Content uploaded by Gergö Hadlaczky
Author content
All content in this area was uploaded by Gergö Hadlaczky on Sep 04, 2015
Content may be subject to copyright.
Correspondence: Gerg ö Hadlaczky, National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, 171 77, Stockholm,
Sweden. Tel: ⫹ 46 8 524 870 26. Fax: ⫹ 46 8 30 64 39. E-mail: Gergo.Hadlaczki@ki.se, Gergo.Hadlaczky@sll.se
(Rece ived 8 May 2014 ; a ccepte d 13 May 2014 )
Mental Health First Aid is an effective public health intervention for
improving knowledge, attitudes, and behaviour: A meta-analysis
GERG Ö HADLACZKY , SEBASTIAN H Ö KBY , ANAHIT MKRTCHIAN , VLADIMIR CARLI
& DANUTA WASSERMAN
National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden
Abstract
Mental Health First Aid (MHFA) is a standardized, psychoeducational programme developed to empower the public
to approach, support and refer individuals in distress by improving course participants ’ knowledge, attitudes and
behaviours related to mental ill-health. The present paper aims to synthesize published evaluations of the MHFA pro-
gramme in a meta-analysis to estimate its effects and potential as a public mental health awareness-increasing strategy.
Fifteen relevant papers were identifi ed through a systematic literature search. Standardized effect sizes were calculated
for three different outcome measures: change in knowledge, attitudes, and helping behaviours. The results of the meta-
analysis for these outcomes yielded a mean effect size of Glass’s Δ ⫽ 0.56 (95% CI ⫽ 0.38 – 0.74; p ⬍ 0.001), 0.28 (95%
CI ⫽ 0.22 – 0.35; p ⬍ 0.001) and 0.25 (95% CI ⫽ 0.12 – 0.38; p ⬍ 0.001), respectively. Results were homogenous, and
moderator analyses suggested no systematic bias or differences in results related to study design (with or without con-
trol group) or ‘ publication quality ’ (journal impact factor). The results demonstrate that MHFA increases participants ’
knowledge regarding mental health, decreases their negative attitudes, and increases supportive behaviours toward
individuals with mental health problems. The MHFA programme appears recommendable for public health action.
Background
Mental health problems are major contributors to
the global burden of disease, with mental and sub-
stance abuse disorders accounting for 7.4% of the
total disease burden in 2010, as measured by dis-
ability-adjusted life years (DALYs) (Whiteford et al.,
2013). In the European Union (EU) alone, this
number was more than 25% in 2010 for mental and
other brain disorders, which are also the largest con-
tributors to the morbidity burden (Wittchen et al.,
2011). The most frequent mental disorders are
depression, anxiety and substance abuse (Whiteford
et al., 2013). These mental disorders further repre-
sent one of the most important risk factors for sui-
cide, and constitute one of the largest public health
problems in the world (Ferrari et al., 2014).
Although treatment for these disorders exists, only
a minority of individuals experiencing mental health
problems receive it. It has been estimated that in
serious cases of mental disorders alone, only 11% to
62.1% receive treatment over the course of a year
(Wang et al., 2007). There are various putative expla-
nations for this. Individuals with mental health prob-
lems may be unaware that they are experiencing a
diagnosable and treatable condition, or in regions
where professional care is available, they may be
unaware of how it can be accessed. The general public
could be an important asset in these situations. Social
contacts could inform or refer affl icted individuals to
professionals and may even provide actual support
during mental health crises. However, stigmatized atti-
tudes and a general lack of knowledge regarding men-
tal ill-health, including causes, determinants and
treatment options for various illnesses, or how they
might be expressed by affected individuals, constitute
serious obstacles to the prospective benefi ts of social
support (Ahmedani, 2011; Baumann, 2007; Hatzen-
buehler, 2013; Henderson et al., 2013; Kelly et al.,
2007; Rickwood & Thomas, 2012). Thus, it can be
assumed that improving the quality and frequency of
social support may facilitate earlier detection and refer-
ral, which in turn could increase the odds of successful
treatment outcome and reduce individual suffering
(WHO World Mental Health Survey Consortium,
2004; Wang et al., 2005). An important public health
strategy towards a general improvement of the overall
mental health in communities might be widespread
psychoeducation (Dumesnil & Verger, 2009).
International Review of Psychiatry, August 2014; 26(4): 467–475
ISSN 0954– 0261 print/ISSN 1369–1627 online © 2014 Institute of Psychiatry
DOI : 10.3109 /095 40261.2 014.924910
Int Rev Psychiatry Downloaded from informahealthcare.com by Karolinska Institutet University Library on 08/20/14
For personal use only.
468 G. Hadlaczky et al.
Mental Health First Aid
Mental Health First Aid (MHFA) is a standardized
educational programme developed to combat men-
tal health problems and suicide in the general public
by increasing mental health literacy, improving atti-
tudes and stimulating helping behaviours (Kitchener
& Jorm, 2002). The programme was originally devel-
oped and implemented in Australia (Kitchener &
Jorm, 2002) but has since then been adopted in 21
other countries around the world and has been eval-
uated in several studies (e.g. Kitchener & Jorm,
2004; Massey et al., 2010). MHFA strategies are
aimed at the general public, using a similar peda-
gogical approach as in somatic fi rst aid programmes
(e.g. cardiopulmonary resuscitation). One of these
is a fi ve-step action plan for mental health fi rst aid,
which describes how to practically assist individuals
in mental health crises.
The course programme aims to increase partici-
pants ’ knowledge about mental health in general as
well as about common disorders (e.g., depression,
anxiety, psychosis, substance abuse, self-harm, sui-
cidal behaviours) and available treatment options.
Another aim is to reduce stigma surrounding mental
disorders, as negative attitudes have an adverse
impact on supportive and help-seeking behaviours
(Kitchener & Jorm, 2006). By teaching proactive
techniques that can facilitate healthy relations and
communication, MHFA aims to equip the partici-
pant with skills to provide help to a person in distress
or someone who is suicidal. Course participants
learn how to recognize psychological distress and
how to approach and provide help to a person devel-
oping mental health problems or those in a mental
health crisis, until appropriate professional treatment
is received or until the crisis is resolved. The standard
version of the MHFA programme targets mental
problems in the adult population, while another ver-
sion is tailored for adults that come in contact with
young people with mental health problems.
The key messages of MHFA and the contents of
each course module are based on scientifi c evidence,
established through comprehensive literature reviews
or, regarding issues where comprehensive evidence
does not exist, on expert consensus achieved using
the Delphi method (Beehler et al., 2013; Berk et al.,
2011; Clyne et al., 2012; Colucci et al., 2010a, 2010b,
2011; Hart et al., 2009, 2010; Hemmings et al.,
2009; Jorm et al., 2008; Kelly et al., 2008a, 2008b,
2009, 2010; Kingston et al., 2009, 2011; Langlands
et al., 2008a, 2008b; McGinn et al., 2012; McIntyre
et al., 2010; Morgan & Jorm, 2009; Norder et al.,
2012; Reavley et al., 2012, 2013; Ross et al., 2012;
Ryan et al., 2011). For an in depth description of the
MHFA programme, its development and roll-out,
see Kitchener and Jorm (2008).
The MHFA public health intervention is spread
using the cascade principle: a small team of MHFA
trainers, highly experienced in training, deliver a
fi ve-day course for carefully selected individuals,
who are trained to become MHFA instructors. The
selection process emphasizes pedagogical skills and
interest in the topic. Then MHFA instructors deliver
two-day courses open to the general public. The pro-
gramme and all included materials are standardized
to ensure the homogeneity of the delivered informa-
tion. The core of the educational material is the fi rst
aider ’ s manual, which contains all essential parts of
the course content. This is complemented by instruc-
tor guidelines, PowerPoint slides and exercises. On
an international level, the course content is carefully
adapted to each country ’ s specifi c conditions by pro-
fessionals. This adaptation is done in close collabo-
ration with MHFA-Australia in order to ensure that
the standardized educational procedures are fol-
lowed. A literature review by (Kitchener & Jorm,
2006) gives a summary of the results from three
evaluation studies on MHFA, but additional studies
have since been conducted and the results have
never been quantitatively synthesized.
Objectives and hypotheses
The aim of this study is to conduct a meta-analysis
estimating the effects of the MHFA programme,
both for adults and young people, based on results
published up to March 2014 (including non-peer-
reviewed literature) and aims at examining changes
in: (1) mental health literacy, in terms of knowledge
about treatment of common mental health problems
as recommended by mental health professionals,
and recognition of symptoms of mental ill-health,
(2) attitudes towards people suffering from mental
health problems and (3) help-related behaviours
exhibited by participants of the MHFA programme
(i.e. mental health fi rst aiders).
Methods
Identifi cation and selection of studies
PubMed, PsycINFO, Cochrane Library, and Google
Scholar were searched for peer-reviewed articles
related to MHFA interventions carried out at any
point before March 2014. Only papers in the English
or Swedish languages were considered. Search terms
such as ‘ mental health fi rst aid ’ , ‘ MHFA ’ , ‘ mental
health training ’ , ‘ mental health gatekeeper training ’ ,
‘ mental health gatekeeper ’ and ‘ mental health educa-
tion ’ were used, as were different combinations of
those words. References in relevant articles were also
screened for publications of interest. An additional
Int Rev Psychiatry Downloaded from informahealthcare.com by Karolinska Institutet University Library on 08/20/14
For personal use only.
A meta-analysis of the effects of the Mental Health First Aid programme 469
Google search was made to identify possible grey
literature. The aim of this literature search was to
obtain original research reporting outcomes of the
MHFA programme (standard or youth version). It
should be noted that the offi cial length of the pro-
gramme was originally 9 hours and later extended to
12 hours. Both versions were included in the present
meta-analysis.
Studies were included if they met the following
criteria: (1) included the standard MHFA or youth
programme, (2) included the full course programme
(not just a specifi c module), (3) included an evalua-
tion of the programme, (4) the evaluation was quan-
titative, (5) included either the 9- or 12-h programme
and (6) included at least one out of the three out-
come measures used in this meta-analysis (change in
knowledge, attitudes and/or behaviour).
Studies were excluded if they met the following
criteria: (1) included a modifi ed version of MHFA
that was not the standard or the youth version of
MHFA, (2) did not include an evaluation of the
course programme, or (3) presented only qualitative
evaluation data.
Altogether 599 papers were identifi ed, of which 45
met the inclusion criteria on the fi rst round. The
majority of these papers were, however, not evalua-
tions of the MHFA programme but Delphi-consen-
sus papers describing the development of different
parts of the MHFA material. These were excluded.
Two additional evaluations were excluded, one con-
cerning the Internet-based version of MHFA, and
the other on a specifi c eating disorder module.
Another three studies were excluded due to lack of
a pre-test measure or due to missing all three out-
come measures used in this meta-analysis. One paper,
exclusively focused on the description of MHFA, was
also excluded. A total of 15 papers remained after
selection criteria had been applied, and were included
in the present meta-analysis.
Study characteristics
Nine of the fi fteen selected papers described the results
of single-group pre/post studies. The remaining six
reported controlled trials, four of which were random-
ized. In all four randomized control trials, the control
group consisted of participants on a course waiting list.
Five studies involved interim and long-term follow-up
measures, taking place immediately after a course and
six months after course completion. Eight studies
involved long-term follow-up measures between six
weeks to six months and two studies had evaluations
immediately after the course completion but no long-
term follow-up. Four out of the fi fteen studies used
intention-to-treat analysis.
Two of the studies were conducted in Sweden, one
in Canada, and the remaining twelve in Australia, of
which three were early studies that evaluated the 9-h
version of the standard programme. A large propor-
tion of subjects were members of the public partici-
pating in open courses, with varying demographic
characteristics. Nine Australian studies recruited
subjects from more specifi c populations: pharmacy
students, Chinese-speaking individuals, Vietnamese-
speaking individuals, members of multicultural orga-
nizations, employees in government departments
(Health and Ageing, and Family and Community
Services), workers in agricultural-related services,
rural football club leaders, advisory and extension
agents in rural farming communities and high school
teachers. The majority of subjects were female.
Outcome measures
Outcome measures were fairly consistent across
studies. All 15 studies used similar data acquisition
tools and psychometric scales to measure change in
knowledge, attitudes and behaviour. Although most
studies reported a number of different variables for
‘ knowledge ’ , ‘ attitudes ’ and ‘ behaviour ’ outcomes,
most had used at least one common quantitative
measure of each of the three areas. Qualitative inter-
view data were not considered for the present meta-
analysis. The outcome measures selected for this
meta-analysis are as follows:
Knowledge: Data regarding ‘ knowledge ’ were extracted
from two scales then combined for the analysis. The
fi rst scale assessed participants ’ beliefs about effec-
tive treatment methods of common mental health
problems. Participants ’ answers to test questions in
this scale were compared with ‘ correct ’ answers
(obtained through experts ’ consensus in Delphi stud-
ies and systematic reviews). The aim of the question-
naire was to measure the degree of the agreement
between participants ’ answers and the ‘ correct ’
answers, before and after the course. The second
scale was a measure of participants ’ ability to accu-
rately identify a mental health problem experienced
by a person. Background information and symptoms
were described in a vignette.
At least one of these scales was reported in all 15
papers, although the results were sometimes calculated
using different statistical methods. When available,
effect sizes from the two scales were extracted sepa-
rately and pooled through a random effects model.
Attitudes: Data regarding ‘ attitudes
’ were extracted from
studies that had used modifi ed versions of the social
distance scale (Bogardus, 1947). Participants were
asked to read two scenarios: one regarding an individual
suffering from depression, and the other regarding
an individual suffering from schizophrenia. They
were then asked to rate a number of items measuring
Int Rev Psychiatry Downloaded from informahealthcare.com by Karolinska Institutet University Library on 08/20/14
For personal use only.
470 G. Hadlaczky et al.
attitudes towards these individuals. Effect sizes were
extracted for the social distance scale. In papers where
a combined effect size was not reported, this was cal-
culated by extracting data separately for each item
and pooling them through a random effects model.
Behaviour: Behaviour-related changes were measured
by several different items within different studies.
Some items focused on the participant ’ s ‘ confi dence ’
to approach and help a person with mental health
problems, while other items regarded the participant ’ s
‘ intent ’ to do so. The variable selected for this meta-
analysis however, was an item used to measure the
actual number of times when help had been provided
to another person during the time between course
completion and follow-up measures (i.e. between 6
weeks to 6 months). This variable was selected because,
among those available, it was considered to be the
most valid measure of actual behavioural change.
Nine of the fi fteen studies reported these data.
Statistical methods (meta-analyses)
All statistical analyses were made in Meta53 software
(Schwarzer, 1989) and used an alpha level set to
0.05. In studies where t-tests or ANOVA had been
used, standardized effect sizes were extracted using
the method described by Durlak (2009). Odds ratios
were converted to standardized effect sizes using the
method described by Chinn (2000). Effect sizes were
based on the difference between scores obtained at
baseline and the latest follow-up, while interim mea-
sures were ignored.
Although the 15 selected studies involved different
designs (use of control subjects or not), they all used
similar outcome measures and were hence included
in the same primary meta-analysis.
Mixing studies of different designs poses no
statistical problems as long as the methodological
difference itself does not create logical incompara-
bility (Cooper et al., 2009). Nevertheless, two
moderator analyses were carried out to identify
possible systematic biases that may arise from dif-
ferent study designs or study quality. In the fi rst
analysis, studies using a control group were com-
pared with those using a within-subject pre-post
measures design. To assess study quality, papers
published in peer-reviewed journals with an impact
factor higher than 1.28 (i.e. above the median of
the impact factors amongst all the included stud-
ies) were compared with those published in jour-
nals with a lower impact factor, or without peer
review.
A random effects model was used in all analy-
ses, which reduced the effect of large-sample
studies, if there was heterogeneity among effect
sizes in the sample. If studies were homogenous,
studies were weighted similarly to the fixed-effect
model.
Results
Main results
The studies included in the performed analyses are
listed in Table 1.
Table 1. Characteristics of the 15 studies included in the meta-analyses.
Mean sample size used
in analyses (treatment
versus control)
c
Effect size Moderator variables
Study Knowledge Attitudes Behaviours
Control
group
Journal
impact
factor
MHFA
version
Kitchener & Jorm, 2002 210 0.31 0.16 0.18 No 2.23
b Adult
Jorm et al., 2004 753 (416 vs 337) 0.32 0.17 0.17 Yes 2.23
b Adult
Kitchener & Jorm, 2004 301 (146 vs155) 0.22 0.18 0.09 Yes 2.23
b Adult
Sartore et al., 2008 61 0.50 0.71 0.13 No 1.55
b Adult
Hossain et al., 2009 32 1.33 0.28 – No 0.6 Adult
Minas et al., 2009 114 0.75 0.16 – No
a 1.06 Adult
Jorm et al., 2010 327 (221 vs 106) 0.39 0.28 0.20 Yes 2.23
b Youth
Lam et al., 2010 108 0.84 0.42 – No
a 1.06 Adult
Massey et al., 2010 84 (28 vs 56) 1.06 – 0.31 0.72 Yes 0 Adult
Pierce et al., 2010 23 1.13 – – No 1.06 Adult
Kelly et al., 2011 220 0.90 0.43 0.56 No 1.06 Youth
O ’ Reilly et al., 2011 194 (47 vs 147) 0.15 0.55 – Yes 3.29
b Adult
Morawska et al., 2013 402 0.27 0.35 – No 1.29
b Adult & youth
Svensson et al., 2013a 277 (135 vs 142) 0.36 0.20 0.24 Yes 0 Adult
Svensson et al., 2013b 270 0.75 0.18 0.23 No 0 Adult
Mean effect size Glass’s Δ 0.56 0.28 0.25
a The study did not involve long-term follow-up measures.
b Impact factor of the journal in which the study was published exceeds the median value.
c Separate and unequal sample sizes were sometimes reported for different outcomes within the same study. The average sample size is
therefore reported here .
Int Rev Psychiatry Downloaded from informahealthcare.com by Karolinska Institutet University Library on 08/20/14
For personal use only.
A meta-analysis of the effects of the Mental Health First Aid programme 471
Knowledge: The outcome variable for ‘ knowledge ’
included 15 studies (a total sample size of 3807 sub-
jects), with a mean effect size of Glass’s Δ ⫽ 0.56 (95%
confi dence interval (CI) ranged from 0.38 to 0.74),
p ⬍ 0.001. Heterogeneity among the effect sizes was
indicated: Q14 ⫽ 55.03, p ⬍ 0.001. Orwin ’ s fail-safe for
critical d ⫽ 0.20 was 27. (Most but not all studies
reported two separate measures of ‘ knowledge ’ . These
were (a) identifi cation of mental health problems; and
(b) knowledge about effective treatments. The result
reported here is the combined effect size. Mean effect
sizes for the individual measures were 0.63 (n ⫽ 14)
and 0.40 (n ⫽ 13) respectively, both with p ⬍ 0.0001).
Attitudes: The outcome variable for ‘ attitudes ’ included
14 studies (a total sample size of 3,929 subjects) and
had a mean effect size of Glass’s Δ ⫽ 0.28 (95% CI
ranged from 0.22 to 0.35), p ⬍ 0.001. There was no
indication of heterogeneity among the effect sizes:
Q13 ⫽ 16.55, p ⫽ 0.22. Fail-safe for critical d ⫽ 0.20
was 6.
Behaviours: The outcome variable for ‘ behaviour ’
included nine studies (a total sample size of 2,502
subjects), which yielded a mean effect size of Glass’s
Δ ⫽ 0.25 (95% CI ranged from 0.12 to 0.38),
p ⬍ 0.001. There was no indication of heterogeneity
among the effect sizes: Q8 ⫽ 12.24, p ⫽ 0.14. Fail-
safe for critical d ⫽ 0.20 was 2.
Post hoc analyses
Although the observed effect sizes among outcomes
regarding ‘ knowledge ’ were heterogeneous, it should
be noted that all effects in all outcomes were in the
predicted direction. Outcomes for attitudes and
behaviours were homogenous. Nevertheless explor-
ative moderator analyses were performed to investi-
gate how study design or publication ‘ quality ’ may
have affected the results. The results are described in
Table 2.
Moderator analyses compared the effect sizes of
controlled versus uncontrolled studies, and studies
published in journals with high versus low impact
factor (IF). Analyses showed consistently signifi cant
results in all groups for all three outcomes. Effect sizes
for controlled studies were consistently smaller than
for uncontrolled studies in all outcomes, but these
differences were not signifi cant. Effect sizes for lower
IF were also smaller than high IF in ‘ knowledge ’ and
‘ behaviours ’ , but not in ‘ attitudes ’ , where the sample
of high IF publications was signifi cantly heteroge-
neous. IF in the ‘ knowledge ’ outcome was the only
moderator variable for which there was no observed
CI overlap between conditions and thus a signifi cant
difference (Cumming & Finch, 2005).
Discussion
The aim of the present paper was to assess the
effectiveness of the MHFA programme based on pre-
viously reported results using meta-analytic method-
ology. Following a systematic literature search, more
than 590 papers were analysed by three reviewers
independently, and a total of 15 articles were included.
The results indicate that the MHFA programme can
be considered effective in increasing knowledge
regarding mental health problems. The effect is highly
robust and has a moderately high effect size (Glass’s
Δ ⫽ 0.56). Although the studies were not entirely
homogenous, they consistently showed a highly sig-
nifi cant positive effect, but with varying effect sizes.
Table 2. Results of moderator analyses performed for the main outcome variables ‘ attitudes ’ , ‘ knowledge ’ and ‘ behaviours ’ : Controlled/
uncontrolled study design and impact factor (IF) of the journal in which the article was published (above/below median ⫽ 1.28).
Moderator
n ⫽ studies
(subjects)
Glass ’ s
Δ(SE) 95% CI
p-value
(Effects) Q
p-value
(Homogeneity)
Knowledge
Controlled 6 (1875) 0.38 (0.130) 0.13 – 0.64 0.002 10.60 0.060
Uncontrolled 9 (1932) 0.68 (0.109) 0.46 – 0.89 ⬍ 0.001 37.72 ⬍ 0.001
a
IF above 1.28 7 (2644) 0.30 (0.040) 0.22 – 0.37 ⬍ 0.001 2.40 0.879
IF below 1.28 8 (1163) 0.79 (0.091) 0.61 – 0.97 ⬍ 0.001 16.73 0.019
a
Attitudes
Controlled 6 (1998) 0.23 (0.046) 0.14 – 0.32 ⬍ 0.001 5.59 0.348
Uncontrolled 8 (1931) 0.33 (0.046) 0.24 – 0.42 ⬍ 0.001 8.76 0.270
IF above 1.28 7 (2716) 0.31 (0.078) 0.16 – 0.47 ⬍ 0.001 12.80 0.046
a
IF below 1.28 7 (1213) 0.28 (0.058) 0.17 – 0.39 ⬍ 0.001 3.75 0.711
Behaviours
Controlled 5 (1742) 0.24 (0.107) 0.03 – 0.45 0.013 5.84 0.212
Uncontrolled 4 (760) 0.30 (0.087) 0.13 – 0.47 ⬍ 0.001 5.00 0.172
IF above 1.28 5 (1651) 0.16 (0.050) 0.06 – 0.26 0.001 0.64 0.959
IF below 1.28 4 (851) 0.39 (0.112) 0.17 – 0.62 ⬍ 0.001 6.38 0.094
SE, standard error; IF, impact factor.
a Indicates statistically signifi cant (p ⬍ 0.05) heterogeneity amongst the effect sizes within the sample.
Int Rev Psychiatry Downloaded from informahealthcare.com by Karolinska Institutet University Library on 08/20/14
For personal use only.
472 G. Hadlaczky et al.
The moderator analyses suggested no systematic bias
related to study design. Reports that were not peer-
reviewed or were published in journals with a lower
IF were found to report greater effects. The observed
moderate heterogeneity could perhaps be explained by
different scoring procedures of the outcome measures.
An alternative explanation could be that different study
populations had different levels of pre-MHFA knowl-
edge. Populations who knew less about mental health
to begin with, increased their knowledge to a greater
degree.
The analyses also suggest that participating in a
MHFA course effectively decreases negative attitudes
toward individuals suffering from mental health
problems. The observed difference between interven-
tion and control subjects, as well as in pre-post mea-
sures, was highly signifi cant, suggesting a very robust
but moderate effect (Glass’s Δ ⫽ 0.28). Moderator
analyses further suggest that the results are indepen-
dent of study design and quality of publication.
Finally, the results show that the MHFA interven-
tion is effective in increasing help-providing behav-
iour. Unfortunately, the measure of behavioural
change (i.e. the number of times that the fi rst-aider
had helped another person after completing the
course) is biased toward the null hypothesis because
the answer is contingent on the number of opportu-
nities in which help could be given. Therefore, in this
behavioural measure, participants who had not
encountered any situation in which help could be
offered, are assumed to have undergone no behav-
ioural change. For this reason it is likely that the
mean effect size estimated by this meta-analysis
(Glass’s Δ ⫽ 0.25) is an underestimation of the true
effect of MHFA on helping behaviours. Moderator
analyses suggest homogeneity among studies and
that these results are independent of study quality
and design.
In interpreting the utility of the MHFA pro-
gramme based on these results, the reality in which
it is to be implemented should be considered. One
of the greatest public health-related obstacles in sui-
cide prevention is the widespread stigmatization of
mental health problems as well as the taboo sur-
rounding suicide and the lack of knowledge regard-
ing the identifi cation of mental health problems, of
suicidal communication, suicide risk and protective
factors and treatment options (Ahmedani, 2011;
Baumann, 2007; Hatzenbuehler, 2013; Henderson
et al., 2013; Kelly et al., 2007; Rickwood & Thomas,
2012; Wasser man et al., 2012; Wasserman & Wasser-
man, 2009). For example, individuals with mental
health problems are often perceived as incompetent
and dangerous, and the general public often exhibit
an unwillingness to socialize with them (Hinshaw &
Cicchetti, 2000). Individuals with mental health
problems also face extensive discrimination and
marginalization in all aspects of their lives, such as
reduced access to healthcare services (Corrigan,
2004) and employment exclusion (Stuart, 2006).
This can lead to unemployment, poverty and home-
lessness. These prejudices can carry signifi cant
adverse effects on those who are affl icted (McDaid,
2008) by reducing their well-being, self-esteem and
quality of life. Prejudice and discrimination against
individuals with mental health problems also has
adverse effects on intimate relationships (Hinshaw,
2005) and for the families and friends of the affl icted
(Corrigan & Miller, 2004).
These problems are interdependent and may have
several consequences: affl icted individuals may
neglect to seek help until the affl iction becomes
unbearable (and more diffi cult to treat). They may
be more likely to conceal their problems from rela-
tives, friends and co-workers, resulting in reduced
peer-support. Also, affl icted individuals may be less
likely to enter the healthcare system. Due to the lack
of knowledge about mental health problems, parents,
other relatives and peers could misinterpret or com-
pletely fail to notice symptoms of mental ill-health,
and in this way further reduce the affl icted person ’ s
treatment opportunities and perhaps even aggravate
the condition.
The results of this meta-analysis suggest that
MHFA ultimately increases mental health literacy of
the general population. As such, it induces a series
of cascading effects, including improvement in self-
recognition, increased insight into one ’ s own and
others ’ emotional well-being, and enhanced mental
health-related vocabulary, thus also counteracting
stigma. All these effects are expected to lead to
increased coping skills and improved confi dence to
render informed peer support.
Importantly, results indicate not only changes in
knowledge and attitudes, but also changes in the
behaviour of those who attend the training. This is
of major importance because it shows a pragmatic
change in trainees who become more active in sup-
porting those with mental health problems and sui-
cidality.
Considering the estimated effects of the MHFA
programme on knowledge, attitudes and behaviour,
this intervention programme seems to be a promising
public health tool for tackling stigma and taboo sur-
rounding people with mental disorders and suicidal-
ity. An important question that remains unanswered,
and perhaps one that is a valid focus of future stud-
ies, is how MHFA actually improves the mental
health of the general public.
Acknowledgements
We would like to thank Jerzy Wasserman for critically
revising the manuscript for important intellectual
Int Rev Psychiatry Downloaded from informahealthcare.com by Karolinska Institutet University Library on 08/20/14
For personal use only.
A meta-analysis of the effects of the Mental Health First Aid programme 473
content, as well as Maria Anna Di Lucca for statisti-
cal consultation.
Declaration of interest: The preparation of the
manuscript was funded solely through the Swedish
National Centre for Suicide Research and Preven-
tion of Mental Ill-Health (NASP) personnel salaries,
acquired from Karolinska Institutet (V.C., D.W.),
and Stockholm County Council (G.H., S.H., A.M.).
Articles included in the analyses were downloaded
via the Karolinska Institutet electronic library. The
institution of the authors, NASP, also constitutes the
scientifi c and educational basis for MHFA in
Sweden. The authors alone are responsible for the
content and writing of the paper.
References
Ahmedani , B . (2011) . Mental health stigma: Society, individuals, and
the profession . Jour nal of Social Work Values and Ethics , 8 , 1 – 14 .
Baumann , A.E . (2007) . Stigmatization, social distance and
exclusion because of mental illness: The individual with
mental illness as a ‘ stranger. ’ International Review of Psychiatry,
19 , 131 – 135 .
Beehler , G.P. , Funderburk , J.S. , Possemato , K. & Vair , C.L .
(2013) . Developing a measure of provider adherence to improve
the implementation of behavioral health services in primary
care: A Delphi study . Implementation Science , 8 , 19 .
Berk , L. , Jorm , A.F. , Kelly , C.M. , Dodd , S. & Berk , M . (2011) .
Development of guidelines for caregivers of people with bipolar
disorder: A Delphi expert consensus study . Bipolar Disorders , 13 ,
556 – 570 .
Bogardus , E.S . (1947) . Measurement of personal – group relations .
Sociometr y , 10 , 306 – 311 .
Chinn , S . (2000) . A simple method for converting an odds ratio
to effect size for use in meta-analysis . Statistics in Medicine , 19 ,
3127 – 3131 .
Clyne , W. , White , S. & McLachlan , S . (2012) . Developing
consensus-based policy solutions for medicines adherence
for Europe: A Delphi study . BMC Health Services Research ,
12 , 425 .
Colucci , E. , Kelly , C.M. , Minas , H. , Jorm ,
A.F. & Chatterjee , S .
(2010a) . Mental Health First Aid guidelines for helping a sui-
cidal person: A Delphi consensus study in India . Inter national
Journal of Mental Health Systems , 4 , 4 .
Colucci , E. , Kelly , C.M. , Minas , H. , Jorm , A.F. & Nadera , D .
(2010b) . Mental Health First Aid guidelines for helping a sui-
cidal person: A Delphi consensus study in the Philippines . Inter-
national Journal of Mental Health Systems , 4 , 32 .
Colucci , E. , Kelly , C.M. , Minas , H. , Jorm , A.F. & Suzuki , Y .
(2011) . Mental Health First Aid guidelines for helping a sui-
cidal person: A Delphi consensus study in Japan . International
Journal of Mental Health Systems , 5 , 12 .
Cooper , H. , Hedges , L. & Valentine , J . (2009) . Handbook of
Research Synthesis and Meta-Analysis (2nd ed.) . New York: Rus-
sell Sage Foundation .
Corrigan , P . (2004) . How stigma interferes with mental health
care . Amer ican Psychologist , 59 , 614 – 625 .
Corrigan , P. W. & Miller , F.E . (2004) . Shame, blame, and con-
tamination: A review of the impact of mental illness stigma on
family members . Journal of Mental Health , 13 , 537 – 548 .
Cumming , G. & Finch , S . (2005) . Inference by eye: Confi dence
intervals and how to read pictures of data . American Psycholo-
gist , 60 , 170 – 180 .
Dumesnil , H. & Verger , P . (2009) . Public awareness campaigns
about depression and suicide: A review . Psychiatric Services ,
60 (9) , 1203 – 1213 .
Durlak , J.A . (2009) . How to select, calculate, and interpret effect
sizes . Journal of Pediatric Psychology , 34 , 917 – 928 .
Ferrari , A.J. , Norman , R.E. , Freedman , G. , Baxter , A.J. , Pirkis ,
J.E. , Harris , M.G. , … Whiteford , H.A . (2014) . The burden
attributable to mental and substance use disorders as risk fac-
tors for suicide: Findings from the global burden of disease
study 2010 . PLOS ONE , 9 (4) , e91936 .
Hart , L.M. , Bourchier , S.J.
, Jorm , A.F. , Kanowski , L.G. , King-
ston , A.H. , Stanley , D. & Lubman , D.I . (2010) . Development
of mental health fi rst aid guidelines for Aboriginal and Torres
Strait Islander people experiencing problems with substance
use: A Delphi study . BMC Psychiatry , 10 , 78 .
Hart , L.M. , Jorm , A.F. , Kanowski , L.G. , Kelly , C.M. & Lang-
lands , R.L . (2009) . Mental health fi rst aid for Indigenous Aus-
tralians: Using Delphi consensus studies to develop guidelines
for culturally appropriate responses to mental health problems .
BMC Psychiatry , 9 , 47 .
Hatzenbuehler , M . (2013) . Stigma as a fundamental cause of
population health inequalities . American Journal of Public Health ,
103 (5) , 813 – 821 .
Hemmings , C.P. , Underwood , L.A. & Bouras , N . (2009) . Services
in the community for adults with psychosis and intellectual
disabilities: A Delphi consultation of professionals ’ views . Jour-
nal of Intellectual Disability Research , 53 , 677 – 684 .
Henderson , C. , Evans-Lacko , S. & Thornicroft , G . (2013) . Men-
tal illness stigma, help seeking, and public health programs .
American Journal of Public Health , 103 , 777 – 780 .
Hinshaw , S.P . (2005) . The stigmatization of mental illness in chil-
dren and parents: Developmental issues, family concerns, and
research needs . Journal of Child Psychology and Psychiatr y , 46 ,
714 – 734 .
Hinshaw , S.P. & Cicchetti , D . (2000) . Stigma and mental disorder:
Conceptions of illness, public attitudes, personal disclosure,
and social policy . Development and Psychopathology , 12 ,
555 – 598 .
Hossain , D. , Gorman , D. & Eley , R . (2009) . Enhancing the knowl-
edge and skills of Advisory and Extension Agents in mental
health issues of farmers . Australasian Psychiatry , 17 , S116 –
120 .
Jorm , A.F. , Kitchener , K.A. , O ’ Kearney , R. & Dear , K.B.G .
(2004) . Mental health fi rst aid training of the public in a rural
area: A cluster randomized trial [ISRCTN53887541] . BMC
Psychiatry , 4 , 33 .
Jorm , A.F. , Kitchener , K.A. , Sawyer , M.G. , Scales , H. & Cvetko-
vski , S . (2010) . Mental health fi rst aid training for high school
teachers: A cluster randomized trial . BMC Psychiatry , 10 , 51 .
Jorm , A.F. , Minas , H. , Langlands , R.L. & Kelly , C.M . (2008) . First
aid guidelines for psychosis in Asian countries: A Delphi consen-
sus study . Inter national Journal of Mental Health Systems , 2 , 2 .
Kelly , C. , Jorm , A. & Wright , A . (2007) . Improving mental health
literacy as a strategy to facilitate early intervention for mental
disorders . Medical Jour nal of Australia , 187 (Suppl.7), S26 – 30 .
Kelly , C.M. , Jorm , A.F. & Kitchener , B.A . (2009) . Development
of mental health fi rst aid guidelines for panic attacks: A Delphi
study . BMC Psychiatry , 9 , 49 .
Kelly , C.M. , Jorm , A.F. & Kitchener , B.A . (2010) . Development
of mental health fi rst aid guidelines on how a member of the
public can support a person affected by a traumatic event: A
Delphi study . BMC Psychiatr y , 10 , 49 .
Kelly , C.M. , Jorm , A.F. , Kitchener , B.A. & Langlands , R.L .
(2008a) . Development of mental health fi rst aid guidelines for
deliberate non-suicidal self-injury: A Delphi study . BMC Psy-
chiatry , 8 , 62 .
Kelly , C.M. , Jorm , A.F. , Kitchener , B.A. & Langlands , R.L .
(2008b) . Development of mental health fi rst aid guidelines for
Int Rev Psychiatry Downloaded from informahealthcare.com by Karolinska Institutet University Library on 08/20/14
For personal use only.
474 G. Hadlaczky et al.
suicidal ideation and behaviour: A Delphi study . BMC Psychia-
try , 8 , 17 .
Kelly , C.M. , Mithen , J.M. , Fischer , J.A. , Kitchener , B.A. , Jorm ,
A.F. , Lowe , A. & Scanlan , C . (2011) . Youth mental health fi rst
aid: A description of the program and an initial evaluation .
Inter national Journal of Mental Health Systems , 5 , 4 .
Kingston , A.H. , Jorm , A.F. , Kitchener , B.A , Hides , L. , Kelly ,
C.M. , Morgan , A.J. , … Lubman , D.I . (2009) . Helping someone
with problem drinking: Mental health fi rst aid guidelines – A
Delphi expert consensus study . BMC Psychiatry
, 9 , 79 .
Kingston , A.H. , Morgan , A.J. , Jorm , A.F. , Hall , K. , Hart , L.M. ,
Kelly , C.M. & Lubman , D.I . (2011) . Helping someone with
problem drug use: A Delphi consensus study of consumers,
carers, and clinicians . BMC Psychiatry , 11 , 3 .
Kitchener , B.A. & Jorm , A.F . (2002) . Mental health fi rst aid train-
ing for the public: Evaluation of effects on knowledge, attitudes
and helping behavior . BMC Psychiatry , 2 , 10 .
Kitchener , B.A. & Jorm , A.F . (2004) . Mental health fi rst aid train-
ing in a workplace setting: A randomized controlled trial
[ISRCTN13249129] . BMC Psychiatr y , 4 , 23 .
Kitchener , B.A. & Jorm , A.F . (2006) . Mental health fi rst aid train-
ing: Review of evaluation studies . Australian and New Zealand
Journal of Psychiatry , 40 , 6 – 8 .
Kitchener , B.A. & Jorm , A.F . (2008) . Mental Health First Aid: An
international programme for early intervention . Early Interven-
tion in Psychiatry , 2 , 55 – 61 .
Lam , A.Y.K. , Jorm , A.F. & Wong , D.F.K . (2010) . Mental health
fi rst aid training for the Chinese community in Melbourne,
Australia: Effects on knowledge about and attitudes toward
people with mental illness . International Journal of Mental Health
Systems , 4 , 18 .
Langlands , R.L. , Jorm , A.F. , Kelly , C.M. & Kitchener , B.A .
(2008a) . First aid for depression: A Delphi consensus study
with consumers, carers and clinicians . Journal of Affective Dis-
orders , 105 , 157 – 165 .
Langlands , R.L. , Jorm , A.F. , Kelly , C.M. & Kitchener , B.A .
(2008b) . First aid recommendations for psychosis: Using the
Delphi method to gain consensus between mental health
consumers, carers, and clinicians . Schizophrenia Bulletin , 34 ,
435 – 443 .
Massey , J. , Brooks , M. , Burrow , J. & Sutherland , C . (2010) . Increas-
ing mental health literacy among student affairs staff : Assessing
‘ Mental Health First Aid ’ . Retrieved from http://www.mental
healthfirstaid.ca/EN/about/Documents/Increasing%
20Mental%20Health%20Literacy%20among%20Student%
20Affairs%20Staff,%20Assessing%20Mental%20Health%20
First%20Aid,%20Queens%20University.pdf
McDaid , D . (2008) . Countering the stigmatisation and discrimi-
nation of people with mental health problems in Europe . Euro-
pean Commission. Retrieved from http://sid.usal.es/idocs/F8/
FDO23165/estigma_enfer_mental.pdf
McGinn , C.A. , Gagnon , M.-P. , Shaw , N. , Sicotte , C. , Mathieu ,
L. , Leduc , Y. , … L é gar é , F . (2012) . Users ’ perspectives of key
factors to implementing electronic health records in Canada: A
Delphi study . BMC Medical Informatics and Decision Making ,
12 , 105 .
McIntyre , S. , Novak , I. & Cusick , A . (2010) . Consensus research
priorities for cerebral palsy: A Delphi survey of consumers,
researchers, and clinicians . Developmental Medicine and Child
Neurology , 52 , 270 – 275 .
Minas , H. , Colucci , E. & Jorm , A.F . (2009) . Evaluation of mental
health fi rst aid training with members of the Vietnamese com-
munity in Melbourne, Australia . Inter national Journal of Mental
Health Systems , 3 , 19 .
Morawska , A. , Fletcher , R. , Pope , S. , Heathwood , E. , Anderson ,
E. & McAuliffe , C . (2013) . Evaluation of mental health fi rst aid
training in a diverse community setting . International Journal of
Mental Health Nursing , 22 , 85 – 92 .
Morgan , A.J. & Jorm , A.F . (2009) . Self-help strategies that are
helpful for sub-threshold depression: A Delphi consensus study .
Journal of Affective Disorders , 115 , 196 – 200 .
Norder , G. , Roelen , C.A.M. , van Rhenen , W. , Buitenhuis , J. , B ü lt-
mann , U. & Anema , J.R . (2012) . Predictors of recurrent sick-
ness absence due to depressive disorders – A Delphi approach
involving scientists and physicians . PLOS ONE , 7 (12) ,
e51792 .
Reavley , N.J. , Ross , A. , Killackey , E.J. & Jorm , A.F . (2012) . Devel-
opment of guidelines to assist organisations to support employ-
ees returning to work after an episode of anxiety, depression or
a related disorder: A Delphi consensus study with Australian
professionals and consumers . BMC Psychiatry , 12 , 135 .
Reavley , N.J. , Ross , A.M. , Killackey , E. & Jorm , A.F . (2013) .
Development of guidelines for tertiary education institutions to
assist them in supporting students with a mental illness: A Del-
phi consensus study with Australian professionals and consum-
ers . PeerJ , 1 , e43 .
Rickwood , D. & Thomas , K . (2012) . Conceptual measurement
framework for help-seeking for mental health problems . Psy-
chology Research and Behavior Management , 5 , 173 – 183 .
Pierce , D. , Liaw , S.-T. , Dobell , J. & Anderson , R . (2010) . Austral-
ian rural football club leaders as mental health advocates: An
investigation of the impact of the Coach the Coach project .
Inter national Journal of Mental Health Systems , 4 , 10 .
Ross , A.M. , Hart , L.M. , Jorm , A.F. , Kelly , C.M. & Kitchener , B.A .
(2012) . Development of key messages for adolescents on pro-
viding basic mental health fi rst aid to peers: A Delphi consensus
study . Early Intervention in Psychiatry , 6 , 229 – 238 .
Ryan , S.M. , Jorm , A.F. , Kelly , C.M. , Hart , L.M. , Morgan , A.J. &
Lubman , D.I . (2011) . Parenting strategies for reducing adoles-
cent alcohol use: A Delphi consensus study . BMC Public Health ,
11 , 13 .
Sartore , G.-M. , Kelly , B. , Stain , H. J. , Fuller , J. , Fragar , L. &
Tonna , A . (2008) . Improving mental health capacity in rural
communities: Mental health fi rst aid delivery in drought-
affected rural New South Wales . Australian Journal of Rural
Health , 16 , 313 – 318 .
Schwarzer , R . (1989) . Meta: Meta-analysis Programs, Version 5.3 .
Raleigh, NC: National Collegiate Software Clearinghouse .
Stuart , H . (2006) . Mental illness and employment discrimination .
Current Opinion in Psychiatry , 19 , 522 – 526 .
Svensson , B. , Stjernsw ä rd , S. & Hansson , L . (2013a) . UTBILDN-
ING I F Ö RSTA HJ Ä LPEN VID PSYKISK OH Ä LSA. En
effektstudie i tv å l ä n. [Mental Health First Aid education. An
evaluation study in two counties] . Socialstyrelsen. Retrieved from
http://www.socialstyrelsen.se/nyheter/2013februari/Documents/
Utbildning-i-forsta-hjalpen-vid-psykisk-ohalsa.pdf. Pg. 15 – 17
Svensson , B. , Stjernsw ä rd , S. & Hansson , L . (2013b) . UTBILDN-
ING I F Ö RSTA HJ Ä LPEN VID PSYKISK OH Ä LSA. En
effektstudie i tv å l ä n. [Mental Health First Aid education. An
evaluation study in two counties] . Socialstyrelsen. Retrieved from
http://www.socialstyrelsen.se/nyheter/2013februari/Documents/
Utbildning-i-forsta-hjalpen-vid-psykisk-ohalsa.pdf. Pg. 17 – 19
Wang , P.S. , Aguilar-Gaxiola , S. , Alonso , J. , Angermeyer , M.C. ,
Borges , G. , Bromet , E.J. , … Wells , J.E . (2007) . Worldwide
use of mental health services for anxiety, mood, and sub-
stance disorders: Results from 17 countries in the WHO
World Mental Health (WMH) Surveys . Lancet , 370 (9590) ,
841 – 850 .
Wang , P.S. , Berglund , P. , Olfson , M. , Pincus , H.A. , Wells , K.B.
& Kessler , R.C . (2005) . Failure and delay in initial treatment
contact after fi rst onset of mental disorders in the National
Comorbidity Survey Replication . Archives of General Psychia-
try , 62 , 603 – 613 .
Wasserman, D., Rihmer, Z., Rujescu, D., Sarchiapone, M.,
Sokolowski, M., Titelman, D., ¼ European Psychiatric Asso-
ciation . (2012) . The European Psychiatric Association (EPA)
Int Rev Psychiatry Downloaded from informahealthcare.com by Karolinska Institutet University Library on 08/20/14
For personal use only.
A meta-analysis of the effects of the Mental Health First Aid programme 475
guidance on suicide treatment and prevention . European Psy-
chiatry , 27 , 129 – 141 .
Wasserman , D. & Wasserman , C. (Eds.) (2009) . Oxford Textbook
of Suicidology and Suicide Prevention: A Global Perspective . Oxford:
Oxford University Press .
Whiteford , H.A , Degenhardt , L. , Rehm , J. , Baxter , A.J. , Ferrari ,
A.J. , Erskine , H.E. , … Vos , T . (2013) . Global burden of disease
attributable to mental and substance use disorders: Findings
from the Global Burden of Disease Study 2010 . Lancet ,
382 (9904) , 1575 – 1586 .
WHO World Mental Health Survey Consortium . (2004) . Prev-
alence, severity, and unmet need for treatment of mental dis-
orders in the World Health Organization World Mental Health
Surveys . Journal of the American Medical Association , 291 ,
2581 – 2590 .
Wittchen , H.U. , Jacobi , F. , Rehm , J. , Gustavsson , A. , Svensson ,
M. , J ö nsson , B. , … Steinhausen , H.-C . (2011) . The size and
burden of mental disorders and other disorders of the brain
in Europe 2010 . European Neuropsychophar macology , 21 ,
655 – 679 .
Int Rev Psychiatry Downloaded from informahealthcare.com by Karolinska Institutet University Library on 08/20/14
For personal use only.
