other 40 min Post NA ↑ NA Moderate
mental illnesses, treatment, common intervention
myths and video of youth struggling
with a mental illness
Schulze et al. 150 Germany Secondary Quasi Education on schizophrenia and No 1 week Post; 1 NA ↑ NA Moderate
(2003)43 pro-social skills through lectures and intervention month
contact with mentally ill youth
Sharp et al. 123 UK College RCT Education on depression, anxiety, and Other 3 sessions Post; 1 NA ↑/↓ NA Moderate
(2006)44 substance abuse through classroom intervention month
lectures and presentations by mentally
Effectiveness of school mental health literacy programs

ill individuals
Spagnolo et al. 426 US Secondary CBA Education addressing concepts of mental No 1h Post NA ↑ NA High
(2008)32 illness, stigma, common myths, and comparison
treatment with involvement of the
mentally ill developing and delivering
the material
Spagnolo (2009)33 238 US Secondary Quasi Presentation on the myths and factual No 40 min Post; 3 ↑ ↑ NA High
information about mental illness, intervention months
supplemented by personal stories of
recovery
Stuart (2006)45 571 Canada Secondary CBA Education on schizophrenia with No 2 lessons Post ↑ ↑/↓ NA High
portrayals of the beliefs, feelings, comparison
through class lessons and a video
about personal experiences of
teenagers with mental illness
Swartz et al. 4299 US Secondary CBA Lectures and videos on depression No 3h Post; 6 ↑ NA NA High
(2010)46 literacy, such as symptoms, diagnosis intervention weeks
and treatment strategies
Watson et al. 1566 US Secondary CBA Awareness and understanding of the No 6 lessons Post ↑ ↑ NA High
(2004)34 biological, psychological and social comparison
aspects of mental illness, and
treatment
Wood & Wahl 114 US College RCT Education on mental illness and Other Unknown Post ↑ ↑ NA Moderate
(2006)35 attitudes through videos, intervention
presentations and discussion hosted
by mental health consumers.

CBA, controlled-before-and-after studies; NA, not applicable; RCT, randomized controlled trial.

© 2013 Wiley Publishing Asia Pty Ltd


FIGURE 2. Results of risk of bias assessment of included studies
(n = 27). ( ) Low risk of bias. ( ) Moderate risk of bias. ( ) High
risk of bias.
Risk of bias assessment
Ten studies met criteria for moderate
ROB,22,25,29,31,35,37,38,40,43,44 17 studies met criteria for
high ROB,20,21,23,24,26–28,30,32–34,36,39,41,42,45,46 and no studies
met criteria for low ROB.
The internal validity of the included studies was
jeopardized by a number of methodological issues.
Most studies failed to define and/or control impor-
tant potential confounding factors such as group
differences in baseline characteristics, participants’
previous experience with mental disorders, time lag
for intervention measurement at post-test, type of
schools and testing effect. There was no randomiza-
tion of participants in 22 out of 27 studies and there
was lack of information to determine the repre-
sentativeness of study samples. Twelve of the 27
studies did not report attrition, and many of those
reporting attrition rates (6 out of 12 studies) did not
describe whether there were important differences
between key characteristics and outcomes in par-
ticipants who completed the study and those who
did not. The three outcomes were evaluated by
various measurements. Of these, only 13% of knowl-
edge outcome measures and 43% of attitude
outcome measures had been validated prior to
study application; no measurements for help-
seeking behaviours outcome were validated.
Figure 2 shows our judgments about each risk of
bias item across all included studies.
Meta-analysis
It was not possible to use meta-analysis to synthe-
size the study results because of important clinical
and methodological heterogeneity in intervention,
population, study design and measurement across
studies for all three outcomes. Thus, we present a
narrative description of results, looking for patterns
© 2013 Wiley Publishing Asia Pty Ltd
Y. Wei et al.
in results within and between groups of studies to
inform our conclusions.
Effectiveness on knowledge acquisition
Twelve of 15 studies regarding knowledge
outcome demonstrate a statistical significant
increase in knowledge associated with the
interventions.20,27,28,30,33–35,37,41,42,45,46 Table 2 provides
details of effect sizes and statistics of interven-
tions that reported knowledge increase. Of these,
eight studies reported within-group knowledge
increase,20,28,33–35,41,45,46 and four studies27,30,37,42
reported between-group knowledge increase fol-
lowing the intervention. Only three studies28,33,37 dis-
cussed results beyond the post-test follow-up
period: two studies33,37 indicated knowledge per-
sisted over time at 1-month37 and 3-month33 follow-
up, and one study showed knowledge decay28 at
6-month follow-up.
Two studies found mixed results.39,40 Merritt39
indicated students’ knowledge about treatment for
depression did not improve compared with the
control group (mean difference = -0.9%, 95 CI -5.1
to 3.7, P = 0.76). However, it reported statistically
significant improvement for students’ recognition
of five out of seven depressive symptoms. Naylor40
found an increase in knowledge for three assess-
ment questions and no increase for the other three
questions at post-test. One study29 yielded no statis-
tical significance 8 weeks following the intervention
(P > 0.05).
The general method of measuring knowledge in
the studies was the use of individual test questions.
Test results were analysed either by question or by
total test scores. Knowledge gain was determined by
comparing mean differences,27,29,30,33–35,37,40 or com-
paring the number or percentages20,28,39,41,42,45,46 of
correct questions answered before and after the
intervention. Only two studies used validated
tests.29,37
Knowledge was measured at different time points,
with 10 studies only at the post-test,20,27,30,34,35,39–42,45 4
studies at 1-month,37 1.5-month,46 3-month,33 and
6-month28 follow-up, and only 1 study29 at four
points of time: baseline, 1 week, 4 weeks and 8 weeks.
This made it impossible to conduct cross-study com-
parisons of knowledge acquisition and decay.
Eleven studies were classified as high
ROB20,27,28,30,33,34,39,41,42,45,46 and four studies as
moderate ROB.29,35,37,40 Ten of the 12 studies that
reported an increase in knowledge were high
ROB.20,27,28,30,33,34,41,42,45,46 Findings from four studies
with moderate ROB demonstrated conflicting
results: two studies showed a statistically significant
115
116
TABLE 2. Effect sizes of interventions assessed with knowledge increase

Author Control/Pretest knowledge score Intervention/Post-test knowledge Statistics Significance

score

Chan et al. (2009)37 Education: Education: F(2,249) = 3.88, post-test; P < 0.05, post;
M = 21.89; SD = 4.5, pre M = 26.72; SD = 4.48, post; F(2,248) = 10.21, 1 month; P < 0.001, 1 month
Education-video: M = 22.51; SD = 4.79, hp2 = 0.03
M = 22.44; SD = 3.50, pre 1 month
Video-education: Education-video:
M = 22.08; SD = 3.97, pre M = 28.23; SD = 3.64, post;
M = 25.41; SD = 4.10,
1 month
Video-education:
M = 26.56; SD = 4.51, post
M = 23.40, SD = 4.39,
1 month
Essler et al. (2006)20 Median = 2 Median = 3 P = 0.015
Effectiveness of school mental health literacy programs

Petchers et al. (1988)27 M = 63.81 M = 74.77 t (100) = 5.67 P < 0.001

Pinfold et al. (2003)28 1%, pre 24%, post; 6%, 6 months
Pinfold et al. (2005)41 5% (Canada); 18% (Canada); X2 = 50.9, d.f. = 1 (Canada); P < 0.001
0.2% (UK) 42% (UK) X2 = 50.9, d.f. = 1 (UK)
Rahman et al. (1998)42 M = 7.2, pre; M = 6.4, pre; P < 0.01 (intervention);
M = 8.7, post M = 14, post P = 0.01 (control)
Rickwood et al. (2004)30 M = 37.07, pre M = 59.39, post t(243) = 5.123 P = 0.000
Spagnolo (2009)33 M = 2.8881, SD = 0.3922, pre M = 3.0835; SD = 0.4324, post; t = -6.025, pre; P = 0.000, pre
M = 2.9371 ; SD = 0.4258, t = -2.046, post P = 0.043, post
3 months
Stuart (2006)45 47.70%, pre 78.80%, post X2 = 61.1, d.f. = 1, post P < 0.001
Swartz et al. (2010)46 M = 12.96, pre M = 15.76, post P < 0.0001
Watson et al. (2004)34 M = 6.87; SD = 2.30, pre M = 9.75; SD = 2.41, post t(1,249) = -44.575 P = 0.000
Wood & Wahl (2006)35 M = 64.4; SD = 5.3, pre; M = 64.3; SD = 5.7, pre; F(1,112) = 27.71 P < 0.01
M = 64.9; SD = 5.7, post M = 70.6; SD = 5.3, post

M, mean; SD, standard deviation.

© 2013 Wiley Publishing Asia Pty Ltd

 Y. Wei et al.

and important increase in knowledge35,37; one dem- tudes at post-test, and one found significant
onstrated changes in some outcome measures but improvement both at post-test and 1-month follow-
not in others40; and one found no change.29 up.43 Two studies25,44 presented mixed findings and
one study showed no change in attitudes.29
Effectiveness of reducing stigmatizing attitudes
Twenty-one studies20–26,28–35,37,38,41,43–45 addressed atti- Effectiveness on help-seeking behaviours
tudes towards mental illness with 14 observing
Eight studies addressed help-seeking behaviours. Of
decrease in stigma following intervention.21–23,28,30–
these, only three studies measured actual help-
35,37,38,41,43 Sixteen studies were conducted in second-
seeking behaviours30,36,38 with self-report measures.
ary schools, and the rest of the five conducted
The other five studies investigated attitudes towards
among college students.22,23,25,35,44 In the 14 studies
help-seeking behaviours.21,22,25,31,44
reporting positive results, 8 reported outcomes both
The three studies addressing actual help-seeking
at post-test and follow-up from 1 to 6 months.21–
behaviours reported mixed findings, with evidence
23,28,33,37,38,43 Of these eight, only four showed statisti-
of improved outcome from some sources but not
cally significant differences both at post-test and
from others. For example, Battaglia et al.36 reported
follow-up compared with the baseline,21,23,28,43 the
that help seeking from psychiatrists (intervention
rest of the four studies only showed change at post-
9.6% vs. comparison 5.7%, P < 0.05), counsellors
test, but not at subsequent follow-up periods.22,33,37,38
(intervention 9.8% vs. comparison 3.5%, P < 0.005)
Six studies measured the attitude only immediately
and teachers (intervention 2.8% vs. comparison
following the intervention and demonstrated posi-
0.4%, P < 0.05) was enhanced significantly at post-
tive results,30–32,34,35,41 including one study conducted
test. However, data showed no statistically signifi-
among college participants.35 Table 3 presents effect
cant difference from other sources, such as friends
sizes of these 14 studies.
and other medical authorities at post-test. Conrad
Six studies,20,24–26,44,45 including two involving post-
and colleagues38 indicated no significant changes
secondary students,25,44 presented mixed results, in
over time except for willingness to seek help from
which improved attitudes showed in some sub-
teachers following the intervention (5.2% pretest;
measures/questions, but not in others. One
10.6% post-test; and 17.9% post post-test). Rick-
study indicated no difference in attitude changes
wood and colleagues30 showed evidence of effec-
(P > 0.05) between intervention and comparison
tiveness regarding psychiatrists (P = 0.000) and
groups across four points of time follow-up.29
friends (P = 0.046), but not from family or school
Changes in stigmatizing attitudes were evaluated
sources.
using ten different measurement tools, in which six
None of these three studies, however, used vali-
reported on the established validity and reliability:
dated measures to evaluate this outcome. One
PSS, r-AQ, CAMI, OMI, SSRPH and SD.24,25,29,31–33,35,37,44
study38 administered a questionnaire designed for
The validity and reliability of the NCMIQ, CAQ-B and
that particular study, and the other two30,36 pre-
tools designed for specific interventions were not
sented a single self-report question to assess the
reported and therefore unknown.20,22,23,30
outcome.
The timing for outcome measurement varied
Two of the studies30,36 met criteria for high ROB
extensively across studies. Nine studies measured
and the other study for moderate ROB.38 However,
attitudes only post intervention20,25,30–32,34,35,41,45; 11
the study with moderate ROB38 reported no behav-
studies assessed attitudes at various points of time:
iour change over time except for increased help
1 month,22,37,43,44 5 weeks,23 6 weeks,46 3 months,21,33,38
seeking from teachers.
4 months,42 6 months26,28 and 7 months24 at post-
test; only 1 study29 assessed attitudes at four differ-
ent time points: baseline, 1 week, 4 weeks and 8
weeks. The time difference in measuring the atti- DISCUSSION
tude made comparisons across studies challenging.
Despite the fact that most studies identified posi- This systematic review provides a comprehensive
tive results, critical appraisal demonstrated that 12 synthesis of the evidence for the effectiveness of
of 21 met criteria for high ROB.20,21,23,24,26,28,30,32–34,41,45 school-based mental health literacy programs for
Nine studies met criteria for moderate youth. Although most studies reported positive evi-
ROB.22,25,29,31,35,37,38,43,44 When only considering the evi- dence in each of the defined outcomes, particularly
dence from nine moderate ROB studies, five the attitude outcome, major methodological issues
reported22,31,35,37,38 a significant improvement in atti- embedded in the studies make it challenging to con-

© 2013 Wiley Publishing Asia Pty Ltd 117

Effectiveness of school mental health literacy programs
clude that current school-based mental health lit-
eracy interventions have been established to be
effective.
Applying the GRADE framework, we rated the
overall body of evidence as very low for studies
addressing the knowledge and help-seeking out-
comes, and low for studies with attitude outcome.
No studies met criteria for low ROB, illustrating the
overall weakness of the literature in this area.
Further concerns include the limited generalizabil-
ity of the research available due to the poor internal
validity of most included studies.
Added concerns include the clinical and meth-
odological heterogeneity embedded in most of the
studies. For instance, the methodological heteroge-
neity resulted from the variability across studies in
types of design; validity of measurements; variabil-
ity of measurements used; and the difference of
measurement timing. The clinical heterogeneity
was caused by the variability of intention types;
variability of duration of interventions that makes
meaningful cross-study comparison impossible;
and variability of participants’ age. As a result, we
were unable to use meta-analysis to synthesize the
study results and to determine levels of confidence
for any of the outcomes of interest. Furthermore, we
were unable to assess the likelihood of publication
bias due to inadequate data.
Health literacy, including mental health literacy, is
considered to be an important and fundamental
component of health.47 Studies in other health con-
ditions have shown that increased health literacy is
associated with improved health in numerous
domains.48 Most studies included in this review
reported similar findings and claimed that school-
based mental health literacy interventions have the
potential to increase knowledge, change stigmatiz-
ing attitudes and enhance help-seeking behaviours
in youth. However, this review, based on the
Cochrane approach that emphasizes the robustness
of research designs, does not support such a positive
point of view. Our findings demonstrate that at the
current state of knowledge, there is little substantive
evidence for the effectiveness of current school-
based mental health literacy programs. Similar con-
cerns have been raised by others.13,14 Furthermore,
because of the lack of appropriate monitoring for
adverse events, we were unable to determine
whether these programs cause harm although no
adverse events were documented.
Lack of evidence of effectiveness of current pro-
grams however does not imply that there may not be
promising interventions that have not yet been the
focus of rigorous studies. Research into school
mental health literacy as a vehicle for improving
118
knowledge, attitudes and help-seeking behaviour is
still in its infancy. It is encouraging to see that there
is accumulating evidence showing promising
results as indicated by included studies. Future
research should address the complexities of the
school setting when considering appropriate
research methodologies for program evaluation.
Research designs such as process evaluations, and
observational and qualitative studies can be used to
deal with some of the complexities and inform
further research approaches. For instance, the
expectation that fidelity in operationalization of a
program may need to be modified in different
school settings, where observational and qualitative
studies are appropriate to identify lessons learned.
Despite the alternatives discussed above, it is
essential that future research be based on methodo-
logically sound designs whenever possible, such as
well-conducted cluster RCTs to provide highest level
of evidence on ‘what works’. These study designs
appropriately control known and unknown con-
founders that many currently available studies in
this field do not adequately address. These include
site differences in baseline characteristics, such as
age, gender, race, social and economic status;
mental health status of the participant; previous
contact with individuals with mental health prob-
lems; previous exposure to similar programs; and
critical mental health crisis happening at the time of
measurement. It is essential to report on attrition
and determine whether the loss to follow-up in
study samples is likely to cause potential bias to the
observed relationship between intervention and
outcome. In addition, future research should also
direct to developing validated measurement tools
so that outcomes can be appropriately evaluated
and data are accurately collected.
Determining the effectiveness of school-based
mental health literacy programs will help establish
strong foundation for addressing mental health
promotion, prevention and intervention among
adolescents. Their potential effectiveness can be
established through multiple and complimentary
research approaches, including both qualitative and
quantitative methodologies. Once effectiveness is
established, cost-effectiveness can be examined and
established so that schools can choose the most
appropriate programs for their students.
In the interim, educators, school administrators
and policy makers need to be better informed about
the strengths and weaknesses of the current data-
base on the effectiveness of currently available
mental health literacy programs. Application of
interventions not known to be effective may not be
the best use of public funds. An alternative option
© 2013 Wiley Publishing Asia Pty Ltd
 TABLE 3. Effect sizes of interventions showing improved attitudes
Author
Chan et al. (2009)37†
© 2013 Wiley Publishing Asia Pty Ltd
Conrad et al. (2009)38
Esters et al. (1998)21
Gonzalez et al. (2002)22†
Morrison et al. (1979)23
Pinfold et al. (2003)28
Pinfold et al. (2005)41
Rickwood et al. (2004)30
Saporito (2009)31
Schulze et al. (2003)43
Spagnolo et al. (2008)32
Spagnolo (2009)†
Watson et al. (2004)34
Wood & Wahl (2006)
†Higher scores indicate greater stigmatizing attitudes.
119
M, mean; SD, standard deviation.
Control/Pretest attitude scores
Education:
M = 3.14; SD = 0.81, pre
Education-video:
M = 3.21; SD = 0.71, pre
Video-education:
M = 3.33; SD = 0.79, pre
M = 105.90; SD = 12.99, pre
M = 101.35; SD = 14.32, post
M = 104.35; SD = 13.61, 12 weeks
M = 197.2; SD = 24.2, post
M = 195.7; SD = 28.2, 1 month
M = 34.70; SD = 4.60, pre
M = 1.2;
SD = 1.8, pre
40% no stigma, pre (UK)
15% no stigma, pre (Canada)
ATSPPH measure:
M = 15.1; SD = 4.3
CAMI measure:
M = 22.20; SD = 5.72
IAT-treatment measure:
M = 0.12; SD = 2.90
IAT-MI measure:
M = 0.32; SD = 2.80
Coefficient = -0.12
M = 28.99, pre
M = 3.196, pre
M = 22.57; SD = 7.55
M = 64.4; SD = 7.6, pre
M = 65.3; SD = 8.0, post
Intervention/Post-test attitude scores Statistics Significance
Education: F(2,249) = 3.74; P < 0.05, post
M = 2.57; SD = 0.96, post hp2 = 0.03, post P > 0.05, 1 month
M = 2.76; SD = 1.00, 1 month F(2,247) = 1.59, 1 month
Education-video:
M = 2.34; SD = 0.82, post;
M = 2.64; SD = 0.80, 1 month
Video-education:
M = 2.65; SD = 0.98, post
M = 2.93; SD = 0.90, 1 month
Coefficient P = 0.000, post
Group ¥ point in time t2 = -0.405, post P = 0.684; 3 months
Group ¥ point in time t3 = 0.071, 3 months
M = 103.55; SD = 10.96, pre; F(1,37) = 30.66 P < 0.025
M = 115.10; SD = 13.00, post; hp2 = 45%
M = 111.05; SD = 16.16, 12 weeks
M = 186.5; SD = 21.8, post F(2,160) = 3.53, post P < 0.05, post
M = 193.9; SD = 25.7, 1 month F(2,158) = 0.24, 1 month P > 0.05, 1 month
M = 47.10; SD = 4.99, post t = 8.98; d.f. = 23, post P < 0.0001, post;
M = 45.40; SD = 5.60, 5 weeks t = 7.22; d.f .= 23, 5 weeks P < 0.0001, 5 weeks
M = 2.8; SD = 1.9, post t = -16.4, post P < 0.0001
M = 2.3 6; SD = 1.9, 6 months t = -8.5, 6 months
53% no stigma, post (UK) X2 = 20.4, df = 1 (UK) P < 0.001
31% no stigma, post (Canada) X2 = 70.1, df = 1 (Canada)
F(1,453) = 31.667 P = 0.000
hp2 = 6.7%
ATSPPH measure: F(4,126) = 2.88; P = 0.03
M = 17.70; SD = 5.25 hp2 = 0.08
CAMI measure:
M = 20.92; SD = 6.19
IAT-treatment measure:
M = -0.92; SD = 3.71
IAT-MI measure:
M = 0.75; SD = 3.35
Project ¥ time coefficient = 0.50, 1 month P = 0.01
M = 25.17, post t(506) = 4.86 P < 0.000
M = 2.817, post; t = 6.341, post P = 0.000, post;
M = 3.000, 3 months t = 1.425, 3 months P = 0.157, 3 months
M = 21.99; SD = 7.88 t(1,249) = 2.821 P = 0.005
M = 66.0; SD = 7.3, pre F(1,112) = 10.56 P < 0.01 (F value)
M = 70.1; SD = 6.8, post t = -5.59 (intervention) P < 0.01 (intervention)
t = -1.54 (control) P = 0.13 (control)
Y. Wei et al.
Effectiveness of school mental health literacy programs
may be investment in higher quality and more rig-
orous research that could then give educators,
policy makers and the public greater assurance as to
the effectiveness of mental health literacy programs
being implemented in schools.
The evidence of this review is based on data
obtained from scientific databases, peer-reviewed
journals and government documents, thus it may
have missed information from other sources such as
unpublished reports from educational institutions,
and data from non-profit organizations and com-
munity services. The reviewers did not contact
authors for unknown information in the studies
reviewed, and therefore may be at risk of misjudging
the quality of studies if important details were not
included in the study reports.
In conclusion, the strength of evidence regarding
the effectiveness of current school-based mental
health literacy programs has been demonstrated to
be relatively low when applying Cochrane criteria.
As this is a relatively new and developing research
field, however, researchers, policy makers and prac-
titioners should be aware that there is much to be
done before consensus can be reached on the best
evaluation methods that should be applied, appro-
priately weighing the place of advanced research
designs such as RCTs and other designs.
ACKNOWLEDGEMENT
The authors would like to acknowledge Tim Ruggles,
the Health Librarian at the Kellogg Library, Dalhou-
sie University, for his contribution to the develop-
ment of search strategies of this review.
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APPENDIX
Search strategy
‘mental health’ OR ‘mental disorders’ OR (mental
and (health OR well-bing OR illness* OR disorder*)
OR ‘adolescent behavior’ OR ‘adolescent psychol-
ogy’ OR ‘adolescent psychiatry’ OR ‘Diagnostic and
Statistical Manual of Mental Disorders’
AND
‘health education’ OR ‘attitude to health’ OR
‘health promotion’ OR awareness OR ‘health pro-
motion’ OR ‘health promotion’ OR literacy or cur-
ricul* OR educat*
AND
Adolescent* OR students OR ‘young adult’ OR
‘young people’ OR teen* OR ‘young person*’
AND
‘program evaluation’ OR ‘program development’
OR assessment OR test* OR effective* OR effica*
AND
school* OR universit* OR college* OR ‘school
health services’
Search strategies with PubMed database
(((((‘Mental Health’[Mesh]) OR (‘Mental
Disorders’[Mesh]) OR (MENTAL AND (HEALTH OR
WELL-BEING OR ILLNESS* OR DISORDER*)) OR
(‘Adolescent Behavior’[Mesh] OR ‘Adolescent
Psychology’[Mesh] OR ‘Adolescent Psychiatry’
[Mesh]) OR (‘Diagnostic and Statistical Manual
of Mental Disorders’[Mesh])) AND ((‘Health
Education’[Mesh]) OR (‘Attitude to Health’[Mesh])
OR (‘Health Promotion’[Mesh]) OR (‘Awareness’
[Mesh]) OR (‘health promotion’[MeSH Terms] OR
‘health promotion’[TIAB]) OR (LITERACY OR
CURRICUL* OR EDUCAT*))) AND (((‘Adolescent’
[Mesh] OR ‘Students’[Mesh]) OR ‘Young Adult’
[Mesh]) OR (‘YOUNG PEOPLE’[TIAB] OR TEEN*
[TIAB] OR ‘YOUNG PERSON’[TIAB] OR ‘YOUNG
PERSONS’[TIAB] OR ADOLESCEN*[TIAB]))) AND
((‘Program Evaluation’[Mesh]) OR (‘Program
Development’[Mesh]) OR (ASSESSMENT[TIAB] OR
TEST[TIAB] OR TESTS[TIAB] OR EFFECTIVE*[TIAB]
OR EFFICAC*[TIAB]))) AND (((SCHOOL*[TIAB] OR
UNIVERSIT*[TIAB] OR COLLEGE*[TIAB]) OR
(‘Schools’[Mesh:noexp])) OR (‘School Health
Services’[Mesh:noexp]))
121