Mental health literacy among Internet users

Original Article

Mental health literacy among Internet usersElizabeth Lawlor,1 John G. Breslin,4 Laoise Renwick,1 Sharon Foley,1 Una Mulkerrin,1

Anthony Kinsella,1 Niall Turner1 and Eadbhard O’Callaghan1–3

1DETECT Early Intervention in PsychosisService, 3Department of Adult Psychiatry,Hospitaller Order of St. John of God,Blackrock, Co Dublin, 2Department ofPsychiatry, University College Dublin,Dublin, and 4Digital Enterprise ResearchInstitute and the Department ofElectronic Engineering, NationalUniversity of Ireland, Galway, Ireland

Corresponding author: Ms ElizabethLawlor, Principal Clinical Psychologist,DETECT Early Intervention in PsychosisService, Avila House, Block 5, BlackrockBusiness Park, Carysfort Avenue,Blackrock, Co Dublin, Ireland. Email:[email protected]

Authors’ contributions: EL, LR, SF, NT andEOC participated in the design of thestudy and the online questionnaire. JBand UM collated the onlinequestionnaire. EL, UM NT and EOCcompleted the initial statistical analysisand draft manuscript. AK conducted thesubsequent statistical analysis. All authorsread and approved the final manuscript.

Received 21 March 2008; accepted 14July 2008

Abstract

Background: Intervening early inthe course of psychotic illness mayimprove the long-term outcome.Early intervention requires early rec-ognition, and one factor that influ-ences early recognition is the level ofmental health literacy (MHL) in thepopulation.

Aim: To investigate the level of MHLregarding depression and psychosisin an Irish population.

Method: We invited the registeredusers of Ireland’s most popular com-munity website (http://www.boards.ie) to participate in an online survey.Two standardized vignettes depictingdepression and psychosis were pre-sented, and respondents were askedabout what they thought the condi-tions were and who might be bestplaced to help the person. Parti-cipants were asked a series of

knowledge-based questions aboutpsychosis.

Results: Nine hundred and ninety-eight (770 males, 228 females) peopleparticipated. Using a case vignettemodel, 78% and 93% of respondentscorrectly identified depression andpsychosis/schizophrenia, respecti-vely. However, half of the participantsdescribed schizophrenia as a ‘splitpersonality disorder’. Neither age norurbanicity influenced the probabilityof correctly identifying the diagnosis,but females and university studentswere more likely to correctly identifythe diagnosis. More than 90%believed intervening early in psycho-sis is likely to improve outcome.

Conclusion: The Internet users inthis survey have high levels of MHL,identify appropriate pathways to care,and their views on managementare consistent with evidence-basedtreatments.

Key words: depression, Internet survey, mental health literacy, psycho-sis, schizophrenia.

INTRODUCTION

Recent research findings confirm that the durationof untreated psychosis is associated with the short-and midterm outcome of schizophrenia.1,2 Con-sequently, several countries have initiated earlydetection and intervention programmes for schizo-phrenia and other psychotic disorders.3,4 One factorthat may influence the efficacy of early detectionprogrammes is the population level of mentalhealth literacy (MHL).5 The term ‘mental healthliteracy’ was defined by Jorm and colleagues as‘knowledge and beliefs about mental disorderswhich aid their recognition, management or pre-vention’.6 Inherent in the notion of early interven-

tion is adequate public knowledge regarding mentalillness, which ensures that symptoms are recog-nized, help is sought from the appropriate party,and the appropriate treatment is undertaken andadhered to. A lack of appropriate knowledge regard-ing mental illness probably acts as a potentialbarrier to both early and appropriate interventions.7

Despite its importance, there are relatively fewEuropean studies of MHL. A recent online survey byLauber and colleagues reported wide variability inliteracy levels particularly among males.8 This Swissstudy was restricted to university students and sug-gested that the general population may have lesscapacity to recognize mental illness. The incidenceof mental disorders peaks in late adolescence and

Early Intervention in Psychiatry 2008; 2: 247–255 doi:10.1111/j.1751-7893.2008.00085.x

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Asia Pty Ltd

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mailto:[email protected]

http://www.boards.ie


early adulthood: age groups that use the Internetextensively. Consequently, we surveyed MHL inIreland among Internet users. We chose the Internetmethodology because it allows access to largesample sizes and is a medium which is increasinglybeing used as a source for health information. Weset out to assess (i) people’s ability to recognizeclinically defined depression and psychosis (ii) whothey believed would help an individual with theseproblems and how helpful they might be (iii) spe-cifically for psychosis, peoples’ knowledge aboutsymptoms, treatment and recovery, and (iv) becauseprevious literature has varyingly identified age,gender, occupation and urbanicity as influencingMHL, we sought to determine their influence onMHL.9–12

METHODS

Boards.ie (http://www.boards.ie) is Ireland’s largestInternet forum with more than 75 000 registeredusers (Table 1). All individuals (1 306 041) whoaccessed the website between October 2006 andDecember 2006 were shown a link to the question-naire, and participants who chose to enter wereredirected to the appropriate webpage. As a gestureof appreciation for taking part, those who com-

pleted the questionnaire were entered into a drawfor an Apple iPod. There were no national mentalhealth promotion campaigns running at the time ofthe study.

Demographic information relating to age (dividedinto nine categories: <15, 15–19, 20–25, 25–29,30–34, 35–39, 40–44, 45–49 and >50), gender andnationality (Irish, other EU and non-EU) was com-piled. We asked the participants if they were attend-ing school, unemployed, attending a university/equivalent or employed. If the person choseemployed, we provided a free text to specify thenature of employment. We also asked if people clas-sified themselves as living in a city, a suburb or arural setting. We combined city and suburban dwell-ers to form an urban–rural variable for subsequentanalyses.

The questionnaire comprised two sections(Appendix 1). The first section comprised of twovignettes adapted from those developed by Wrightand colleagues.12 The first vignette depicted a20-year-old woman with symptoms of depression.The second depicted a 24-year-old man with symp-toms of psychosis. After each vignette, we asked therespondent to choose a response from a series ofoptions (Appendix 1). To examine help seeking, weasked a further question inquiring who they wouldadvise the person in the vignette to seek help from.The third question asked the participants to ratehow helpful they believed various people/serviceswould be in relation to that particular vignette.Multiple responses were possible for the latter twoquestions. For the purposes of this research, onlysingle (and first in the case of those suggesting morethan one form of help) responses were included foranalyses.

The second section comprised multiple-choicequestions, with nine questions (three possibleanswers, one of which was correct) asking about thedefinition and rates of psychosis, symptoms andsigns, risk factors, treatments, stigma, and prognosis.

Data were analysed using appropriate non-parametric statistics including chi-square test andMann–Whitney U-test.

RESULTS

Nine hundred and ninety-eight participantsresponded to the questionnaire, yielding a partici-pation rate of 0.076%. Table 1 illustrates the charac-teristics of the survey sample compared with a 2005census survey of users of the website. The partici-pants in this study were significantly more likely tobe female and aged between 15 and 34 years.

TABLE 1. Comparison between the characteristics of the surveysample and a 2005 census survey of www.boards.ie website users

Sample% (n)

Boards census% (n)

Age P = 0.02*<24 43.68 (436) 87.5 (15–34)25–34 40.58 (405)35–49 13.92 (139)>50 1.8 (18)

OccupationSchool 6.9 (69) No dataUniversity 23.5 (235)Employed 62.8 (627)Unemployed 6.7 (67)

Gender P = 0.001Male 77.2 (770) 84 (1550)Female 22.8 (228) 16 (295)

DwellingUrban 82 (818) No dataRural 18 (180)

Nationality P = 0.13Irish 92.5 (923) 94 (1734)Non-Irish 7.5 (75) 6 (111)

*Combination of <24 and 25–34 categories in the sample versus censussample of 15–34.

Mental health literacy among Internet users

248 © 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Asia Pty Ltd



Recognizing depression and psychosis

Almost 80% (78%) of the participants correctlyidentified the problem in the vignette depictingdepression. In the vignette depicting psychosis/schizophrenia, 93% reported the individual ashaving psychosis or schizophrenia. On both occa-sions, 75% were correct. Females were significantlymore likely to recognize depression (192/228 vs.586/770, P = 0.01) than males, but not more likely torecognize psychosis (216/228 vs. 713/770, P = 0.30).Table 2 illustrates the percentage of people, classi-fied by age group, who correctly identified theproblem in each vignette. There was no significantrelationship between age and recognition of depres-sion (Mann-Whitney U, z = -1.21, P = 0.2) or psy-chosis (Mann-Whitney U, z = -0.6, P = 0.5). Therewas no gender by age interaction.

Education and employment

For the 304 people who said they were in schoolor university, those attending university or equiva-lent better recognized depression (depression:48/69 vs. 198/235, P = 0.006) but not psychosis/schizophrenia (62/69 vs. 220/235, P = 0.30). Eightyper cent of those attending university correctlyidentified conditions in both vignettes, whereas63.8% of school students were correct on both occa-sions (188/235 vs. 44/69, Fishers exact, P = 0.01).Those employed were no more likely to recognizedepression (583/627 vs. 64/67, P = 0.47) or psy-chosis (485/627 vs. 47/67, P = 0.22) than thoseunemployed.

Urbanicity

There was no significant difference between urbanand rural dwellers with regard to recognition ofdepression (79.8% vs. 78.9%; P = 0.77) or psychosis(93.3% vs. 92.2%; P = 0.63).

Help seeking

For depression, 53% of the respondents said that ifthe individual depicted in the vignette were theirsibling, they would suggest they seek help from theirGeneral Practitioner (GP). The second most popularform of help chosen was family or friends (9%), fol-lowed by a counsellor, which was chosen by 5% ofthe respondents. For psychosis, 49% of the respon-dents claimed that they would suggest that theirsibling seek help from their GP, while 28% suggesteda psychiatrist and 7% favoured a psychologist.

Understanding of psychosis

Definition of psychosis

When asked to choose from three possible defini-tions of psychosis, 96% of the respondents correctlyidentified the definition as being ‘when a person hasdifficulty distinguishing between what is real andnot real’. Only 3% of the respondents misidentifiedpsychosis as not being a type of mental illness, with1% believing that psychosis most frequently occursamong people over 40 years old.

Prevalence rates for psychosis

Thirty-seven per cent of the respondents correctlyidentified the total number of the cases of psychosisin Ireland as 82 000, 43% incorrectly asserted thatthe total number of the cases is 34 000, and 19%believed it to be only 10 000.

Schizophrenia as a form of psychosis

In terms of schizophrenia’s relationship with psy-chosis, only 47% correctly identified it as the mostcommon type of psychosis, and 51% of the respon-dents incorrectly described schizophrenia as a ‘split

TABLE 2. Percentages of male and female respondents who recognized depression and psychosis across the age groups

Age group(years)

Correct recognition:depression,

n (%)

Malen (%)

Femalen (%)

Correct recognition:psychosis (includingschizophrenia), n (%)

Malen (%)

Femalen (%)

<15 9 (75) 7 (70) 2 (100) 10 (83.3) 8 (80) 2 (100)15–19 107 (75.4) 81 (75) 26 (76.5) 131 (92.3) 101 (93.5) 30 (88.2)20–24 220 (78) 156 (74.3) 64 (88.9) 266 (94.3) 197 (93.8) 69 (95.8)25–29 180 (75.9) 128 (72.3) 52 (86.7) 217 (91.7) 160 (90.4) 57 (95)30–34 135 (80.4) 109 (81.3) 26 (76.5) 154 (91.7) 122 (91) 32 (94.1)35–39 61 (79.2) 50 (79.4) 11 (78.6) 76 (98.7) 62 (98.4) 14 (100)40–49 52 (83.9) 44 (83) 8 (88.9) 59 (95.2) 50 (94.3) 9 (100)>50 14 (77.8) 11 (73.3) 3 (100) 16 (88.9) 13 (86.7) 3 (100)

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personality disorder’. The notion that ‘schizophre-nia is an incurable condition’ was supported by 3%of the respondents.

Causes of psychosis

In terms of potential causes of psychosis, 83% of therespondents correctly acknowledged that psychosiscan be caused by cannabis. The view that psychosisis purely hereditary was supported by 15% of therespondents, while only 2% believed psychosis to bea result of poor parenting.

Hallucinations

When given three possible explanations of halluci-nations, 98% of the respondents correctly identifiedthem as ‘hearing, seeing, tasting, smelling or feelingthings that are not there’. The notion that hallucina-tions are bizarre, firmly held beliefs was endorsed byonly 1% of the respondents.

Delusions

The respondents were presented with three defini-tions of delusions; 71% identified the correct defini-tion of delusions as being ‘false, fixed beliefs that areunshakeable’, while 25% of the respondents incor-rectly associated them with hearing voices whennobody is around. Only 5% supported the statementthat delusions can easily be challenged by others.

Prognosis in psychosis

In relation to prognosis, 93% of the respondentsidentified the benefits of early intervention for psy-chosis, agreeing with the statement ‘people withpsychosis recover quicker if treated sooner’; 3%believed that ‘people with psychosis rarely recover’,with 5% supporting the assertion that ‘people withpsychosis are violent’.

Helpfulness rating of anti-psychotic medication fortreatment of psychosis

Ninety-one per cent of the respondents correctlyidentified anti-psychotic medication as importantfor preventing relapse in psychosis, and 6% of theparticipants incorrectly labelled anti-psychotics asbeing addictive, while 3% wrongly asserted that theycould be bought over the counter or in health foodstores.

Other useful treatments for psychosis

When asked to choose from three possibleadjunctive treatments for psychosis, 87% of the

respondents chose cognitive–behavioural therapyas a useful treatment, while 9% chose hypnotherapy.Psychosurgery was opted for by 3% of therespondents.

DISCUSSION

This Internet survey of a sample of almost 1000registered users of Ireland’s largest Internet forumindicates that most participants correctly identifydepression and psychosis from case vignettes. Mostrespondents described appropriate help-seekingbehaviours. Additionally, the level of knowledgeabout risk factors, symptoms and treatment ofpsychosis was high, with the notable exception thathalf the sample considers schizophrenia as a splitpersonality.

Studies that have examined knowledge aboutmental illness, particularly MHL regarding depres-sion and psychosis, report conflicting results.6,11–16

For example, in a study of the general population inPakistan, only 19% of the public recognized depres-sion, and 5% correctly identified psychosis.11 Incontrast, in a recent Australian study, almost halfthe respondents correctly identified depression,while only a quarter identified psychosis correctly.12

Lauber and colleagues reported recognition rates of40% for depression and 74% for psychosis among844 people in Switzerland.8 We found recognitionrates for depression similar to the Australian studybut much higher recognition rates for psychosis/schizophrenia than these previous studies.

One possible explanation for the high recognitionrates in the present study was that we used Internet-mediated research. Although using the Internet isassociated with advantages including anonymityand candidness, there are also potential limita-tions.10,17 Respondents could theoretically seek theanswers to questions on alternative websites or inbooks while completing the questionnaire, and theuse of an incentive could motivate people to do this.However, the incentive was for those who partici-pated, not for those who got correct answers.Furthermore, we did not allow people to save orprogress without completing the entire question-naire or save a partially completed questionnaire,thus avoiding ‘resourceful intervals’. However, we donot have information about those who started thesurvey but did not complete it.

This sample was not representative of either theusers of the website or indeed the Irish generalpopulation with a predominance of younger agegroups, males and the highly educated, and sothe results cannot be generalized to the general



population. Additionally, we did not apply arigorous definition of urbanicity, leaving it to theparticipant to classify themselves, which may beunreliable. Using vignettes, although popular, haslimitations because it focuses on the disorder ratherthan specific mental symptoms.7–9,11,12 We partiallyaddressed this by supplementing the vignette strat-egy with a series of questions about symptoms in amultiple-choice format.

Studies from Australia and Switzerland indicatethat females are better at recognizing depression ina vignette and the symptoms of depression, respec-tively.9,10 Similarly, our study found that womenwere better at recognizing depression from avignette than their male counterparts. Females wereno more likely to recognize psychosis than theirmale counterparts, which is consistent with anAustralian study reporting no gender differences inrecognizing psychosis.9 A quantitative design formeasuring MHL may mask complex and importantinterpretations; open-ended qualitative data maybe more helpful in identifying these interactions.18

Unlike Wright and colleagues, we failed to find amarked influence of age on recognizing depressionor psychosis.12 In the present study, people attend-ing university or equivalent education had thehighest level of literacy in terms of depression andpsychosis recognition, and therefore supports thehypothesis that there may be a relationship betweeneducation and MHL.12 Unlike Suhail, we did not findany difference between urban and rural dwellersin terms of recognition of either depression orpsychosis/schizophrenia.11

In terms of help-seeking advice, most peopleadvised a health professional, particularly a GP. Theproportion of respondents who would seek helpfrom a GP was consistent with previous researchfindings, while fewer respondents opted for familyand friends in this study than in those of Jorm et aland Wright et al.6,12 However, caution is required ininterpreting these findings; while they may advisea sister or brother to act in this way, there is nocertainty that when faced with the same personalsituation, they would consult a health-careprofessional.

Psychosis questionnaire

Sixty-three per cent of the respondents underesti-mated the prevalence of psychosis. This may lead tounderrecognition and perpetuate stigma. In termsof aetiology, most respondents recognized that can-nabis may play a role in contributing to psychoticsymptoms, contradicting previous research find-ings, which suggested that people may not be

aware of the potential risks of cannabis use.19,20

This heightened awareness may reflect the currentdebate in the media regarding cannabis.

More than 95% of the people correctly identifiedthe definition of a hallucination. While mostcorrectly identified the accurate definition of adelusion, a quarter confused delusions with hallu-cinations. Lauber et al. observed a similar confusionamong university students, whereby 30% of respon-dents asserted that delusions of control are not asymptom of psychosis, and 32% believed hallucina-tions of taste to be the same.10 Despite these encour-aging overall findings, half the sample consideredschizophrenia to be a ‘split personality’, a findingconsistent with that in a similarly educated Swisssample.10

The knowledge about prognosis, medicationand adjunctive treatments compare favourablywith previous research and may reflect a seculartrend.5,14,21 Strikingly, almost 92% of the respondentsbelieved that people with psychosis recover quickerif treated sooner, endorsing the concept of earlyintervention services for psychosis.

CONCLUSION

The MHL among a sample of Ireland’s largestInternet forum is high with good levels of disorderrecognition, symptom recognition, appropriatehelp-seeking behaviour and views on treatment.However, many still believe schizophrenia is a‘split-personality’.

ACKNOWLEDGEMENTS

The authors acknowledge the members of the EarlyIntervention in Psychosis consortium: Dr SiobhanBarry (Cluain Mhuire Service), Dr Justin Brophy(Newcastle Service), Dr Melanie Gallagher (LucenaChild and Adolescent Services), Dr Abbie Lane (StJohn of God Hospital), Professor Fiona Mc Nicholas(Lucena Child and Adolescent Services), Dr FreedaO’Connell (Elm Mount Service), Mr John Saunders(Schizophrenia Ireland) and Mr Jim Ryan (HSE).

Funding acknowledgements: St John of God Ser-vices and the Health Service Executive.

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2. Clarke M, Whitty P, Browne S et al. Untreated illness andoutcome of psychosis. Br J Psychiatry 2006; 189: 235–40.

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young Australians and their beliefs about treatment. Med JAust 2005; 183: 18–23.

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17. Hewson C, Yule P, Laurent D, Vogel C. Internet ResearchMethods: A Practical Guide for the Social and BehaviouralSciences. London: Sage Publications Ltd, 2003.

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APPENDIX 1

Detect questionnaire

Enter age: <15 years Where do you live: City15–19 years Suburb20–24 years Rural25–29 years30–34 years Gender: Male/Female35–39 years40–50 years>50 years

Nationality: Irish Occupation: School studentOther European Third Level studentNon-EU national Unemployed

Employed:(Job title)

__________

Vignette 1:Sally is 20 years old. For the last few weeks, she has been feeling unusually sad and miserable. Even thoughshe is tired all the time, she has trouble sleeping nearly every night. Sally doesn’t feel like eating and has lostweight. She can’t keep her mind on her work and puts off making decisions. Even day-to-day tasks seem toomuch for her. This has come to the attention of her boss, who is concerned about Sally’s recent poor workperformance.



A) What, if anything, do you think is most likely wrong with Sally? (Please tick one only)

Anxiety SchizophreniaAnorexia DepressionStress Nothing at allPsychosis None of the above

B) If Sally was your sister, who would you suggest she go to for help?______________________________________

C) How helpful do you think the following people could be to Sally?(please rate all)

1 2 3 4 5 6 7No help Some help Very helpful

Family 1 2 3 4 5 6 7Friends 1 2 3 4 5 6 7Counsellor 1 2 3 4 5 6 7GP 1 2 3 4 5 6 7Herbalist or Chinese medicine practitioner 1 2 3 4 5 6 7Hypnotherapist 1 2 3 4 5 6 7Acupuncturist 1 2 3 4 5 6 7Psychiatrist 1 2 3 4 5 6 7Human resource officer 1 2 3 4 5 6 7Self-help books 1 2 3 4 5 6 7Priest 1 2 3 4 5 6 7Psychologist 1 2 3 4 5 6 7Casualty dept. 1 2 3 4 5 6 7Helplines 1 2 3 4 5 6 7Psychic or spiritual healer 1 2 3 4 5 6 7Gardai 1 2 3 4 5 6 7

Vignette 2:John is 24 years old and lives at home with his parents. He has had a few temporary jobs since finishingschool but is now unemployed. Over the last 6 months, he has stopped seeing his friends and has begunlocking himself in his bedroom and refusing to eat with the family or to have a shower. His parents also hearhim walking about his bedroom at night while they are in bed. Even though they know he is alone, they haveheard him shouting and arguing as if someone is there. When they try to encourage him to do more things,he whispers that he won’t leave home because he is being spied upon by the neighbour. They know he is nottaking drugs because he never sees anyone or goes anywhere.

A) What, if anything, do you think is most likely wrong with John? (please tick one only)

Anxiety SchizophreniaAnorexia DepressionStress Nothing at allPsychosis None of the above

B) If John were your brother, who would you suggest he go to for help?________________________________________

C) How helpful do you think the following people could be to John? (please rate all)

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1 2 3 4 5 6 7No help Some help Very helpful

Family 1 2 3 4 5 6 7Friends 1 2 3 4 5 6 7counsellor 1 2 3 4 5 6 7GP 1 2 3 4 5 6 7Herbalist or Chinese medicine practitioner 1 2 3 4 5 6 7Hypnotherapist 1 2 3 4 5 6 7Acupuncturist 1 2 3 4 5 6 7Psychiatrist 1 2 3 4 5 6 7Human resource officer 1 2 3 4 5 6 7Self-help books 1 2 3 4 5 6 7Priest 1 2 3 4 5 6 7Psychologist 1 2 3 4 5 6 7Casualty dept. 1 2 3 4 5 6 7Helplines 1 2 3 4 5 6 7Psychic or spiritual healer 1 2 3 4 5 6 7Gardai 1 2 3 4 5 6 7

MCQPlease circle the one correct answer for each of the following:

Q1. Psychosis:Is not a type of mental illness �

Is when a person has difficulty distinguishing between what is real and not real �

Most often occurs in people over 40 years old �

Q2. Psychosis affects:Enough people in Ireland to fill Croke Park (75,000) �

Enough people in Ireland to fill Landsdowne Road (34,000) �

Enough people in Ireland to fill the Point Depot (10,000) �

Q3. Schizophrenia is:A split personality disorder �

The most common type of psychosis �

An incurable condition �

Q4. Psychosis:Can be caused by cannabis �

Is purely hereditary �

Is caused by poor parenting �

Q5. Hallucinations:Are bizarre, firmly held beliefs �

Are hearing/seeing/tasting/smelling or feeling things that are not there �

Are usually untreatable �

Q6: Delusions:Are when you hear voices when no one is around �

Are unusual beliefs held with conviction �

Can be easily challenged by others �

Q7. People with psychosis:Rarely recover �

Are usually violent �

Recover quicker if treated sooner �



Q8. Medications for psychosis:Are addictive �

Can be bought over the counter or in health food stores �

Help prevent relapse �

Q9. Other proven useful treatments for psychosis include:Hypnotherapy �

Cognitive Behavioural Therapy (CBT) �

Psychosurgery �

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Documents

Mental health literacy among Internet users