Summary of evidence
Summary of evidence
Summary of mental health awareness
For this topic, we consider mental health awareness interventions that aim to raise awareness of mental health in order to improve mental health related outcomes (e.g. mental health awareness, knowledge etc.) within workplace settings. A number of mental health awareness interventions are available and the content, design and delivery format is varied. The mental health awareness format provided by Mental Health First Aid has been subject to the most evaluation research to date. For many interventions, the aim is to improve mental health awareness, knowledge, stigma/attitudes and behaviour towards mental health problems. Some mental health awareness interventions, but not all, also specifically aim to equip trainees with the knowledge and skills to help someone experiencing mental ill-health in crisis situations (e.g. suicidal behaviours or drug overdose).
There is a growing body of academic and practitioner literature that demonstrates the benefits of mental health awareness on trainee outcomes (i.e. awareness, knowledge, decreased stigma). To date, there is little evidence of the impact of mental health awareness interventions on changing the behaviour of those who have attended the training. There is a lack of good quality research that examines the impact of mental health awareness interventions on those who are experiencing mental ill-health at work. Therefore, the impact of mental health awareness interventions on recipient employee wellbeing (i.e. beyond the experience of the trainee) is not yet known. Case study findings demonstrate reduced absence where mental health awareness programmes have been organisation wide, however it is noteworthy that organisations that invest in large programmes of awareness are also likely to have a number of other health-related activities in place that make it difficult to isolate findings. Evaluation of the impact of mental health awareness interventions on the behaviour of trainees, and on others in the organisation, is strongly encouraged.
Research examining the implementation of mental health awareness interventions provide useful information. A number of different strategies have been used to raise awareness including face to face training, online training, blended learning and guidance. Comparative findings are presented in this review. Factors relating to the facilitators and barriers to implementing mental health training; the role and support required by mental health first aiders, and the need to incorporate mental health awareness within a wider strategy including prevention, training and support are discussed.
What is mental health awareness?
In this hub topic, we consider mental health awareness interventions that aim to raise awareness of mental health in order to improve mental health related outcomes (e.g. mental health awareness, knowledge etc.) within workplace settings.
A number of mental health awareness interventions are available and the content, design and delivery format is varied. For many interventions, the aim is to improve mental health awareness, knowledge, stigma/attitudes and behaviour towards mental health problems. Some mental health awareness interventions move beyond knowledge and aim to support the development of skills (e.g. talking about mental health). Some mental health awareness interventions, but not all, also specifically aim to equip trainees with the knowledge and skills to help someone experiencing mental ill-health in crisis situations (e.g. suicidal behaviours or drug overdose).
Why is mental health awareness at work important?
Mental health is a priority issue for individuals, organisations and society. Common mental health conditions such as stress, anxiety and depression are among the most prevalent reasons for short and long term sickness absence, contributing to over 70 million work days lost each year, and costing UK employers alone approximately £2.4 billion per year (HSE, 2018).
Mental health awareness is one important component of a workplace mental health programme of activities. The recent Stevenson and Farmer review (2017), an independent review into how employers can better support mental health at work, identified mental health awareness as one action that employers could take to reduce the impact of mental health at work. The ‘mental health core standards' set out in their review include:
- Produce, implement and communicate a mental health at work plan;
- Develop mental health awareness among employees;
- Encourage open conversations about mental health and the support available when employees are struggling;
- Provide employees with good working conditions and ensure they have a healthy work life balance and opportunities for development;
- Promote effective people management through line managers and supervisors;
- Routinely monitor employee mental health and wellbeing.
Mental health awareness interventions – aims, content, design and delivery
Mental health awareness interventions vary greatly in their content, design and delivery format. Reviews suggest that there are a number of shared and distinct features, with many interventions being delivered to different populations, in different ways. In this hub topic, we aim to highlight shared and distinct characteristics and summarise the available evidence of their impact.
Mental health awareness interventions typically aim to improve:
- awareness – including raising the knowledge of mental health, prevalence, signs and symptoms, the impact of mental health on individuals, and the sources of support available
- knowledge – including developing knowledge of what mental health is including definitions, signs and symptoms, prevalence, impact of mental ill-health, and the sources of support available
- stigma/attitudes – including addressing negative attitudes and beliefs, common misconceptions and unfair practices, and normalising mental health through improved knowledge and understanding
- confidence – including how to talk about mental health and specifically, how to talk to someone with mental ill-health about their needs
- behaviour change (in supporting those with mental ill-health) – including initiating conversations about mental health, developing active listening skills and sign posting support.
Booth et al. (2017) reviewed 19 studies which evaluated mental health training for non-mental health professionals (sample populations included police officers, teachers and other public sector workers within the UK, USA, Australia and Sweden). The findings highlight that training interventions ranged from awareness raising to changing practice and differed in training design, delivery methods and content, with some focusing more broadly on mental health and over half of the studies focusing on specific conditions where mental health may co-occur (e.g. learning disabilities).
A review of the evidence (e.g. Booth et al., 2017; Gayed et al., 2018) suggests that mental health awareness interventions differ in the following ways:
- The spectrum of mental health disorders considered: Some focus on common mental disorders (e.g. stress, anxiety and depression) while others give insights into a wide spectrum of mental health disorders
- The depth of knowledge and skills development: Some focus on raising awareness while others provide interactive opportunities with expert feedback to enable skill development
- The attention paid to typical and/or crisis situations: Some mental health awareness interventions, but not all, specifically aim to equip trainees with the knowledge and skills to help someone experiencing mental ill-health in crisis situations (e.g. suicidal behaviours or drug overdose)
- The focus on work and workplace causes and resources: Some mental health awareness interventions balance work and non-work factors and resources, others focus more heavily on non-work or work
- The duration of training: Ranging from 1 hour to 14 hours, some delivered on a single day while others are delivered over time (one study reported delivering training over a ten week period)
- The delivery mode: Ranging from guidance, e-learning/ online training, blended learning and face to face delivery, with or without interactive components.
The research suggests largely comparable findings with no strong and consistent evidence to propose one delivery mechanism over another. E-learning accompanied by a supporting manual was found to be superior to e-learning or the manual alone in reducing stigma (Jorm et al., 2010a), while participants rated blended delivery more favourably (Jorm et al., 2010b). The differences in training designs and research study designs, make comparisons between mental health awareness interventions difficult so further research is needed before conclusions can be made.
A review of mental health training for UK Line Mangers by the Institute for Employment Studies and the Rail Safety Standards Board (2019), identified a number of core components of good mental health training for line managers, including awareness and communication skills, line manager specific content, and first response skills. The authors also suggest interactive components, real-life examples and tailored content in training is likely to improve mental health and wellbeing. Due to a lack of high-quality evaluations included in the review it is unclear which aspects of line manager training produce successful outcomes.
The differences in design and delivery of mental health awareness interventions makes the generalisability of findings from evaluation studies difficult, an issue that has been noted in a number of recent evidence reviews (e.g. Gayed et al., 2018; Narayanasamy et al, 2018; Booth et al, 2017). This is discussed further in the following section.
A number of different mental health awareness interventions are considered in the academic and practitioner research. Mental Health First Aid is the most widely evaluated and reported mental health awareness provider within the academic and practitioner reviews noted here and elsewhere. Mental Health First Aid (MHFA) was first developed by Betty Kitchener and Tony Jorm in 2000 and aims to teach trainees the necessary first aid skills to support individuals with mental ill-health. MHFA is designed to provide support to those who are either developing mental health related problems or who are in a mental health related crisis, until professional help is able to take over and support the individual. The course involves: teaching trainees how to recognise the symptoms of different mental health disorders and crises, how to offer appropriate support, and how to guide the individual towards seeking treatments and other supportive help (Morgan, Ross & Reavley, 2018). Since its development in Australia, MHFA courses are now available worldwide and have been tailored for delivery in the workplace setting.
There are a number of organisations and research teams that provide mental health awareness interventions and the findings are shared in this review where available. For example, interventions such as ‘Respect’ (Milligan-Svaille et al., 2017), the Coworker Health Awareness Training (Oakie et al., 2018) provide details of the intervention design and delivery alongside evaluation data and are included in this review.
In practice, a number of organisations offer mental health awareness interventions that deliver evidence-based content but have not yet reported any evaluation information in the public domain. Providers of mental health awareness interventions in the UK that draw on evidence-based content but are not considered in the evidence review that follows include those delivered by Mind, the Samaritans and ACAS among others.
Mental health awareness interventions run for employees demonstrate a range of positive trainee outcomes including increased awareness and knowledge and reduced stigma. Some studies show trainees report increased confidence in discussing mental ill-health and an intention to change behaviour. However, little is known about the impact of the interventions beyond the trainee experience.
The majority of research is focused on training delivered by MHFA. Studies evaluating MHFA training in the workplace demonstrate improvements in participant’s awareness, knowledge, confidence, stigma/attitudes, and to some extent, behavioural intentions to help those with mental ill-health (Hadlaczky et al., 2014; Jorm et al., 2010a; Jorm et al., 2010b; Kitchener et al., 2004; Morgan et al., 2018; Reavley et al., 2018;).
A review and meta-analysis of the effectiveness of MHFA training conducted by Morgan et al. (2018) concluded that MHFA training can lead to improved mental health knowledge and recognition of mental disorders. An increase in confidence in helping someone with a mental health issue and intentions to provide first aid and a small reduction in stigmatising attitudes were also found.
Reavley et al. (2018) offered insight into the comparative benefits of the e-learning (online) and blended learning (online plus some face-to-face delivery) versions of MHFA over a Red Cross e-learning course. The findings highlighted that both the e-learning and blended learning MHFA courses had positive effects on mental health knowledge, attitudes and stigma, intentions and confidence in helping an individual with mental ill-health.
Morgan, Ross & Reavley (2018) conducted a systematic review and meta-analysis on the effectiveness of Mental Health First Aid (MHFA) training. They included 18 trials in their evaluation and found that there were small to moderate effects at post training and 6 months following training, however the effects at 12 months following training were less clear. More specifically, MHFA training improved mental health knowledge, recognition of a mental condition, confidence in helping someone with mental ill-health, intentions to provide first aid and slightly reduced levels of stigma.
A review of MHFA training in the workplace by the Health & Safety Executive (2018) revealed some key gaps of knowledge in the current evidence base on the effectiveness of MHFA in the workplace. Specifically, they note the small number of high quality published occupational studies which have included MHFA; the limited evidence surrounding the adaptation of MHFA training content for a workplace context; the consistency of evidence around MHFA training improving trainees’ awareness of mental ill‐health conditions, including signs and symptoms; the limited evidence surrounding MHFA leading to sustained improvements in trainees’ ability to support a colleague experiencing mental ill‐health; and conclude that there is no supporting evidence to suggest that MHFA training has improved the management of mental health within the workplace.
The need for further research into the impact of MHFA in the workplace was echoed in a report by Narayanasamy et al. (2018). In a scoping review and feasibility study conducted for the Institute of Occupational Safety and Health, the authors identified that a number of mental health awareness courses were in use in UK workplaces and that while MHFA was largely positively received by participants of the study, further research is needed to examine the effectiveness and cost-effectiveness of MHFA. This report also identified a number of factors relating to the necessary conditions for successful implementation of mental health awareness. These are summarised in the implementation section below.
A wider range of mental health awareness interventions designed for managers have been evaluated in the academic and practitioner research.
The ‘RESPECT’ manager training program combines mental health knowledge (within workplace settings) and communication training to enhance managers’ confidence when supporting employees mental health. Training focused on three key areas: key features and effects of common mental health issues in the workplace; roles and responsibilities of senior officers (in terms of employee mental health); and the development of effective skills for discussing mental health matters with staff. Milligan-Saville et al. (2017) found a significant increase in the likelihood of managers contacting employees (who are experiencing mental ill-health) and higher confidence when communicating after receiving the training. Interestingly, there was also a significant decrease in work-related sickness absence at the 6 months follow up period. This reduction in absence translated to return on investment of £9.98 for each pound spent, however the factors influencing the reduction in sickness absence were not explored in this study so it is unclear how much of reduction was due to the mental health awareness training of managers alone.
A pilot study conducted by Gayed et al. (2018b) evaluated the feasibility, usability and likely effectiveness of a newly developed self-paced online training program for managers, HeadCoach, covering three topics: common mental illnesses, how to help an employee and minimizing mental health risks in the workplace. The intervention aims to build managers’ confidence when supporting employees with mental ill-health and encourage behaviours which are likely to create a mentally healthy workplace. The results showed significant improvements in self-reported confidence in communicating with employees with mental ill-health, actions to employ managerial strategies to prevent and reduce stress and managers’ knowledge regarding their role in managing mental health.
The Mental Health Awareness Training (MHAT) for workplace leaders (Dimoff, Kelloway & Burnstein, 2016) is a three-hour lecture programme incorporating lecture based materials, interactive discussion and videos. Pre- and post- analysis found the intervention significantly improved managers’ knowledge, self-efficacy, attitudes and intent to promote mental health at work. Despite the favourable impact, the authors highlight the importance of including the MHAT as part of a broader mental health strategy.
Despite these promising findings, reviews of the available evidence suggest the benefits of mental health awareness interventions are less clear. A meta-analysis conducted by Gayed et al. (2018) considered the effectiveness of training for managers to support the mental health of their employees. Ten different intervention studies were included in the review, ranging from face-to-face, online and a blended learning delivery, with durations between 2.25 hours and 14 hours, across a variety of organisational settings. Findings indicated significant improvements in managers’ mental health knowledge, non-stigmatising attitudes towards mental health and self-reported behaviours in supporting employees with mental ill-health. Few studies reported effects at the employee level (e.g. employees’ levels of psychological distress). In pooling the available data, the authors concluded that no significant impact of manager training on employee outcomes was evident.
Similar findings have been highlighted across the literature with authors stating there is less evaluation considering measurable changes in the participants’ behaviours (in terms of supporting an individual with mental ill-health) and the experience of the recipient (i.e. the individual in need of support). Some small improvements have been found in the amount of help provided to a person with a mental health issue (Morgan, Ross & Reavley, 2018), although the quality of behaviours offered are less clear. Despite the lack of clarity surrounding the effect of such interventions at the employee level, it is generally well established that these interventions improve various aspects of mental health related outcomes at the manager (trainee) level.
We could not find any studies that examined the effectiveness of organsiation wide mental health awareness interventions.
A number of papers have examined the way mental health awareness interventions have been implemented in the workplace. These reviews provide valuable insights into the considerations required by organisations and those who commission mental health awareness interventions.
Implementation of mental health awareness interventions in the workplace
A number of papers have examined the implementation of mental health awareness interventions in the workplace. In their review Scantlebury, Parker, Booth, McDald & Mitchell (2018), noted a number of barriers and facilitators when delivering and implementing mental health training to non-mental health trained professionals. In their paper, they highlight the need for:
- Tailored training content, with involvement from key stakeholders and consideration of wider organisational practice
- Training to be delivered by experienced and skilled trainers
- Well structured supporting resources to aid familiarisation and engagement with materials
- Staff willingness to engage with training (e.g. recognising the need to improve practice and develop new skills to manage those with mental ill-health)
- Careful consideration of organisational factors (e.g. time, cost, culture, incentives and buy-in)
In a review of Mental Health First Aid provision in the UK, Narayanasamy et al. (2018) identified a number of considerations that can impede the effective implementation of mental health awareness interventions, including the lack of:
- Clear boundaries for the MHFA role and inconsistent strategies to identify trained MHFA persons and promote this role within the organisation
- Refresher training opportunities for MHFA trained staff
- Evaluation opportunities and challenges in measuring impact.
Careful consideration of these factors is likely to increase the likelihood that the mental health awareness intervention(s) will have the desired outcome.
Evaluating the impact of mental health awareness interventions in the workplace
The information presented in this hub topic draws from the available evidence for mental health awareness interventions. A common conclusion from both academic and practitioner evidence reviews is that there are a number of gaps in our understanding.
Organisations commissioning mental health awareness and providers of mental health awareness interventions are therefore encouraged to evaluate the effectiveness and cost-effectiveness of mental health awareness interventions. In doing so, we will be better positioned to know what impact mental health awareness has, who it benefits and when it works best.
Booth, A., Scantlebury, A., Hughes-Morley, A., Mitchell, N., Wright, K., Scott, W., & McDaid, C. (2017). Mental health training programmes for non-mental health trained professionals coming into contact with people with mental ill health: a systematic review of effectiveness. BMC psychiatry, 17(1), 196.
Bovopoulos, N., LaMontagne, A. D., Martin, A., & Jorm, A. (2018). Exploring the role of mental health first aid officers in workplaces: A qualitative study using case study methodology. International Journal of Workplace Health Management, 11(6), 366-381.
Dimoff, J. K., Kelloway, E. K., & Burnstein, M. D. (2016). Mental health awareness training (MHAT): The development and evaluation of an intervention for workplace leaders. International Journal of Stress Management, 23(2), 167.
Gayed, A., Milligan-Saville, J. S., Nicholas, J., Bryan, B. T., LaMontagne, A. D., Milner, A., ... & Glozier, N. (2018). Effectiveness of training workplace managers to understand and support the mental health needs of employees: a systematic review and meta-analysis. Occupational and environmental medicine, 75(6), 462-470.
Gayed, A., LaMontagne, A. D., Milner, A., ... & Harvey, S.B. (2018b). A new online mentla health training program for workplace managers: Pre-Post pilot study assessing feasibility, usability and possible effectiveness. JMIR mental health, 5(3) e10517
Hadlaczky, G., Hökby, S., Mkrtchian, A., Carli, V., & Wasserman, D. (2014). Mental Health First Aid is an effective public health intervention for improving knowledge, attitudes, and behaviour: A meta-analysis. International Review of Psychiatry, 26(4), 467-475.
Health & Safety Executive (HSE), 2018. Summary of the evidence on the effectiveness of Mental Health First Aid (MHFA) training in the workplace.
Institute for Employment Studies & Rail Safety Standards Board (2018). Understanding the conditions for successful mental health training for managers.
Jorm, A. F., Kitchener, B. A., Fischer, J. A., & Cvetkovski, S. (2010a). Mental health first aid training by e-learning: a randomized controlled trial. Australian and New Zealand Journal of Psychiatry, 44(12), 1072-1081.
Jorm, A. F., Kitchener, B. A., Sawyer, M. G., Scales, H., & Cvetkovski, S. (2010b). Mental health first aid training for high school teachers: a cluster randomized trial. BMC psychiatry, 10(1), 51.
Kitchener, B. A., & Jorm, A. F. (2004). Mental health first aid training in a workplace setting: a randomized controlled trial [ISRCTN13249129]. BMC psychiatry, 4(1), 23.
Milligan-Saville, J. S., Tan, L., Gayed, A., Barnes, C., Madan, I., Dobson, M., ... & Harvey, S. B. (2017). Workplace mental health training for managers and its effect on sick leave in employees: a cluster randomised controlled trial. The Lancet Psychiatry, 4(11), 850-858.
Morgan, A. J., Ross, A., & Reavley, N. J. (2018). Systematic review and meta-analysis of mental health first aid training: effects on knowledge, stigma, and helping behaviour. PloS one, 13(5), e0197102.
Narayanasamy¹, M., Geraghty¹, J., Coole¹, C., Nouri¹, F., Thomson, L., Callaghan, P., & Drummond¹, A. MENtal health first aid in The wORkplace (MENTOR): A feasibility study.
Oakie, T., Smith, N. A., Dimoff, J. K., & Kelloway, E. K. (2018). Coworker health awareness training: An evaluation. Journal of Applied Biobehavioral Research, 23(4), e12148.
Reavley, N. J., Morgan, A. J., Fischer, J. A., Kitchener, B., Bovopoulos, N., & Jorm, A. F. (2018). Effectiveness of eLearning and blended modes of delivery of Mental Health First Aid training in the workplace: randomised controlled trial. BMC psychiatry, 18(1), 312.
Scantlebury, A., Parker, A., Booth, A., McDaid, C., & Mitchell, N. (2018). Implementing mental health training programmes for non-mental health trained professionals: A qualitative synthesis. PloS one, 13(6), e0199746.