A survey of mental health literacy in Japanese high school teachers

The prevalence of mental illnesses increases sharply during adolescence [1, 2], but adolescents may have difficulty in recognizing their own mental health problems [3]; even when they can, they may be reluctant to seek help [4]. Considering that adolescents spend a major part of their time in schools, school teachers are uniquely positioned to recognize mental health problems in students and should be encouraged to support student help-seeking behavior [5]. To recognize these problems and provide support, teachers need to have sufficient knowledge of mental illnesses [6, 7]. Supporting behaviors of teachers are thought to be more frequent [6, 7] and more effective [8], when teachers have positive beliefs towards mental health problems and confidence in helping adolescents with the problems.

Knowledge and beliefs which aid in the recognition, management or prevention of mental health problems are defined as mental health literacy (MHL) [9]. MHL comprises several components, including the ability to recognize specific disorders, knowledge of risk factors and causes, and having attitudes that promote recognition and appropriate help-seeking [3, 9]. Thus far, a number of studies have observed that teacher-led MHL programs had positive impacts on MHL in adolescents [10‐17], and schools are thought to be the best setting for sustainably delivering MHL programs to all students [18]. However, before teachers can deliver MHL programs, they must have sufficient MHL themselves.

A number of studies have examined teacher MHL in several countries and areas including Europe [19‐22], the US [23‐25] and Africa [26‐29]. According to these studies, the majority of teachers had limited knowledge about mental health problems [25, 26, 29] and were not confident in helping students who were suffering from those problems [24]. Also, correct recognition of specific mental illnesses in vignettes was insufficient, especially in terms of schizophrenia and depression. Recognition was very low in several areas or countries (for instance, 33% for schizophrenia in certain regions in Italy [20] and 16% for depression in Nigeria [28]).

Meanwhile, few studies have investigated teacher MHL in Asia. In East Asia, only one study has examined MHL in teachers, assessing knowledge about schizophrenia in Japanese and Taiwanese primary school teachers [30]. The study observed that most surveyed primary school teachers could not correctly recognize schizophrenia in a vignette. MHL about depression and other mental health problems has not yet been examined in East Asian teachers.

In East Asia, most countries/areas have nation-wide examinations at the end of high school that determine entry into university [31‐34]. These examinations make educational environments highly competitive, and a heavy emphasis on academic achievement causes academic stress, a major stressor in adolescents [33‐37]. In addition, the average sleep duration of adolescents in East Asia is much shorter compared to other areas [38]; the competitive educational environment may contribute to this [36, 37]. The combination of stress and lack of sleep might lead to higher vulnerability to mental health problems in East Asian adolescents, a situation which requires more MHL from teachers.

The present study aimed to examine MHL in East Asian high school teachers. Knowledge about mental health/illnesses, the ability to recognize specific mental illnesses, and stigma towards mental illnesses were assessed.

To our knowledge, this is the first study to investigate MHL in high school teachers in East Asia (Japan). The teachers had limited knowledge about mental health and illnesses. The majority of teachers did not know about the high prevalence of mental illnesses, sharp increase of mental illnesses in adolescence, and optimal sleep duration for prevention of depression. Also, the majority of teachers did not correctly recognize depression and schizophrenia in the vignettes. In addition, few teachers felt confident in helping students with depressive symptoms, or in teaching mental health knowledge to students. This lack of knowledge, low recognition, and low confidence may lead to difficulty/inability in supporting students who have mental health problems.

Regarding the sharp increase of mental illnesses in adolescence, the majority of teachers seemed unaware that their students are at the age of the highest risk for mental illnesses. The onset of mental illnesses sharply increases in adolescence; 50% of all lifetime mental illnesses manifest by the age of 14 [1, 2]. This knowledge may be highly crucial for teachers in East Asia, considering that their students may be at high risk for mental health problems due to heavy stress arising from academic pressure [33‐37]. It may be that a lack of teacher MHL can lead to delayed detection of mental illnesses and failure to administer a timely and appropriate intervention.

Most of the teachers agreed with the item stating that 7-h of sleep is appropriate to decrease the risk of depression in high school students. Teachers in East Asia may need to be educated about the optimal sleep duration to maintain good mental health for high school students, considering that the average sleep duration of high school students in East Asia is much shorter (approximately 6.5–7.0 h) [38] than suggested optimal sleep duration (8–10 h) [43]. Indeed, a Japanese study has observed a sleep duration of 8.5–9.5 h was associated with the lowest risk of depression/anxiety in male adolescents [44].

The majority of the participants did not correctly identify the names of illnesses in the vignette cases with depression and schizophrenia. The proportion of correct recognition was especially low for schizophrenia (35%), much lower than in several European countries (e.g. 60–68% in UK [20, 21], and 66–78% in Norway [22]). The low recognition of schizophrenia among the teachers should be improved, considering that the incidence of schizophrenia is very high in adolescence [39]. A potential reason for this low recognition may be linked to the fact that in Japan, schizophrenia was renamed in 2002 from “Seishin-Bunretsu-Byo” (English: mind-split-disease) to “Togo-Shitcho-Sho” (English: integration disorder) [45]. In addition, the proportion of correct identification was significantly lower among teachers in their 40s and 50–60s (37.0 and 31.8%, respectively) than in their younger counterparts; the renaming may have contributed to the lower proportion of correct recognition of schizophrenia in older teachers. This renaming of schizophrenia was also done in other countries/areas in East Asia (e.g., Korea, Taiwan, and Hong Kong) after the renaming in Japan [45]. Another potential reason for the low recognition may be linked to the state of the psychiatric care system in Japan; Japan had 2.61 psychiatric beds per 1000 persons in 2018, which was much higher than in other OECD countries (mean: 0.61 psychiatric beds per 1000 persons; range: 0.03–1.35) [46] and a figure which is largely unchanged over the last two decades (2.84 per 1000 persons in 1998) [46]. In addition, more than half (52.8%) of these beds are occupied by patients who have schizophrenia [46]. Lack of inclusion of patients into regular society may mean that Japanese people have fewer opportunities to communicate with schizophrenia patients than people in other countries, leading to lower recognition of schizophrenia by Japanese teachers.

The proportion of the correct recognition of schizophrenia was low and significantly lower in male teachers than female teachers. This gender difference was observed for all three illnesses, not only for schizophrenia. This may be in line with previous studies which observed the same trend in the general population [47‐53]. In contrast to the gender difference, the level of education in teachers did not have a significant effect on knowledge score and recognition of specific mental illnesses. This may reflect that, in Japan, taking a mental health course is not required to obtain a teacher license in post-secondary school, including undergraduate and graduate school [54]. In addition, previous participation in mental health seminars did not have a significant effect on recognition of specific mental illnesses. A potential reason for no effect of mental health seminar may be linked to the fact that few MHL programs have been confirmed to be effective, and particularly in Japan, there have been no MHL program with confirmed effectiveness [55]. MHL programs for teachers need to be developed, with the confirmation of their effectiveness. Also, teachers’ experiences dealing with someone suffering from a mental illness did not have a significant effect on knowledge score and recognition of specific mental illnesses. Regarding the effect of previous experience, studies of teacher MHL have reported inconsistent results [19, 21]. Future studies need to investigate how teachers deal with someone suffering from a mental illness, as previous studies only investigate whether or not teachers had such experiences.

The current study has several limitations. First, participants were high school teachers from a single prefecture in Japan. Caution may be needed when generalizing results to other populations. As the present study is the first one from a single Japanese prefecture, further studies need to be carried out in different sites in Japan, as well as in East Asia. Second, it should be noted that the participation rate was not high (53.3%), which might reflect the busy schedules and heavy workloads of the teachers; a recent survey showed that Japanese teachers work the longest hours among all OECD countries [56]. Further research in more comprehensive samples is needed to confirm whether the present findings are representative of teachers in Japan. Third, the vignettes used in the current study were not validated; they were developed according to the DSM-5 criteria [41]. Fourth, we did not measure beliefs towards causes of symptoms of schizophrenia and panic disorder, nor the confidence in helping students with symptoms of these illnesses; future research will need to include these assessments.

MHL in the Japanese high school teachers who participated in the present study was observed to be low. Teachers with low MHL may not notice mental health problems in their students, and even when they do, may have difficulty in helping them effectively. Knowledge about mental health/illnesses, and confidence in helping students may need to be improved in these teachers, so that they become able to notice the problems in students and support their help-seeking behaviours appropriately [8]. Improvements in MHL may also enable the teachers to confidently teach mental health knowledge to students. Presently, although a number of MHL programs targeting teachers have been developed, only a few have been confirmed to be effective [55]. Programs for teachers with confirmed effectiveness need to be developed. Such programs may also need to be incorporated into teacher education at the university level, because in most East Asian countries/areas in addition to Japan, the inclusion of MHL is not currently standard [54, 57‐59].