Major depressive disorder among adolescents is commonly under-detected and undertreated. The rising trend of depression is also seen in the context of Malaysian adolescents. A recent study among secondary school adolescents in an urban setting in Malaysia revealed that symptoms of mild depression were found in 33.2% of the respondents, whereas the prevalence of moderate-to-extremely severe depression was cumulatively as high as 42.6%. Multiple local studies looking at risk factors for depression among adolescents in Malaysia showed that higher association was found among females, Chinese students, low education level among parents, increased number of siblings, and habit of drugs, stress, loneliness, and poor self-esteem.
It is widely recognized that mental health literacy is one of the vital elements in the primary prevention for depression. Improving mental health literacy among adolescents will lead to a reduction in stigma regarding mental illness, better recognition of symptoms, shorter duration of untreated illness, and overall improvements in prognosis.[3,4] Exploring mental health literacy among adolescents in Malaysia will provide insight into deficiencies that need to be addressed in this vulnerable population.
Ratzan and Parker (2010) described health literacy as “the degree to which individuals have a capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Meanwhile, the term mental health literacy refers to the knowledge and understanding of mental illnesses which includes information on prevention, recognition of symptoms, appropriate help-seeking options and treatment available, effective self-help strategies for a milder problem, and first aid skills to support others affected by mental health problems. Mental health literacy is a vital key to enable them to identify early symptoms and promote timely help-seeking actions. The same concept can also be applied to a specific mental illness, such as depression literacy.
Low mental health literacy among the public is one of the major public health concerns worldwide. The WHO’s World Health Initiative examined data from developing countries, which revealed a worrying status regarding public health awareness regarding mental health issues. This survey showed that only a minority of patients received appropriate treatment for mental illness. Another important issue is the delay in the onset of treatment initiation. The median delays in a treatment-seeking range from 1 to 14 years for mood disorders. Even for the more severe psychotic disorders, delays of months are common. Studies of a range of mental disorders have shown that the longer the duration of untreated illness, the poorer the outcomes of treatment tend to be. One of the most widely accepted explanations for this delay was the low mental health literacy among the public on this matter. Low mental health literacy often results in treatments being delayed, resisted, or questioned with suspicion.
With the increasing attention given to adolescents’ mental health, studies on mental health literacy among this population have also gained momentum. It is widely believed that improved mental health literacy among adolescents is an important protective factor for mental illness. This is due to the fact that this group of the population is more likely to engage in treatment if they are better informed about mental health issues.[12-14]
School-based mental health literacy programs have started to gain attention among health-care providers. These programs are generally aimed at three major outcomes, which include knowledge acquisition, stigmatizing attitudes, and help-seeking behaviors among adolescents with the mental health problem. To date, there have been many studies that showed the beneficial outcome of the program.
The most common method used in assessing mental health literacy (MHL) is using a vignette technique which requires them to articulate their own beliefs and knowledge based on a hypothetical case scenario. There are now over 30 vignettes used in different studies including those which describe a range of particular problems within one area of disorders. The approach used in vignettes was by presenting case scenarios of persons with mental disorders to the participants. This is followed by a series of open-ended questions that cover several domains which include general knowledge about the illness, recognition of the symptoms of the illness, perceptions about the causes of illness, and knowledge regarding the medicines used to treat the problem and about seeking professional help.
The objectives of this study are to explore the current level of mental health literacy among local school adolescents and to determine the significant predictors for their mental health literacy. The findings will help us identify the existing gap and plan the appropriate action to improve the situation. The eventual impact of this study will be seen when public awareness regarding the recognition, management, and prevention of mental illness is improved.
MATERIALS AND METHODS
This is an observational study using a cross-sectional survey method. The responses from the survey questionnaire of this study were analyzed quantitatively. This study was conducted among secondary schools in Kuantan, Pahang. The list of secondary schools was obtained from the local education department, from which, three schools were randomly selected, with consideration of the demographic areas in Kuantan. One urban school and two rural schools were selected, representing their respective demographic areas. A systematic sampling method was applied in deciding the school to be involved in the study. The purposive sampling method was applied in the sampling of the students who will be involved in the study. Students, aged 14 and 16 years old, were selected as the respondents, representing students of lower and upper secondary education. This also corresponded to the policy of the Ministry of Education in involving students in nonexamination years in any researches. The inclusion criteria set includes enrolling as a student in the school involved, being literate in the Malay language, and receiving parental consent. Those who had previously answered a similar questionnaire were excluded.
Sample size calculation
The sample size was calculated using single proportion formula. Each research objective will be calculated separately to determine the number of samples required. The higher of these two will be used as the final required number of samples. Based on this formula, the final sample size of 442 was required for the study.
(where n is a required sample size, Z21-a/2 is Z value at 95% significant level = 2, P is expected prevalence, and d is precision = 5%).
Procedures of data collection
Once the consent was obtained, the respondents were asked to complete the set of a questionnaire prepared by the researcher on their own to avoid any bias. Any assistance required during the completion of the form was given by the researchers who were present. The completed sets of questionnaires were returned to the researchers for further evaluation. The school counselors were also involved in facilitating the data collection process.
The respondents were required to fill out a questionnaire which will identify their age, race, religion, and class in the school. They were also asked if they have any experience with mental illness in the past or know any person in their life with mental illness.
The respondents were given one case vignette that represents a case of depression identified in a teenager aged 16 years old. The case vignette was adapted from an existing case vignette of clinical depression, as defined based on criteria set by the Diagnostic and Statistical Manual of Mental Disorders 5.
The adapted version of the case vignettes was first validated by a panel of experts in the area. The researchers performed a contextual translation of the case vignette, and the content of the story was modified according to the local context. Three experts, who consisted of a general psychiatrist, a child and adolescent psychiatrist, and a child and adolescent clinical psychologist, reviewed the translation.
The depression literacy questionnaire is a set of open-ended questions pertaining to the case given. It was aimed to assess the respondents’ ability to recognize the case vignette given as depression and the appropriate help that should be offered. The questionnaire also explored the respondents’ views on the severity of the situation and their views on the outcome of the situation. They were asked to give answer freely in the answer section given.
The data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 22.0. The sociodemographic data were analyzed using descriptive statistics. All open-ended responses were translated into English and systematically grouped thematically for quantification. Results from the survey were classified as dichotomous for the purpose of statistical analysis. This process was conducted by two researchers independently.
For the first survey question related to diagnosis, any answer relating to “depression” was classified as correct while others as incorrect. Meanwhile, in the second question related to appropriate help-seeking actions, answers related to mental health professionals including psychiatrists, psychologists, and counselors were classified as correct. The proportion of correct answers from the sample was presented as a percentage.
The Chi-square test was used to analyze differences in the proportion of the sample that can correctly identify depression and its treatment. To identify the best predictors for the identification of depression and its treatment, logistic regression analysis with forward selection was computed with gender, age, education, school demographic background, and prior experience with mental as predictor variables.
Four hundred and sixty-seven questionnaires were distributed to the three selected schools. Out of these, five were incomplete, leaving a total of 462 questionnaires analyzed. Table 1 presents the prevalence of sociodemographic characteristics and prior exposure to depression among the respondents. There were a slightly higher proportion of female students who participated (56.9%). About 56.3% of the participants were 14 years old, representing the lower form age category. A vast majority of the respondents, 95% were Malay. There was almost equal distribution between rural and urban samples. Among this sample, 58.4% reported having prior exposure to depression among any person close to them.
The percentage of students who are able to identify the problems was 51.3%. From these data, the relationship between the ability to identify the problem with sociodemographic factors and prior exposure to depression was carried out. Table 2 displays the correlation between sociodemographic characteristics and prior exposure to depression with the ability to identify the problem. It is found that gender and school demographic have significant correlations with students’ ability to identify the problem, with both having a P < 0.001. Female students have a higher ability to correctly identify depression as the problem, with a percentage of 59.7%. Meanwhile, the majority of respondents attending schools in urban demographic areas were able to correctly identified depression, with a percentage of 63.5%, as compared to rural areas.
The percentage of students that was able to identify the appropriate help-seeking actions was 42.6%. The Chi-square test was carried out to test the differences between the ability to identify the appropriate help-seeking actions with socio-demographic factors and prior exposure to depression. Table 3 shows the correlation between sociodemographic characteristics and prior exposure to depression with the ability to identify appropriate help-seeking reactions. The data were analyzed using the Chi-square test. Gender, age, race, and school demographic show a significant association with the ability to identify the appropriate help-seeking action with P = 0.005, P = 0.001, P = 0.025, and P < 0.001, respectively, whereas prior exposure to depression did not have a significant association. Those who are female (48.3%), older adolescents (51.5%), non-Malay (65.2%), and came from urban schools (53.2%), usually are the ones able to identify the problem correctly.
We also analyzed those who are able to correctly identify appropriate medical-related help, which consists of “psychiatrists” and psychologists. About 10.8% of participants are able to identify the correct answers. From these data, the relation between the ability to identify the medical-related help-seeking actions with sociodemographic factors and prior exposure to depression was carried out and displayed in Table 4. Out of all these five variables, only gender, age, and race show a significant correlation with the ability to identify medical-related help-seeking behavior where the female (15.6%), older adolescents (17.8%), and non-Malay students (33.3%) are correct in identifying medical-related help-seeking action.
Table 5 presents the multivariate analysis between sociodemographic characteristics and components of mental health literacy. Based on the result, the best predictors for the ability to correctly identify the problem were gender and school demographic (P < 0.05), in which male was two times more likely to incorrectly diagnose the problem (Exp (B) = 1.983), whereas urban school students had higher ability in recognizing depression from the vignette given (Exp (B) = 0.394). Apart from that, for the ability to identify appropriate help-seeking action among different gender, age, race, and school demographic only the school demographic showed a significant association (P < 0.001), whereas students in urban areas had a lower probability (Exp (B) = 0.478) to incorrectly identify appropriate help-seeking action. The result also showed that gender, age, and race had significant associations with the ability to identify medical-related help-seeking action among adolescents (P < 0.05) where 14-year-old male adolescents were three times more likely to be unable to identify a medical-related help-seeking action (Exp (B) = 3.478;3.333, respectively).
In Table 6, the ability to identify the problem had a significant association with the ability to identify appropriate help-seeking action with P = 0.009, in which among those who were correct in identifying the problem, only 48.5% of them had correctly identified appropriate help-seeking action. Meanwhile, its correlation with the ability to identify medical-related help-seeking action was not significant (P = 0.192) and the result also showed that more than one-third of the respondents were unable to identify medical-related help-seeking action.
This study explored mental health literacy for depression among Malaysian secondary school adolescents. To the best of our knowledge, this is the first study that has specifically examined Malaysian adolescents’ ability to recognize depression and has investigated their help-giving responses to depressed peers. The result of the study shows that 51.3% of the participants successfully recognized depression from the vignette. This result is comparable with another study done among Iranian adolescents. Interestingly, the figure was higher in comparison to the studies done in other Asian countries such as Japan and China. The differences between the various studies are not clear and may be due to the differences in the methodology used and also the differences in sample characteristics.
Meanwhile, with regard to the ability to identify appropriate help-seeking action, the percentage of correct identification of medical-related help-seeking action is quite low with only 10.8% out of 42.6%. In our study, appropriate help-seeking actions include counselors, psychologists, and psychiatrists. Many recognized counselors as the main source of professional help due to the availability of counseling services in most schools. This could explain why it is a more popular response from adolescents.
Female students in this sample clearly demonstrated higher mental health literacy, in terms of their ability to correctly label the depression vignettes and their ability to identify a proper help-seeking action. This result is not surprising and is in line with the finding from an earlier study.[20-22] It may be that girls are naturally more intuitive than boys in terms of their emotional understanding and greater personal experience with depression in both themselves and their peers.
Besides, those from urban schools also demonstrated higher mental health literacy in comparison to those from rural schools where they were able to identify the problem as well as appropriate help-seeking action better than students from rural areas. A similar finding was found in the study done on the public in Malaysia.[23-25] It is possible that rural participants had a relative lack of “psychological mindedness” and the psychological language for the experience of depression and also due to the lack of the availability of mental health professionals such as psychiatrists and psychologists which are only concentrated in urban areas.[26-28]
Non-Malays show a high level of knowledge, especially when related to the ability to identify the proper help-seeking action, particularly getting help from psychologists as well as psychiatrists compared to Malay students. The above results may reflect the fact that the stigma among Malay people of referring to physicians is stronger as shown in previous study and Malays showed the highest level of stigma in comparison to Chinese and Indians.
Not only with race differences, age differences also give a significant relationship with the ability to identify the proper help-seeking action where older adolescents can identify better than younger adolescents. These differences may be due to the dissimilarity in the students’ exposure to mental health problems as well as younger adolescents were less mature compared to older adolescents. Younger adolescents are less likely to get professional help-seeking actions as they believe that ignoring the problem or distracting the person affected is helpful in dealing with depressive behavior.
In addition, a significant association between the ability to identify the problem and the ability to identify appropriate help-seeking action was observed in this study and it was congruent with Byrne and friends’ statement that the ability to recognize the appropriate help needed is secondary to the ability to correctly diagnose the problem. This is supported by the finding in the current study that correct identification of depression did have an effect on the type of helping response offered. This premise supports the idea that postulated people who recognize a disorder tend to have better help-seeking and treatment preferences.
Limitations and suggestions
There were few limitations encountered in this study as the first one was the lack of randomization sampling of the students in each school as the type of sampling method used was purposive sampling method. A different method of sampling in future researches may provide a better result. Second, Malay students cannot be a true reflection of the entire adolescents’ population as there were disproportion rates of participation among the students of different races noted in this study and it may be due to the selection method of the school during the selection process. The levels of participation were generally extremely high for school-based research, but the fact that Chinese and Indian students were less likely to participate than Malays makes the identified race differences difficult to be interpreted. Last but not least was that in this study, only a single case vignette was used to assess the participants’ mental health literacy, and for future researchers, a variety of case vignettes should be used to get more accurate results
Even though the ability of adolescents from this sample to identify depression is higher than general populations in Malaysia, their ability to identify treatment is still relatively low. Hence, more work is needed to improve mental health literacy in particular focusing on their knowledge of the treatment of depression. From this study, we were also able to identify the targeted group in the subpopulation who will require more work to improve their mental health literacy mainly male, younger, Malay, and those who come from rural areas. This study is hoped to provide an avenue for more studies in this subject matter among Malaysian adolescents in the near future.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
This work was supported by RIGS Research Grant by the International Islamic University Malaysia (RIGS17-101-0676). We would like to thank all students and their parents, school counselors, and school administrators for their involvement with the study. We would also like to express our gratitude to the Ministry of Education and the Pahang Education Department for their cooperation with the study.
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