Soc Psychiatry Psychiatr Epidemiol DOI 10.1007/s00127-016-1176-9
ORIGINAL PAPER
Effectiveness of Mental Health First Aid training in Denmark: a randomized trial in waitlist design Kamilla B. Jensen1 • Britt Reuter Morthorst1 • Per B. Vendsborg2 Carsten Hjorthøj1 • Merete Nordentoft1
•
Received: 3 September 2015 / Accepted: 10 January 2016 Ó Springer-Verlag Berlin Heidelberg 2016
Abstract Purpose To examine the effect of the Australian educational intervention Mental Health First Aid (MHFA) in a Danish context. Primary outcome was improvement concerning confidence in help-giving behavior towards people suffering from mental illness. Secondary outcomes were increased knowledge and ability to recognize mental illness and improved positive attitudes towards people suffering from mental health problems. Method Study design was a randomized trial with a waitlist control group. The intervention group was compared with the control group at 6-month follow-up. Both groups completed at baseline and at 6-month follow-up. Results A significant difference was found between employees trained in the intervention group compared to the control group at 6-month follow-up on the items of confidence in making contact to (Cohen’s d 0.17), talking to (Cohen’s d 0.18) and providing help to (Cohen’s d 0.31) people suffering from a mental health illness. Further, participants improved in knowledge (Cohen’s d depression vignette 0.40/Cohen’s d schizophrenia vignette 0.32) and in the ability to recognize schizophrenia OR = 1.75 (95 % CI 1.00–3.05), p = 0.05. A significant difference between the intervention group and control group at follow-up concerning actual help offered was not found. Changes in attitudes were limited.
& Britt Reuter Morthorst [email protected] 1
Copenhagen University Hospital, Research Unit, Mental Health Centre, Capital Region of Denmark, Kildega˚rdsvej 28, entrance 15, 4th floor, 2900 Copenhagen, Denmark
2
Danish Mental Health Foundation, Hejrevej 43, 2400 Copenhagen, Denmark
Conclusion The MHFA training was effective in a Danish context. Keywords Mental Health First Aid Randomized trial Mental health Educational training program
Introduction A large number of people in our society struggle with mental health problems. According to the World Health Organization the prevalence of mental disorders is high and growing worldwide [1]. The estimations of the lifetime expectancy of mental health problems in the general population in Europe are about 25 % [2]. However, recent research shows that as much as 38 % of the female population and 32 % of the male population in Denmark is expected to receive treatment in the secondary mental health sector [3]. These high numbers indicate that today mental illness is something many people will encounter during their lifetime. In Denmark, we have conducted several campaigns targeting the mental health literacy of the public and mental health related stigma over the last years [4]. Despite this, the average Dane’s knowledge about mental illness and how to help and support a person in crisis because of an acute mental health condition is limited [5]. In recent years, there has been a change in attitudes towards mental illness, and seeking professional help is more widely accepted by the general population. However, there has been no significant change in the guarded attitudes towards people with mental illness as a consequence of this trend [6]. The initial treatment of people suffering from mental illness is still frequently delayed for many years [7]. It has been suggested that
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poor knowledge of mental illness and mental illness stigma are factors that can explain the low rates of helpseeking behavior among people with these conditions [8]. One way to increase help-seeking behavior among people with mental illness would be to educate the public to recognize significant symptoms and to strengthen their skills to provide the initial first aid to people affected by mental health problems and, among other things, advise them to see their general practitioner. The Mental Health First Aid (MHFA) training program in fact strives to do that. The Mental Health First Aid training program was developed in Australia in 2001, and has since then been adopted in 21 other countries around the world [9]. The MHFA training program was developed to improve the general public’s mental health literacy and to train skills to provide the initial help to people suffering from mental illness [10]. The training program has been widely investigated, and effects of the program have been documented [10–12]. A meta-analysis from 2014 included 15 studies investigating the MHFA training program and presented homogenous results [9]. All the studies, with three exceptions, had been carried out in Australia. Four of the 15 studies included were randomized trials. Samples were diverse, and included different types of staff in government departments, general public in rural areas of Australia, young people, minority groups and football club leaders among others [9]. The overall trends found in these studies were improvements in knowledge, reduced stigma, a rise in confidence in providing help and an increased amount of help provided [9–12].
Aim of the study The aim of this randomized trial was to investigate the effect of the MHFA training with regard to confidence in help-giving behavior as primary outcome in Danish employees and NGO-volunteers. Secondary outcomes investigated were increased knowledge and recognition of mental illness and improved positive attitudes towards people suffering from mental health problems.
Materials and methods Design We conducted a randomized trial with a waitlist control group and a 6-month follow-up period. Self-completed questionnaires were answered at baseline and at 6-month follow-up.
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Participants Initially, the MHFA training program was developed for the general public [13]. However, previous international studies have found the training program to be effective for participants, who most often are in contact with many different individuals in their line of work [14]. Hence, the trial recruited employees and volunteers at ten different workplaces, including public, private and nongovernmental organizations (NGOs). Workplaces were the municipalities of Frederiksberg, Odense, Roskilde and Vejle, covering four of the five administrative regions of Denmark. Furthermore, the Danish Prison and Probation Service, a Job Center in the municipality of Copenhagen, the telephone counseling of the Mental Health Foundation and Young Women’s Christian Association (YWCA) participated. The NGO ‘‘SindUngdom’’ and the public and voluntary organization ‘‘Headspace’’, both organizations for young people with mental health problems, also took part. Eligible organizations or workplaces were contacted by The Mental Health Foundation among their collaborators and professional network all over Denmark. The initial invitation to participate in the trial was sent by mail or conducted by phone calls to leaders in each organization. Responding workplaces showing interest and those facilitating the possibility to participate by letting their employees attend the course may be during work hours was included. Intervention The implementation of the Mental Health First-Aid was managed by the Danish Mental Health Foundation, who provided the training to all participants, in total 41 training courses. Training was given either at workplaces or at the Danish Mental Health Foundation located in Copenhagen. The training course was a manualized 2-day course with 12 h of training given in groups of around 20 participants by one or two instructors. The Australian founder of the program trained seven instructors all affiliated to the Mental Health Foundation in Denmark and all with experience in mental health work, most of the instructors being psychologists or social workers. These insights into training were later passed on to subsequent instructors. The participants allocated to the intervention group got the training course after having answered the baseline questionnaire. They answered the same questionnaire again 6 months later. The participants allocated to waitlist answered the baseline questionnaire and had to wait 6 months before they again answered the same questionnaire, and after having answered this second questionnaire, they got the training course.
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The guiding philosophy behind MHFA training is based on key elements similar to those of conventional physical first aid training: preserve life, provide help to prevent further deterioration, promote the recovery of good mental health, and provide comfort for all persons experiencing mental health problems [15]. The first-aid approach of the MHFA training course was taught in a five step action plan: (1) assess risk of suicide and harm, (2) listen non-judgmentally, (3) give reassurance and information, (4) encourage individuals to get appropriate professional help, and (5) encourage self-help strategies. All steps were applied to the major categories of mental health disorders and crisis. Within all categories of disorders and crisis, participants were introduced to symptoms of the illness, possible risk factors, evidence-based treatment and where and how to get help [10]. The training was based on exercises, knowledge presentations and discussions. It presented cases and involved the participants, who were encouraged to present examples from their own lives. The MHFA program was translated and modified to suit the Danish context. Assessment and scales A baseline questionnaire was sent out electronically using the software program Survey Xact, primarily to the participants’ work email-addresses. Reminders to complete the questionnaire were sent out, and the data were securely stored in the software program. The same procedure was used with the 6-month follow-up questionnaires. The primary outcome was improved confidence in providing help to people suffering from mental illness (compared to the waitlist control group). Secondary outcomes were (1) increased knowledge, including improved ability to recognize mental illness, and (2) decreased stigmatizing attitudes. Knowledge was assessed by questions addressing, e.g. beliefs about treatment. By ‘beliefs’ we mean what the participants thought would be helpful in the situation, and we investigated whether knowledge and beliefs about treatment became more concordant with evidence-based treatment. In this paper we define the participants’ actions as helping behavior, by which we mean making contact to, talking to or actually providing help to individuals, e.g. by referring them to private practitioners. The Danish trial of the MHFA training program used the same self-report questionnaires as in the Australian studies. However, two scales were added according to the design of the Swedish trial and in accordance with recommendations from previous Australian evaluators. With respect to our primary outcome we further added three questions on confidence in helping. The questionnaire was divided into five parts. The first part covered socio-demographic characteristics, the participant’s experience with mental illness,
confidence in making contact to, talking to and providing help to a person suffering from mental problems and finally, contact within the last 6 months to people suffering from mental health problems and whether the participants had offered their help. In the next part the participants were presented with a vignette describing a person with depression or schizophrenia; this section covered the participants’ ability to recognize the illness and their beliefs and knowledge about correct treatment. The third part of the questionnaire was a social distance scale to assess stigmatizing attitudes. The questions were based on the description in the vignette. The scale assessed the participants’ willingness to (1) live next door to the person, (2) make friends with the person, (3) provide a job at their own workplace for the person, and (4) have the person marry into their family. This section ended by asking if the participant or one in his/her family or friends had had the same problem as stated in the vignette. The vignettes were randomly distributed among the participants and given alternately between the depression and schizophrenia case; hence every participant had to comment on the same vignette at baseline and follow-up. The project manager, who was responsible for contact to the participants, distributed the questionnaires and thereby also the vignettes. The primary outcome was measured through three questions concerning the person’s confidence in helping. All three questions were answered on a four step scale: ‘‘not confident at all’’, ‘‘a little confident’’, ‘‘quite confident’’, ‘‘very confident’’. A high level of confidence was reflected in a high mean of the analysis, ‘‘very confident’’ was rated four. Furthermore, if the participant answered ‘‘not confident at all’’, he/she would have to answer another question on the primary cause for this within a five step scale: ‘‘lack of knowledge’’, ‘‘afraid of saying something wrong’’, ‘‘afraid of the person’s reaction’’, ‘‘don’t know what to advice the person to do’’, ‘‘it is too great a responsibility’’. The question concerning ‘‘recognition of illness’’ was answered with a ‘‘yes’’ or a ‘‘no’’. ‘‘Yes’’ rated one and ‘‘no’’ rated two, which meant that a low mean indicated a higher ability to recognize mental illness. Two scales were assessing the participants’ wish for social distance towards people suffering from a mental illness. Concerning the personal and perceived stigma questions were answered within a five categories scale: ‘‘fully agree’’, ‘‘partly agree’’, ‘‘neither agree, nor disagree’’, ‘‘partly disagree’’, ‘‘fully disagree’’. A low mean indicated a low wish for social distance, hence ‘‘fully disagree’’ rated one. In relation to the questions ‘‘become a neighbor; friend, colleague; marry into family’’ these were answered within a three categories scale: ‘‘willing to’’, ‘‘not willing to’’, ‘‘not at all willing to’’, where ‘‘willing to’’ rated one, and a low mean in the analysis showed a higher willingness, than a high mean.
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Beliefs about mental illness and treatment were answered within a three categories scale. There were six possible right answers, and respondents were given one point for each right answer, which means that a high mean, one being low and six being high, equals knowledge about mental illness. The following part of the survey consisted in two scales as recommended by Australian evaluators and used in the Swedish trial as well. The first scale was a personal and perceived stigma scale [16]. It consisted of 18 items, 9 asking the participant how strongly he/she personally agreed with the statement, and the other 9 asking what the participants thought other people believed. Items were rated on a five-point Likert scale, where high scores indicated less stigmatizing attitudes. The second added and last scale in the questionnaire, comprised 16 knowledge questions from the MHFA training, and answers were given in a three-category scale: agree, disagree and don’t know. Randomization and blinding An independent researcher provided the randomization by a computer-generated concealed randomization sequence with variable block size. The investigating researcher was blinded throughout the process of the trial, during analysis as well as for the drafting of the manuscript. This was possible due to an assistant researcher who assigned labels to the two groups, which were then applied throughout the analysis and writing process. The blinding was not removed until after the draft writing process was closed. However, neither the participants, the assessors (the trial being a self-report study) nor the instructors were blinded. Statistical methods Intention to treat analysis was performed (in the RCT). Imputations were estimated based on outcomes for participants who did not complete the assessments. The IBM SPSS [17] multiple imputation module was used to impute data. Age and gender were the only baseline values applied in the imputation model, under the assumption of data being missing at random or completely at random.
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Demographic variables were investigated for differences using independent samples t test. An independent samples t test was also used to analyze group difference, and paired samples t test was used to analyze differences in the same group. Internal consistency concerning the personal and the perceived stigma scale was analyzed by Cronbach’s Alpha. Power analysis was performed using PS—power and sample size calculation. We calculated that with alpha = 0.05, a power of 0.8 and a standard deviation 0.75, and a smallest clinically relevant difference in means between the groups of 0.19, we would require 250 persons per group. Both the choice of primary outcome as increased confidence in providing help and a smallest clinically relevant difference in means between groups of 0.19 was applied from a previous Swedish study [11]. IBM SPSS-statistics 22 [17] was used in all analysis. Ethical statement Approval from an ethics committee was not required, since the purpose of the project was education (The Research Ethics-committee Journal no. 15003034). Data do not include detailed, personal sensitive or disease-related information. Participation was voluntary, and all persons randomized into the trial were offered the education-based training course if not as part of the intervention then after finishing the second questionnaire.
Results The total number of participants assessed for eligibility was 576 (see flowchart). Of these 566 persons agreed to participate and were thus randomized. The randomization resulted in an intervention group of 290 participants and a control group of 276 participants. Of all the participants randomized 538 attended the MHFA training course, i.e. 273 from the intervention group and 265 in the control group. Baseline data as well as follow-up data were collected from both groups. At 6 months follow-up 117 (40 %) participants in the intervention group and 80 (29 %) in the control group had not completed the questionnaire.
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Enrollment Organizations contacted (n=10)
Participants assessed for eligibility (n= 576)
Declined to participate (n= 10)
Randomized (n= 566) xs
Allocation Allocated to intervention (n= 290) Did not complete baseline (n=4) ♦ Received allocated intervention (n= 273)
Allocated to control (n= 276) Did not complete baseline (n=2) ♦ Received allocated intervention (n= 265)
♦
♦
Did not receive allocated intervention (give reasons) (n= 14)
Did not receive allocated intervention (give reasons) (n= 14)
Follow-Up Lost to follow-up (give reasons) (n= 117)
Lost to follow-up (give reasons) (n= 80)
Discontinued intervention (give reasons) (n= 0)
Discontinued intervention (give reasons) (n= 0)
Analysis Analysed (n=173)
Analysed (n= 196)
Imputed analyses (n=286) ♦ Excluded from analysis (give reasons) (n=0)
Imputed analyses (n=274) ♦ Excluded from analysis (give reasons) (n=0)
Demographic data are presented in Table 1, which shows that the participants were mostly women, middleaged, born in Denmark, and holding a college or university degree. The sample differed in terms of geographical location but was homogeneous in terms of occupational status. There were no differences between the groups concerning background characteristics, such as gender, education or age and familiarity with mental health problems.
The primary outcome of the trial showed that the MHFA training improved confidence in making contact to (Cohen’s d 0.17), talking to (Cohen’s d 0.18) and providing help to (Cohen’s d 0.31) people suffering from a mental health illness (Fig. 1). The secondary outcomes of the trial indicated an improvement in knowledge (Cohen’s d depression vignette 0.40/Cohen’s d schizophrenia vignette 0.32). Furthermore, results indicate an improvement in the ability to recognize
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Soc Psychiatry Psychiatr Epidemiol Table 1 Demographic data and familiarity with mental health problems at baseline (n = 560) Variable
Tarzan intervention (n = 286)
Jane control (n = 274)
Age, mean (sd)
43.42 (11.9)
42.61 (12.4)
% (n)
% (n)
Women
84.6 (242)
82.8 (227)
Born in Denmark
90.9 (260)
92.3 (253)
Danish as mother tongue College/university education
87.1 (249) 87.8 (251)
91.6 (251) 88.3 (242)
Professionals within the social or healthcare system
65.7 (188)
65.7 (180)
Met someone with mhpa during last 6 months
85.3 (244)
85.0 (233)
Helped someone with mhp during the last 6 months
84.5 (206)
85.8 (200)
Relatives with mhpa
61.2 (175)
55.8 (153)
Personal mhpa
22.0 (63)
23.7 (65)
a
b
a
Mental health problems
b
Out of the people who have meet someone with mhp during the last 6 months. In the categories ‘‘helped some’’ ‘‘helped a lot’’
Fig. 1 Primary outcomes of the Mental Health First Aid trial: perceived confidence in providing various aspects of help
schizophrenia OR = 1.75 (95 % CI 1.00–3.05), p = 0.05. However, we could not detect any improvement in recognizing depression. Further, we did not detect any significant difference between the two groups at follow-up concerning help offered (Table 2).
Discussion The trial achieved significantly positive results on several of the investigated outcomes. We found that the intervention group improved significantly in confidence in making contact to, talking to, and helping a person suffering from a mental illness. Furthermore, they improved in knowledge about what to do and how to act around persons with
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different kinds of a mental illness, as they improved in recognizing mental illness. The aim of this trial was to investigate the effectiveness of MHFA-training in Denmark regarding confidence in taking contact to, talking to and helping persons with mental illness, improvement of knowledge, recognition and attitudes and the amount of actual help offered. The results do in some regards support the findings from previous MHFA trials [10–12, 16]. The Danish trial resembles a recently published Swedish trial both in population, sample size and demographic characteristics, which is why a comparison is reasonable. Like the Danish trial, the Swedish trial showed that participants gained confidence in their own ability to help [11]. In an Australian trial conducted among employees of two Australian government departments: Health and Ageing, and Family and Community Service, results also showed that participants were feeling more confident in helping someone after attending the MHFA training course [16]. Despite the discrepancy in time between the Australian trial and the Danish (10 years), the populations are to a very high degree similar, hence the comparison [16]. Compared to the international trials mentioned above [10–12, 16], the Danish trial added two questions concerning the confidence outcome, not only asking about the participants’ confidence in helping, but also in making contact to and talking to. We found that the participants improved significantly not only in their confidence in helping, like in the other trials, but also in making contact to and talking to, which are two important aspects of the MHFA training program. These results present a nuanced perspective on what the MHFA training program has to offer.
Soc Psychiatry Psychiatr Epidemiol Table 2 Results from analysis Variable
All participants Help offered Confidence in making contact to Confidence in talking to Confidence in helping
Variable
Depression vignette Recognition of illness (%) MHFA knowledge Recognition of illness Beliefs about treatment Personal stigma Perceived stigma Become a neighbour with X Become a friend with X Become a colleague with X X married into family
Variable
Schizophrenia vignette Recognition of illness (%) MHFA knowledge Recognition of illness Beliefs about treatment Personal stigma Perceived stigma Become a neighbour with X Become a friend with X Become a colleague with X X married into family
Intervention group (n = 286)
Control group (n = 274)
Baseline Mean (sd)
Follow-up
Baseline Mean (sd)
Follow-up
3.2 2.8 2.8 2.2
3.3 2.9 3.1 2.6
3.2 2.8 2.8 2.2
3.1 2.8 2.9 2.3
(0.76) (0.79) (0.79) (0.79)
(0.93) (0.89) (0.89) (0.84)
(0.78) (0.83) (0.8) (0.8)
(0.96) (0.91) (0.92) (0.85)
Intervention group (n = 142)
Control group (n = 132)
Baseline Mean (sd)
Follow-up
Baseline Follow-up Mean (sd)/% (95 % CI)
66.9 (95 % CI 58.4–74.5) 7.8 (2.3) 1.3 (0.47)
72.0 (95 % CI 62.8–81.2) 9.4 (2.5) 1.3 (0.54)
63.0 (95 % CI 54.2–71.0) 8.0 (2.4) 1.4 (0.48)
60.3 (95 % CI 50.4–70.2) 8.3 (2.5) 1.4 (0.56)
5.1 (0.98)
5.1 (1.3)
5.1 (1.09)
5.1 (1.3)
7.8 (1.11) 5.1 (2.55)
7.5 (2.59) 4.9 (2.54)
7.8 (1.15) 4.8 (2.59)
7.5 (2.06) 4.6 (2.49)
1.2 (0.41)
1.1 (0.47)
1.1 (0.47)
1.1 (0.45)
1.3 (0.51)
1.2 (0.87)
1.3 (0.54)
1.2 (0.83)
1.7 (0.62)
1.5 (0.75)
1.7 (0.70)
1.6 (0.73)
1.5 (0.62)
1.4 (0.74)
1.4 (0.61)
1.4 (0.72)
Intervention group (n = 145)
Control group (n = 143)
Baseline Mean (sd)
Follow-up
Baseline Follow-up Mean (sd)/% (95 CI)
58.8 (95 % CI 50.3–66.9) 7.9 (2.1) 1.4 (0.48) 4.5 (0.79)
69.0 (95 % CI 59.6–78.3) 9.5 (2.5) 1.3 (0.55) 4.3 (1.3)
56.1 (95 % CI 47.7–64.2) 8.2 (2.3) 1.4 (0.49) 4.5 (0.78)
55.4 (95 % 45.8–65.0) 8.1 (2.7) 1.4 (0.56) 4.2 (1.2)
7.2 (1.27)
7.3 (2.73)
7.4 (1.35)
7.3 (2.23)
3.8 (2.22) 1.4 (0.57)
3.9 (2.44) 1.3 (0.60)
4.3 (2.67) 1.5 (0.63)
4.5 (2.62) 1.3 (0.59)
1.4 (0.57)
1.4 (1.05)
1.5 (0.60)
1.4 (1.11)
1.7 (0.69)
1.6 (0.83)
1.8 (0.73)
1.6 (0.78)
1.9 (0.71)
1.6 (0.80)
1.9 (0.66)
1.7 (0.73)
p
Effect size/OR (95 % CI)
*n.s. (0.081) 0.037 0.018 \0.001
0.12 0.17 0.18 0.31
p
Effect size/OR (95 % CI)
* n.s. 0.08
OR = 1.66 (95 % CI 0.93–2.95) 0.40 0.2
0.001 *n.s. (0.10) *n.s. (0.964) *n.s. 0.763 *n.s. (0.366) *n.s. (0.820) *n.s. (0.85) *n.s (0.644) *n.s. (0.49)
0.005 0.02 0.11 0.025 0.01 0.05 0.078
p
Effect size/OR (95 % CI)
0.05
OR = 1.75 (95 % CI 1.00–3.05) 0.32 0.34 0.06
\ 0.001 0.037 *n.s. (0.531) *n.s. (0.858) 0.037 *n.s. (0.987) *n.s. (0.776) *n.s. (0.648) *n.s. (0.722)
0.01 0.24 0.002 0.055 0.05 0.04
* n.s. not significant. A p value under 0.05 indicates positive change in the intervention group MHFA Mental Health First Aid, OR Odds ratio
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One of the main targets in the MHFA program was to get people with mental illness to seek professional help. Our findings indicate that the participants could draw from a valuable ‘toolbox’ containing knowledge about what to do and how to act around persons with different kinds of mental illness as well as skills to recognize mental illness, which is also supported in the findings in previous trials [10–12, 16]. In the Australian trial an improvement in knowledge and beliefs were found amongst employees, but researchers were not able to detect an improvement in recognition of disorders opposite the Danish and Swedish trials [11, 16]. In a Canadian trial among Student Affair Staff at a university which resembles the Danish trial in being conducted in a workplace setting, participants also improved in recognizing mental health conditions. The Canadian researchers suggest that the MHFA training could provide a knowledge base from which participants can draw in their daily activities when interacting with others, being more certain of when they are in contact with a person with a mental health condition [12]. However, in the Danish trial the participants did not report drawing from this toolbox in their encounters with people with mental health problems. Thus, the positive results concerning the improvement in confidence, knowledge and recognition did not lead to actual action, which makes it difficult to say if such action could lead to more people seeking help. Following this, we did not find any improvement in the amount of help the participants were actually offering someone in need, which has otherwise been shown in previous studies [10, 11]. This could be explained by a ceiling effect. The majority of the participants were professionals in the social or healthcare system (65.7 %). Many of the participants reported that in the last 6 months (prior to the intervention) they had met someone with mental health problems, and almost all of them had offered their help (84.5 % in the intervention group and 85.8 % in the control group). These results indicate the participants’ skills before training, which could point to a risk of selection bias. However, the selection of population in this trial resembled the population in the Swedish and Australian trials, showing that the MHFA training course was highly acceptable in a workplace setting, and furthermore that this group of employees could benefit from the training [11, 16]. An argument for choosing this particular group of people for the trial was their possible interface with and contact to people suffering from mental illness, which meant that they would have the possibility to offer their help. Further, the results showed that the participants still increased their knowledge, especially by recognizing differences in symptomatology. This suggests that in some ways the MHFA training has an impact even on a very skilled population.
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Further, changes in attitudes were limited, and beliefs and knowledge about treatment did not improve significantly. We detected a limited effect regarding social distance in the control group, but not in the intervention group. An explanation could be a head start in the control group at baseline. Otherwise, attitudes did not improve significantly. However, negatively, this supported results from previous MHFA trials, where no differences were found on the items investigating attitude [11, 12]. These results stand opposite the former Australian trials where they found significant changes in attitudes [10, 16]. This could be due to better mental health literacy in Denmark in general compared to Australia [16]. Danish research shows that the reluctance to socialize with people with mental health problems is very small among the general population in Denmark [5], whereas the stigma faced by people with mental health problems is reported to be widespread in Australia [16]. We know, however, that increased knowledge of mental health conditions does not necessarily impact stigma, which could be understood to be a more deep-rooted social condition [12]. This argument is supported by the results on perceived attitudes in this trial, which in the depression vignette did not change for the better post training. This could perhaps be due to the influence of a wider societal stigma associated with mental health conditions [18]. According to mental health anti-stigma studies at present the most effective way to reduce stigma is considered to be direct contact to people with mental illness [19]. During the MHFA training program participants were introduced to videos presenting people suffering from mental health problems. Discussions on attitudes were facilitated and experiences were drawn in, but there was no direct contact to people suffering from a mental illness. It is conceivable that the method used in the MHFA training could be improved by adding this element to the training. The results regarding beliefs and knowledge about treatment also suggest a possible ceiling effect. The scale used in ‘‘Beliefs about treatment’’ ranges from 1 to 6 in the depression vignette and 1–5 in the schizophrenia vignette. What the results in Table 2 show is that both the participants in the intervention group and in the control group already at baseline had knowledge about the right treatment, limiting the scope for improvement. The intervention did not improve the ability to detect depression. Probably the literacy concerning depression is rather high in Denmark as in other Western countries compared to psychotic symptomatology. Strengths and limitations The design of the study was a strength. The randomized design is the golden standard to detect differences between
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groups, in this case investigating the effect of the MHFA intervention. The randomization provides a powerful tool for controlling for confounding, and it gives a strong basis for statistical inference. Furthermore, it enables blinding and therefore minimizes bias. The investigating researcher was blinded throughout the process of the trial as well as during the drafting of the manuscript. Further, being a replication of the Swedish trial was a strength. It attaches value to and supports our findings, ensuring reliability and validity of results. The trials are comparable in population, sample size and intervention. The results can be used in other contexts and are thus generalizable. A strength is also the high internal validity, based on manual-based intervention described in all details, and a non-selected population with a high degree of generalization. Additionally, the large sample and the high participation rate we have in this trial were strengths. Almost all participants asked to participate accepted. A limitation in this trial is the higher attrition rate among participants in the intervention group compared to the control group, a tendency we see in other studies of the effect of MHFA training [16]. The higher response rate in the control group could be due to the design of the evaluation. The control group had something to gain by filling out the second questionnaire as they were still waiting to get the MHFA training and were asked to complete the questionnaire before they got the training, whereas the intervention group already had received the training. The participation in the MHFA training was voluntary, and perhaps the low attrition rate was due to the absence of other possible benefits from filling out the questionnaire than the actual training. To control for missing data an intention-to-treat approach was employed using multiple imputations on the data. Further, a limitation in the structure of the implementation of the MHFA training course was that it was instructors who trained new instructors. It is of course a strength that the training course is manual-based, but a limitation that the training may depend on a given instructor. This is a pragmatic and maybe necessary approach when aiming at teaching a large population, however in risk of affecting the internal validity of the trial. The trial also implied a risk of contamination between the two groups. The participants were often sharing workplace cross-groups, and experiences and knowledge gained at the training course could have been subject to exchange between the groups in unrelated contexts. Neither participants, instructors on the MHFA training course nor outcome assessors were blinded, which might be a limitation in the respect that the instructors were aware which participants were in the intervention group and which were
in the control group. It is considered to be important to be able to blind outcome assessors when participants and treatment providers are not blinded [20]. However, this was not possible in this trial, since it was a self-report study. Another limitation in the design could be the limited focus on helping-behaviour in the questionnaire, the focus being more on attitudes and knowledge about treatment. An explanation for the reported lack of effect in terms of help being actually given at follow-up could be due to such a limitation in the design of the questionnaire. The questions concerning help offered were hard to operationalize, which then in return could be why the participants did not report any improvements in this area. Future thoughts The MHFA training course has proven effective in participants’ ability to recognize and be confident in help-giving behavior towards people suffering from mental illness. However, it is still up to future research to show if improved confidence and ability to recognize mental illness among the general public will get people in need to seek help. In Sweden the program has been modified and is now being offered to people working with youth or elderly people. It is conceivable that other target groups of citizens could benefit from changes in the MHFA training program in Denmark too. Also, modifications of the training were implemented in Australia, where it has been developed further to fit into many different social, ethnic and occupational contexts [21]. Methodically, it could have been interesting to include more objective assessment scales, or perhaps make the assessment more as an exam. This was, however, not possible with the use of the questionnaire as method replication of the Swedish trial. Finally, the structure of the 12 h training could be changed, and a session with a ‘‘mental health ambassador’’ (a person with/ or who had mental health problems) could be added, a tendency we see in other anti-stigma interventions right now in Denmark. Acknowledgments This study was financially supported by the Danish foundation TrygFonden. The authors thank Ditte Marie Madsen, coordinator in the Mental Health Foundation in Denmark, for systematic and persistent efforts in the project. The protocol and grant application for this trial was performed by PBV and MN. The implementation and performance of the MHFA training course was conducted by the Mental Health Foundation in Denmark. The collection of data was performed by KBJ and BRM. The analyses were performed by KBJ and CH at Copenhagen University Hospital, Research Unit, Mental Health Center Copenhagen, Denmark. The drafting of the manuscript was performed by KBJ, CH, BRM, PBV and MN. The protocol can be obtained by emailing corresponding author: [email protected]. The protocol was registered at https://clinicaltrials.gov on the 25th of April 2015, identifier NCT02334020.
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Soc Psychiatry Psychiatr Epidemiol Compliance with ethical standards Conflict of interest Co-author Per B. Vendsborg is an employee at the Mental Health Foundation in Denmark, the organization that implements and sells the MHFA training course. The other authors have no conflict of interests.
10.
References
12.
1. World Health Organization (WHO) (2005) Mental health: facing the challenges, building solutions. Report from the WHO European Ministerial Conference. WHO Regional Office for Europe 2. Directorate-General for employment, social affairs, and inclusion (2010) Countering the stigmatisation and Discrimination of people with mental health problems in Europe. Research paper. European Commission: Directorate-General for Health and Consumers 3. Pedersen CB, Mors O, Bertelsen A, Waltoft BL, Agerbo E, McGrath JJ, Mortensen PB, Eaton WW (2014) A comprehensive nationwide study of the incidence rate and lifetime risk for treated mental disorders. JAMA Psychiatry 71:573–581 4. http://www.psykiatrifonden.dk, http://www.en-af-os.dk/ 5. Danish National Centre for Social Research and the Danish Health Institute (2010) Stigma and mental disorders. As it is experienced and perceived by people with mental disorders and citizens in Denmark (translated from Danish), Copenhagen 6. Angermeyer MC, Matchinger H, Schomerus G (2013) Attitudes towards psychiatric treatment and people with mental illness: changes over two decades. Br J Psychiatry 203:146–151 7. Kohn R, Saxena S, Levav I, Saraceno B (2004) The treatment gap in mental health care. Bull World Health Organ 82:858–866 8. Ru¨sch N, Evans-Lacko SE, Henderson C, Flach C, Thornicroft G (2011) Knowledge and attitudes as predictors of intentions to seek help for and disclose a mental illness. Psychiatr Serv 62(6):675–678 9. Hadleczky G, Ho¨kby S, Mkrtchian A, Carli V, Wasserman D (2014) Mental Health First Aid is an effective public health
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11.
13. 14.
15. 16.
17. 18. 19.
20.
21.
intervention for improving knowledge, attitudes, and behavior: a meta-analysis. Int Rev Psychiatry 26(4):467–475 Kitchener BA, Jorm AF (2002) Mental Health First Aid training for the public: evaluation of effects on knowledge, attitudes and helping behavior. BMC Psychiatry 2:10 Svensson B, Hansson L (2014) Effectiveness of Mental Health First Aid Training in Sweden. A randomized controlled trial with a 6-month and 2-year follow-up. PLoS One 9(6):e100911 Massey J, Brooks M, Burrow J (2014) Evaluating the effectiveness of Mental Health First Aid Training among student affairs staff at a Canadian University. J Stud Aff Res Pract 51(3):323–336 Kitchener BA, Jorm AF (2006) Mental Health First Aid Training: review of evaluation studies. Aust N Z J Psychiatry 40:6–8 Svensson B, Stjernswa¨rd S, Hansson L (2013) Training in mental health first aid. An effect study in two counties (translated from Swedish), CEPI, Lund http://www.psykiatrifonden.dk/guides/psykisk-foerstehjaelp/bag grund-for-psykisk-foerstehjaelp.aspx Kitchener BA, Jorm AF (2004) Mental Health First Aid training in a workplace setting: a randomized controlled trial. BMC Psychiatry 4:23 Corp IBM (2013) IBM SPSS statistics for Windows, Version 22.0. IBM Corp, Armonk Stevenson R, Elvy N (2007) Evaluation of Scotland’s Mental Health First Aid. NHS Health Scotland, Edinburgh Thornicroft G, Brohan E, Kassam A, Lewis-Holmes E (2008) Reducing stigma and discrimination: candidate interventions. Int J Ment Health Syst 2:3. doi:10.1186/1752-4458-2-3 Wood L, Egger M, Gluud LL (2008) Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study. BMJ 336:60 Kanowski LG, Jorm AF, Hart LM (2009) A Mental Health First Aid training program for Australian Aboriginal and Torres Strait Islander peoples: description and initial evaluation. Int J Ment Health Syst 3:1
ORIGINAL PAPER
Effectiveness of Mental Health First Aid training in Denmark: a randomized trial in waitlist design Kamilla B. Jensen1 • Britt Reuter Morthorst1 • Per B. Vendsborg2 Carsten Hjorthøj1 • Merete Nordentoft1
•
Received: 3 September 2015 / Accepted: 10 January 2016 Ó Springer-Verlag Berlin Heidelberg 2016
Abstract Purpose To examine the effect of the Australian educational intervention Mental Health First Aid (MHFA) in a Danish context. Primary outcome was improvement concerning confidence in help-giving behavior towards people suffering from mental illness. Secondary outcomes were increased knowledge and ability to recognize mental illness and improved positive attitudes towards people suffering from mental health problems. Method Study design was a randomized trial with a waitlist control group. The intervention group was compared with the control group at 6-month follow-up. Both groups completed at baseline and at 6-month follow-up. Results A significant difference was found between employees trained in the intervention group compared to the control group at 6-month follow-up on the items of confidence in making contact to (Cohen’s d 0.17), talking to (Cohen’s d 0.18) and providing help to (Cohen’s d 0.31) people suffering from a mental health illness. Further, participants improved in knowledge (Cohen’s d depression vignette 0.40/Cohen’s d schizophrenia vignette 0.32) and in the ability to recognize schizophrenia OR = 1.75 (95 % CI 1.00–3.05), p = 0.05. A significant difference between the intervention group and control group at follow-up concerning actual help offered was not found. Changes in attitudes were limited.
& Britt Reuter Morthorst [email protected] 1
Copenhagen University Hospital, Research Unit, Mental Health Centre, Capital Region of Denmark, Kildega˚rdsvej 28, entrance 15, 4th floor, 2900 Copenhagen, Denmark
2
Danish Mental Health Foundation, Hejrevej 43, 2400 Copenhagen, Denmark
Conclusion The MHFA training was effective in a Danish context. Keywords Mental Health First Aid Randomized trial Mental health Educational training program
Introduction A large number of people in our society struggle with mental health problems. According to the World Health Organization the prevalence of mental disorders is high and growing worldwide [1]. The estimations of the lifetime expectancy of mental health problems in the general population in Europe are about 25 % [2]. However, recent research shows that as much as 38 % of the female population and 32 % of the male population in Denmark is expected to receive treatment in the secondary mental health sector [3]. These high numbers indicate that today mental illness is something many people will encounter during their lifetime. In Denmark, we have conducted several campaigns targeting the mental health literacy of the public and mental health related stigma over the last years [4]. Despite this, the average Dane’s knowledge about mental illness and how to help and support a person in crisis because of an acute mental health condition is limited [5]. In recent years, there has been a change in attitudes towards mental illness, and seeking professional help is more widely accepted by the general population. However, there has been no significant change in the guarded attitudes towards people with mental illness as a consequence of this trend [6]. The initial treatment of people suffering from mental illness is still frequently delayed for many years [7]. It has been suggested that
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poor knowledge of mental illness and mental illness stigma are factors that can explain the low rates of helpseeking behavior among people with these conditions [8]. One way to increase help-seeking behavior among people with mental illness would be to educate the public to recognize significant symptoms and to strengthen their skills to provide the initial first aid to people affected by mental health problems and, among other things, advise them to see their general practitioner. The Mental Health First Aid (MHFA) training program in fact strives to do that. The Mental Health First Aid training program was developed in Australia in 2001, and has since then been adopted in 21 other countries around the world [9]. The MHFA training program was developed to improve the general public’s mental health literacy and to train skills to provide the initial help to people suffering from mental illness [10]. The training program has been widely investigated, and effects of the program have been documented [10–12]. A meta-analysis from 2014 included 15 studies investigating the MHFA training program and presented homogenous results [9]. All the studies, with three exceptions, had been carried out in Australia. Four of the 15 studies included were randomized trials. Samples were diverse, and included different types of staff in government departments, general public in rural areas of Australia, young people, minority groups and football club leaders among others [9]. The overall trends found in these studies were improvements in knowledge, reduced stigma, a rise in confidence in providing help and an increased amount of help provided [9–12].
Aim of the study The aim of this randomized trial was to investigate the effect of the MHFA training with regard to confidence in help-giving behavior as primary outcome in Danish employees and NGO-volunteers. Secondary outcomes investigated were increased knowledge and recognition of mental illness and improved positive attitudes towards people suffering from mental health problems.
Materials and methods Design We conducted a randomized trial with a waitlist control group and a 6-month follow-up period. Self-completed questionnaires were answered at baseline and at 6-month follow-up.
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Participants Initially, the MHFA training program was developed for the general public [13]. However, previous international studies have found the training program to be effective for participants, who most often are in contact with many different individuals in their line of work [14]. Hence, the trial recruited employees and volunteers at ten different workplaces, including public, private and nongovernmental organizations (NGOs). Workplaces were the municipalities of Frederiksberg, Odense, Roskilde and Vejle, covering four of the five administrative regions of Denmark. Furthermore, the Danish Prison and Probation Service, a Job Center in the municipality of Copenhagen, the telephone counseling of the Mental Health Foundation and Young Women’s Christian Association (YWCA) participated. The NGO ‘‘SindUngdom’’ and the public and voluntary organization ‘‘Headspace’’, both organizations for young people with mental health problems, also took part. Eligible organizations or workplaces were contacted by The Mental Health Foundation among their collaborators and professional network all over Denmark. The initial invitation to participate in the trial was sent by mail or conducted by phone calls to leaders in each organization. Responding workplaces showing interest and those facilitating the possibility to participate by letting their employees attend the course may be during work hours was included. Intervention The implementation of the Mental Health First-Aid was managed by the Danish Mental Health Foundation, who provided the training to all participants, in total 41 training courses. Training was given either at workplaces or at the Danish Mental Health Foundation located in Copenhagen. The training course was a manualized 2-day course with 12 h of training given in groups of around 20 participants by one or two instructors. The Australian founder of the program trained seven instructors all affiliated to the Mental Health Foundation in Denmark and all with experience in mental health work, most of the instructors being psychologists or social workers. These insights into training were later passed on to subsequent instructors. The participants allocated to the intervention group got the training course after having answered the baseline questionnaire. They answered the same questionnaire again 6 months later. The participants allocated to waitlist answered the baseline questionnaire and had to wait 6 months before they again answered the same questionnaire, and after having answered this second questionnaire, they got the training course.
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The guiding philosophy behind MHFA training is based on key elements similar to those of conventional physical first aid training: preserve life, provide help to prevent further deterioration, promote the recovery of good mental health, and provide comfort for all persons experiencing mental health problems [15]. The first-aid approach of the MHFA training course was taught in a five step action plan: (1) assess risk of suicide and harm, (2) listen non-judgmentally, (3) give reassurance and information, (4) encourage individuals to get appropriate professional help, and (5) encourage self-help strategies. All steps were applied to the major categories of mental health disorders and crisis. Within all categories of disorders and crisis, participants were introduced to symptoms of the illness, possible risk factors, evidence-based treatment and where and how to get help [10]. The training was based on exercises, knowledge presentations and discussions. It presented cases and involved the participants, who were encouraged to present examples from their own lives. The MHFA program was translated and modified to suit the Danish context. Assessment and scales A baseline questionnaire was sent out electronically using the software program Survey Xact, primarily to the participants’ work email-addresses. Reminders to complete the questionnaire were sent out, and the data were securely stored in the software program. The same procedure was used with the 6-month follow-up questionnaires. The primary outcome was improved confidence in providing help to people suffering from mental illness (compared to the waitlist control group). Secondary outcomes were (1) increased knowledge, including improved ability to recognize mental illness, and (2) decreased stigmatizing attitudes. Knowledge was assessed by questions addressing, e.g. beliefs about treatment. By ‘beliefs’ we mean what the participants thought would be helpful in the situation, and we investigated whether knowledge and beliefs about treatment became more concordant with evidence-based treatment. In this paper we define the participants’ actions as helping behavior, by which we mean making contact to, talking to or actually providing help to individuals, e.g. by referring them to private practitioners. The Danish trial of the MHFA training program used the same self-report questionnaires as in the Australian studies. However, two scales were added according to the design of the Swedish trial and in accordance with recommendations from previous Australian evaluators. With respect to our primary outcome we further added three questions on confidence in helping. The questionnaire was divided into five parts. The first part covered socio-demographic characteristics, the participant’s experience with mental illness,
confidence in making contact to, talking to and providing help to a person suffering from mental problems and finally, contact within the last 6 months to people suffering from mental health problems and whether the participants had offered their help. In the next part the participants were presented with a vignette describing a person with depression or schizophrenia; this section covered the participants’ ability to recognize the illness and their beliefs and knowledge about correct treatment. The third part of the questionnaire was a social distance scale to assess stigmatizing attitudes. The questions were based on the description in the vignette. The scale assessed the participants’ willingness to (1) live next door to the person, (2) make friends with the person, (3) provide a job at their own workplace for the person, and (4) have the person marry into their family. This section ended by asking if the participant or one in his/her family or friends had had the same problem as stated in the vignette. The vignettes were randomly distributed among the participants and given alternately between the depression and schizophrenia case; hence every participant had to comment on the same vignette at baseline and follow-up. The project manager, who was responsible for contact to the participants, distributed the questionnaires and thereby also the vignettes. The primary outcome was measured through three questions concerning the person’s confidence in helping. All three questions were answered on a four step scale: ‘‘not confident at all’’, ‘‘a little confident’’, ‘‘quite confident’’, ‘‘very confident’’. A high level of confidence was reflected in a high mean of the analysis, ‘‘very confident’’ was rated four. Furthermore, if the participant answered ‘‘not confident at all’’, he/she would have to answer another question on the primary cause for this within a five step scale: ‘‘lack of knowledge’’, ‘‘afraid of saying something wrong’’, ‘‘afraid of the person’s reaction’’, ‘‘don’t know what to advice the person to do’’, ‘‘it is too great a responsibility’’. The question concerning ‘‘recognition of illness’’ was answered with a ‘‘yes’’ or a ‘‘no’’. ‘‘Yes’’ rated one and ‘‘no’’ rated two, which meant that a low mean indicated a higher ability to recognize mental illness. Two scales were assessing the participants’ wish for social distance towards people suffering from a mental illness. Concerning the personal and perceived stigma questions were answered within a five categories scale: ‘‘fully agree’’, ‘‘partly agree’’, ‘‘neither agree, nor disagree’’, ‘‘partly disagree’’, ‘‘fully disagree’’. A low mean indicated a low wish for social distance, hence ‘‘fully disagree’’ rated one. In relation to the questions ‘‘become a neighbor; friend, colleague; marry into family’’ these were answered within a three categories scale: ‘‘willing to’’, ‘‘not willing to’’, ‘‘not at all willing to’’, where ‘‘willing to’’ rated one, and a low mean in the analysis showed a higher willingness, than a high mean.
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Beliefs about mental illness and treatment were answered within a three categories scale. There were six possible right answers, and respondents were given one point for each right answer, which means that a high mean, one being low and six being high, equals knowledge about mental illness. The following part of the survey consisted in two scales as recommended by Australian evaluators and used in the Swedish trial as well. The first scale was a personal and perceived stigma scale [16]. It consisted of 18 items, 9 asking the participant how strongly he/she personally agreed with the statement, and the other 9 asking what the participants thought other people believed. Items were rated on a five-point Likert scale, where high scores indicated less stigmatizing attitudes. The second added and last scale in the questionnaire, comprised 16 knowledge questions from the MHFA training, and answers were given in a three-category scale: agree, disagree and don’t know. Randomization and blinding An independent researcher provided the randomization by a computer-generated concealed randomization sequence with variable block size. The investigating researcher was blinded throughout the process of the trial, during analysis as well as for the drafting of the manuscript. This was possible due to an assistant researcher who assigned labels to the two groups, which were then applied throughout the analysis and writing process. The blinding was not removed until after the draft writing process was closed. However, neither the participants, the assessors (the trial being a self-report study) nor the instructors were blinded. Statistical methods Intention to treat analysis was performed (in the RCT). Imputations were estimated based on outcomes for participants who did not complete the assessments. The IBM SPSS [17] multiple imputation module was used to impute data. Age and gender were the only baseline values applied in the imputation model, under the assumption of data being missing at random or completely at random.
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Demographic variables were investigated for differences using independent samples t test. An independent samples t test was also used to analyze group difference, and paired samples t test was used to analyze differences in the same group. Internal consistency concerning the personal and the perceived stigma scale was analyzed by Cronbach’s Alpha. Power analysis was performed using PS—power and sample size calculation. We calculated that with alpha = 0.05, a power of 0.8 and a standard deviation 0.75, and a smallest clinically relevant difference in means between the groups of 0.19, we would require 250 persons per group. Both the choice of primary outcome as increased confidence in providing help and a smallest clinically relevant difference in means between groups of 0.19 was applied from a previous Swedish study [11]. IBM SPSS-statistics 22 [17] was used in all analysis. Ethical statement Approval from an ethics committee was not required, since the purpose of the project was education (The Research Ethics-committee Journal no. 15003034). Data do not include detailed, personal sensitive or disease-related information. Participation was voluntary, and all persons randomized into the trial were offered the education-based training course if not as part of the intervention then after finishing the second questionnaire.
Results The total number of participants assessed for eligibility was 576 (see flowchart). Of these 566 persons agreed to participate and were thus randomized. The randomization resulted in an intervention group of 290 participants and a control group of 276 participants. Of all the participants randomized 538 attended the MHFA training course, i.e. 273 from the intervention group and 265 in the control group. Baseline data as well as follow-up data were collected from both groups. At 6 months follow-up 117 (40 %) participants in the intervention group and 80 (29 %) in the control group had not completed the questionnaire.
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Enrollment Organizations contacted (n=10)
Participants assessed for eligibility (n= 576)
Declined to participate (n= 10)
Randomized (n= 566) xs
Allocation Allocated to intervention (n= 290) Did not complete baseline (n=4) ♦ Received allocated intervention (n= 273)
Allocated to control (n= 276) Did not complete baseline (n=2) ♦ Received allocated intervention (n= 265)
♦
♦
Did not receive allocated intervention (give reasons) (n= 14)
Did not receive allocated intervention (give reasons) (n= 14)
Follow-Up Lost to follow-up (give reasons) (n= 117)
Lost to follow-up (give reasons) (n= 80)
Discontinued intervention (give reasons) (n= 0)
Discontinued intervention (give reasons) (n= 0)
Analysis Analysed (n=173)
Analysed (n= 196)
Imputed analyses (n=286) ♦ Excluded from analysis (give reasons) (n=0)
Imputed analyses (n=274) ♦ Excluded from analysis (give reasons) (n=0)
Demographic data are presented in Table 1, which shows that the participants were mostly women, middleaged, born in Denmark, and holding a college or university degree. The sample differed in terms of geographical location but was homogeneous in terms of occupational status. There were no differences between the groups concerning background characteristics, such as gender, education or age and familiarity with mental health problems.
The primary outcome of the trial showed that the MHFA training improved confidence in making contact to (Cohen’s d 0.17), talking to (Cohen’s d 0.18) and providing help to (Cohen’s d 0.31) people suffering from a mental health illness (Fig. 1). The secondary outcomes of the trial indicated an improvement in knowledge (Cohen’s d depression vignette 0.40/Cohen’s d schizophrenia vignette 0.32). Furthermore, results indicate an improvement in the ability to recognize
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Soc Psychiatry Psychiatr Epidemiol Table 1 Demographic data and familiarity with mental health problems at baseline (n = 560) Variable
Tarzan intervention (n = 286)
Jane control (n = 274)
Age, mean (sd)
43.42 (11.9)
42.61 (12.4)
% (n)
% (n)
Women
84.6 (242)
82.8 (227)
Born in Denmark
90.9 (260)
92.3 (253)
Danish as mother tongue College/university education
87.1 (249) 87.8 (251)
91.6 (251) 88.3 (242)
Professionals within the social or healthcare system
65.7 (188)
65.7 (180)
Met someone with mhpa during last 6 months
85.3 (244)
85.0 (233)
Helped someone with mhp during the last 6 months
84.5 (206)
85.8 (200)
Relatives with mhpa
61.2 (175)
55.8 (153)
Personal mhpa
22.0 (63)
23.7 (65)
a
b
a
Mental health problems
b
Out of the people who have meet someone with mhp during the last 6 months. In the categories ‘‘helped some’’ ‘‘helped a lot’’
Fig. 1 Primary outcomes of the Mental Health First Aid trial: perceived confidence in providing various aspects of help
schizophrenia OR = 1.75 (95 % CI 1.00–3.05), p = 0.05. However, we could not detect any improvement in recognizing depression. Further, we did not detect any significant difference between the two groups at follow-up concerning help offered (Table 2).
Discussion The trial achieved significantly positive results on several of the investigated outcomes. We found that the intervention group improved significantly in confidence in making contact to, talking to, and helping a person suffering from a mental illness. Furthermore, they improved in knowledge about what to do and how to act around persons with
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different kinds of a mental illness, as they improved in recognizing mental illness. The aim of this trial was to investigate the effectiveness of MHFA-training in Denmark regarding confidence in taking contact to, talking to and helping persons with mental illness, improvement of knowledge, recognition and attitudes and the amount of actual help offered. The results do in some regards support the findings from previous MHFA trials [10–12, 16]. The Danish trial resembles a recently published Swedish trial both in population, sample size and demographic characteristics, which is why a comparison is reasonable. Like the Danish trial, the Swedish trial showed that participants gained confidence in their own ability to help [11]. In an Australian trial conducted among employees of two Australian government departments: Health and Ageing, and Family and Community Service, results also showed that participants were feeling more confident in helping someone after attending the MHFA training course [16]. Despite the discrepancy in time between the Australian trial and the Danish (10 years), the populations are to a very high degree similar, hence the comparison [16]. Compared to the international trials mentioned above [10–12, 16], the Danish trial added two questions concerning the confidence outcome, not only asking about the participants’ confidence in helping, but also in making contact to and talking to. We found that the participants improved significantly not only in their confidence in helping, like in the other trials, but also in making contact to and talking to, which are two important aspects of the MHFA training program. These results present a nuanced perspective on what the MHFA training program has to offer.
Soc Psychiatry Psychiatr Epidemiol Table 2 Results from analysis Variable
All participants Help offered Confidence in making contact to Confidence in talking to Confidence in helping
Variable
Depression vignette Recognition of illness (%) MHFA knowledge Recognition of illness Beliefs about treatment Personal stigma Perceived stigma Become a neighbour with X Become a friend with X Become a colleague with X X married into family
Variable
Schizophrenia vignette Recognition of illness (%) MHFA knowledge Recognition of illness Beliefs about treatment Personal stigma Perceived stigma Become a neighbour with X Become a friend with X Become a colleague with X X married into family
Intervention group (n = 286)
Control group (n = 274)
Baseline Mean (sd)
Follow-up
Baseline Mean (sd)
Follow-up
3.2 2.8 2.8 2.2
3.3 2.9 3.1 2.6
3.2 2.8 2.8 2.2
3.1 2.8 2.9 2.3
(0.76) (0.79) (0.79) (0.79)
(0.93) (0.89) (0.89) (0.84)
(0.78) (0.83) (0.8) (0.8)
(0.96) (0.91) (0.92) (0.85)
Intervention group (n = 142)
Control group (n = 132)
Baseline Mean (sd)
Follow-up
Baseline Follow-up Mean (sd)/% (95 % CI)
66.9 (95 % CI 58.4–74.5) 7.8 (2.3) 1.3 (0.47)
72.0 (95 % CI 62.8–81.2) 9.4 (2.5) 1.3 (0.54)
63.0 (95 % CI 54.2–71.0) 8.0 (2.4) 1.4 (0.48)
60.3 (95 % CI 50.4–70.2) 8.3 (2.5) 1.4 (0.56)
5.1 (0.98)
5.1 (1.3)
5.1 (1.09)
5.1 (1.3)
7.8 (1.11) 5.1 (2.55)
7.5 (2.59) 4.9 (2.54)
7.8 (1.15) 4.8 (2.59)
7.5 (2.06) 4.6 (2.49)
1.2 (0.41)
1.1 (0.47)
1.1 (0.47)
1.1 (0.45)
1.3 (0.51)
1.2 (0.87)
1.3 (0.54)
1.2 (0.83)
1.7 (0.62)
1.5 (0.75)
1.7 (0.70)
1.6 (0.73)
1.5 (0.62)
1.4 (0.74)
1.4 (0.61)
1.4 (0.72)
Intervention group (n = 145)
Control group (n = 143)
Baseline Mean (sd)
Follow-up
Baseline Follow-up Mean (sd)/% (95 CI)
58.8 (95 % CI 50.3–66.9) 7.9 (2.1) 1.4 (0.48) 4.5 (0.79)
69.0 (95 % CI 59.6–78.3) 9.5 (2.5) 1.3 (0.55) 4.3 (1.3)
56.1 (95 % CI 47.7–64.2) 8.2 (2.3) 1.4 (0.49) 4.5 (0.78)
55.4 (95 % 45.8–65.0) 8.1 (2.7) 1.4 (0.56) 4.2 (1.2)
7.2 (1.27)
7.3 (2.73)
7.4 (1.35)
7.3 (2.23)
3.8 (2.22) 1.4 (0.57)
3.9 (2.44) 1.3 (0.60)
4.3 (2.67) 1.5 (0.63)
4.5 (2.62) 1.3 (0.59)
1.4 (0.57)
1.4 (1.05)
1.5 (0.60)
1.4 (1.11)
1.7 (0.69)
1.6 (0.83)
1.8 (0.73)
1.6 (0.78)
1.9 (0.71)
1.6 (0.80)
1.9 (0.66)
1.7 (0.73)
p
Effect size/OR (95 % CI)
*n.s. (0.081) 0.037 0.018 \0.001
0.12 0.17 0.18 0.31
p
Effect size/OR (95 % CI)
* n.s. 0.08
OR = 1.66 (95 % CI 0.93–2.95) 0.40 0.2
0.001 *n.s. (0.10) *n.s. (0.964) *n.s. 0.763 *n.s. (0.366) *n.s. (0.820) *n.s. (0.85) *n.s (0.644) *n.s. (0.49)
0.005 0.02 0.11 0.025 0.01 0.05 0.078
p
Effect size/OR (95 % CI)
0.05
OR = 1.75 (95 % CI 1.00–3.05) 0.32 0.34 0.06
\ 0.001 0.037 *n.s. (0.531) *n.s. (0.858) 0.037 *n.s. (0.987) *n.s. (0.776) *n.s. (0.648) *n.s. (0.722)
0.01 0.24 0.002 0.055 0.05 0.04
* n.s. not significant. A p value under 0.05 indicates positive change in the intervention group MHFA Mental Health First Aid, OR Odds ratio
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Soc Psychiatry Psychiatr Epidemiol
One of the main targets in the MHFA program was to get people with mental illness to seek professional help. Our findings indicate that the participants could draw from a valuable ‘toolbox’ containing knowledge about what to do and how to act around persons with different kinds of mental illness as well as skills to recognize mental illness, which is also supported in the findings in previous trials [10–12, 16]. In the Australian trial an improvement in knowledge and beliefs were found amongst employees, but researchers were not able to detect an improvement in recognition of disorders opposite the Danish and Swedish trials [11, 16]. In a Canadian trial among Student Affair Staff at a university which resembles the Danish trial in being conducted in a workplace setting, participants also improved in recognizing mental health conditions. The Canadian researchers suggest that the MHFA training could provide a knowledge base from which participants can draw in their daily activities when interacting with others, being more certain of when they are in contact with a person with a mental health condition [12]. However, in the Danish trial the participants did not report drawing from this toolbox in their encounters with people with mental health problems. Thus, the positive results concerning the improvement in confidence, knowledge and recognition did not lead to actual action, which makes it difficult to say if such action could lead to more people seeking help. Following this, we did not find any improvement in the amount of help the participants were actually offering someone in need, which has otherwise been shown in previous studies [10, 11]. This could be explained by a ceiling effect. The majority of the participants were professionals in the social or healthcare system (65.7 %). Many of the participants reported that in the last 6 months (prior to the intervention) they had met someone with mental health problems, and almost all of them had offered their help (84.5 % in the intervention group and 85.8 % in the control group). These results indicate the participants’ skills before training, which could point to a risk of selection bias. However, the selection of population in this trial resembled the population in the Swedish and Australian trials, showing that the MHFA training course was highly acceptable in a workplace setting, and furthermore that this group of employees could benefit from the training [11, 16]. An argument for choosing this particular group of people for the trial was their possible interface with and contact to people suffering from mental illness, which meant that they would have the possibility to offer their help. Further, the results showed that the participants still increased their knowledge, especially by recognizing differences in symptomatology. This suggests that in some ways the MHFA training has an impact even on a very skilled population.
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Further, changes in attitudes were limited, and beliefs and knowledge about treatment did not improve significantly. We detected a limited effect regarding social distance in the control group, but not in the intervention group. An explanation could be a head start in the control group at baseline. Otherwise, attitudes did not improve significantly. However, negatively, this supported results from previous MHFA trials, where no differences were found on the items investigating attitude [11, 12]. These results stand opposite the former Australian trials where they found significant changes in attitudes [10, 16]. This could be due to better mental health literacy in Denmark in general compared to Australia [16]. Danish research shows that the reluctance to socialize with people with mental health problems is very small among the general population in Denmark [5], whereas the stigma faced by people with mental health problems is reported to be widespread in Australia [16]. We know, however, that increased knowledge of mental health conditions does not necessarily impact stigma, which could be understood to be a more deep-rooted social condition [12]. This argument is supported by the results on perceived attitudes in this trial, which in the depression vignette did not change for the better post training. This could perhaps be due to the influence of a wider societal stigma associated with mental health conditions [18]. According to mental health anti-stigma studies at present the most effective way to reduce stigma is considered to be direct contact to people with mental illness [19]. During the MHFA training program participants were introduced to videos presenting people suffering from mental health problems. Discussions on attitudes were facilitated and experiences were drawn in, but there was no direct contact to people suffering from a mental illness. It is conceivable that the method used in the MHFA training could be improved by adding this element to the training. The results regarding beliefs and knowledge about treatment also suggest a possible ceiling effect. The scale used in ‘‘Beliefs about treatment’’ ranges from 1 to 6 in the depression vignette and 1–5 in the schizophrenia vignette. What the results in Table 2 show is that both the participants in the intervention group and in the control group already at baseline had knowledge about the right treatment, limiting the scope for improvement. The intervention did not improve the ability to detect depression. Probably the literacy concerning depression is rather high in Denmark as in other Western countries compared to psychotic symptomatology. Strengths and limitations The design of the study was a strength. The randomized design is the golden standard to detect differences between
Soc Psychiatry Psychiatr Epidemiol
groups, in this case investigating the effect of the MHFA intervention. The randomization provides a powerful tool for controlling for confounding, and it gives a strong basis for statistical inference. Furthermore, it enables blinding and therefore minimizes bias. The investigating researcher was blinded throughout the process of the trial as well as during the drafting of the manuscript. Further, being a replication of the Swedish trial was a strength. It attaches value to and supports our findings, ensuring reliability and validity of results. The trials are comparable in population, sample size and intervention. The results can be used in other contexts and are thus generalizable. A strength is also the high internal validity, based on manual-based intervention described in all details, and a non-selected population with a high degree of generalization. Additionally, the large sample and the high participation rate we have in this trial were strengths. Almost all participants asked to participate accepted. A limitation in this trial is the higher attrition rate among participants in the intervention group compared to the control group, a tendency we see in other studies of the effect of MHFA training [16]. The higher response rate in the control group could be due to the design of the evaluation. The control group had something to gain by filling out the second questionnaire as they were still waiting to get the MHFA training and were asked to complete the questionnaire before they got the training, whereas the intervention group already had received the training. The participation in the MHFA training was voluntary, and perhaps the low attrition rate was due to the absence of other possible benefits from filling out the questionnaire than the actual training. To control for missing data an intention-to-treat approach was employed using multiple imputations on the data. Further, a limitation in the structure of the implementation of the MHFA training course was that it was instructors who trained new instructors. It is of course a strength that the training course is manual-based, but a limitation that the training may depend on a given instructor. This is a pragmatic and maybe necessary approach when aiming at teaching a large population, however in risk of affecting the internal validity of the trial. The trial also implied a risk of contamination between the two groups. The participants were often sharing workplace cross-groups, and experiences and knowledge gained at the training course could have been subject to exchange between the groups in unrelated contexts. Neither participants, instructors on the MHFA training course nor outcome assessors were blinded, which might be a limitation in the respect that the instructors were aware which participants were in the intervention group and which were
in the control group. It is considered to be important to be able to blind outcome assessors when participants and treatment providers are not blinded [20]. However, this was not possible in this trial, since it was a self-report study. Another limitation in the design could be the limited focus on helping-behaviour in the questionnaire, the focus being more on attitudes and knowledge about treatment. An explanation for the reported lack of effect in terms of help being actually given at follow-up could be due to such a limitation in the design of the questionnaire. The questions concerning help offered were hard to operationalize, which then in return could be why the participants did not report any improvements in this area. Future thoughts The MHFA training course has proven effective in participants’ ability to recognize and be confident in help-giving behavior towards people suffering from mental illness. However, it is still up to future research to show if improved confidence and ability to recognize mental illness among the general public will get people in need to seek help. In Sweden the program has been modified and is now being offered to people working with youth or elderly people. It is conceivable that other target groups of citizens could benefit from changes in the MHFA training program in Denmark too. Also, modifications of the training were implemented in Australia, where it has been developed further to fit into many different social, ethnic and occupational contexts [21]. Methodically, it could have been interesting to include more objective assessment scales, or perhaps make the assessment more as an exam. This was, however, not possible with the use of the questionnaire as method replication of the Swedish trial. Finally, the structure of the 12 h training could be changed, and a session with a ‘‘mental health ambassador’’ (a person with/ or who had mental health problems) could be added, a tendency we see in other anti-stigma interventions right now in Denmark. Acknowledgments This study was financially supported by the Danish foundation TrygFonden. The authors thank Ditte Marie Madsen, coordinator in the Mental Health Foundation in Denmark, for systematic and persistent efforts in the project. The protocol and grant application for this trial was performed by PBV and MN. The implementation and performance of the MHFA training course was conducted by the Mental Health Foundation in Denmark. The collection of data was performed by KBJ and BRM. The analyses were performed by KBJ and CH at Copenhagen University Hospital, Research Unit, Mental Health Center Copenhagen, Denmark. The drafting of the manuscript was performed by KBJ, CH, BRM, PBV and MN. The protocol can be obtained by emailing corresponding author: [email protected]. The protocol was registered at https://clinicaltrials.gov on the 25th of April 2015, identifier NCT02334020.
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Soc Psychiatry Psychiatr Epidemiol Compliance with ethical standards Conflict of interest Co-author Per B. Vendsborg is an employee at the Mental Health Foundation in Denmark, the organization that implements and sells the MHFA training course. The other authors have no conflict of interests.
10.
References
12.
1. World Health Organization (WHO) (2005) Mental health: facing the challenges, building solutions. Report from the WHO European Ministerial Conference. WHO Regional Office for Europe 2. Directorate-General for employment, social affairs, and inclusion (2010) Countering the stigmatisation and Discrimination of people with mental health problems in Europe. Research paper. European Commission: Directorate-General for Health and Consumers 3. Pedersen CB, Mors O, Bertelsen A, Waltoft BL, Agerbo E, McGrath JJ, Mortensen PB, Eaton WW (2014) A comprehensive nationwide study of the incidence rate and lifetime risk for treated mental disorders. JAMA Psychiatry 71:573–581 4. http://www.psykiatrifonden.dk, http://www.en-af-os.dk/ 5. Danish National Centre for Social Research and the Danish Health Institute (2010) Stigma and mental disorders. As it is experienced and perceived by people with mental disorders and citizens in Denmark (translated from Danish), Copenhagen 6. Angermeyer MC, Matchinger H, Schomerus G (2013) Attitudes towards psychiatric treatment and people with mental illness: changes over two decades. Br J Psychiatry 203:146–151 7. Kohn R, Saxena S, Levav I, Saraceno B (2004) The treatment gap in mental health care. Bull World Health Organ 82:858–866 8. Ru¨sch N, Evans-Lacko SE, Henderson C, Flach C, Thornicroft G (2011) Knowledge and attitudes as predictors of intentions to seek help for and disclose a mental illness. Psychiatr Serv 62(6):675–678 9. Hadleczky G, Ho¨kby S, Mkrtchian A, Carli V, Wasserman D (2014) Mental Health First Aid is an effective public health
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11.
13. 14.
15. 16.
17. 18. 19.
20.
21.
intervention for improving knowledge, attitudes, and behavior: a meta-analysis. Int Rev Psychiatry 26(4):467–475 Kitchener BA, Jorm AF (2002) Mental Health First Aid training for the public: evaluation of effects on knowledge, attitudes and helping behavior. BMC Psychiatry 2:10 Svensson B, Hansson L (2014) Effectiveness of Mental Health First Aid Training in Sweden. A randomized controlled trial with a 6-month and 2-year follow-up. PLoS One 9(6):e100911 Massey J, Brooks M, Burrow J (2014) Evaluating the effectiveness of Mental Health First Aid Training among student affairs staff at a Canadian University. J Stud Aff Res Pract 51(3):323–336 Kitchener BA, Jorm AF (2006) Mental Health First Aid Training: review of evaluation studies. Aust N Z J Psychiatry 40:6–8 Svensson B, Stjernswa¨rd S, Hansson L (2013) Training in mental health first aid. An effect study in two counties (translated from Swedish), CEPI, Lund http://www.psykiatrifonden.dk/guides/psykisk-foerstehjaelp/bag grund-for-psykisk-foerstehjaelp.aspx Kitchener BA, Jorm AF (2004) Mental Health First Aid training in a workplace setting: a randomized controlled trial. BMC Psychiatry 4:23 Corp IBM (2013) IBM SPSS statistics for Windows, Version 22.0. IBM Corp, Armonk Stevenson R, Elvy N (2007) Evaluation of Scotland’s Mental Health First Aid. NHS Health Scotland, Edinburgh Thornicroft G, Brohan E, Kassam A, Lewis-Holmes E (2008) Reducing stigma and discrimination: candidate interventions. Int J Ment Health Syst 2:3. doi:10.1186/1752-4458-2-3 Wood L, Egger M, Gluud LL (2008) Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study. BMJ 336:60 Kanowski LG, Jorm AF, Hart LM (2009) A Mental Health First Aid training program for Australian Aboriginal and Torres Strait Islander peoples: description and initial evaluation. Int J Ment Health Syst 3:1
