The assessment of depression awareness and help-seeking behaviour: experiences with the International Depression Literacy Survey

Depressive disorders are a major source of non-fatal disease burden in developed countries, as well as being a key determinant of health-related disability in the developing world [1, 2]. To achieve meaningful reductions in depression-related health burden a range of preventative and treatment strategies are urgently required [3, 4]. The development of such initiatives, however, usually depends on broad recognition that depression is not only common and disabling but that it also responds to evidence-based treatments.

The concept of 'mental health literacy' has emerged to describe "knowledge and beliefs about mental disorders which aid their recognition, management or prevention" [5]. To date, assessment has rested largely on typical case-based vignettes of persons with schizophrenia or depression. This approach requires the respondent to identify the person as a 'case' of mental disorder and then disclose their knowledge or attitudes about available health services or treatments. This has proved to be a useful way of tracking community attitudes to a range of mental health problems and their treatments, particularly in English-speaking countries [6].

We propose an alternative approach which specifically describes depression as a health condition, and then seeks to determine understanding of its characteristics and impacts relative to other medical and psychological conditions. Through our social marketing strategies for beyondblue: the national depression initiative in Australia, we focused more on these general health and depression-specific literacy issues than on an individual's capacity to recognise a typical 'case' of mental disorder. Our earlier work indicated that while the general public was aware of the potential impacts of depression, common mental disorders generally were not seen to be as important as other major physical disorders such as cancer and heart disease [7]. Further, a range of other factors such as personal or family experiences of depression, previous experiences of seeking care or encountering other stigmatising attitudes towards persons with depression appeared to be impacting on willingness to seek mental health care.

As part of an international movement to promote greater recognition of the social and economic costs of depression [3, 4], we were keen to develop this alternative approach to rating depression literacy. A priority was that the method should be able to be utilised easily in countries where English is not the first language or where there was little priority given to the provision of relevant health services. Consequently, we developed a modular depression literacy self-report instrument for use primarily in countries that are participating in the 'Reducing the Social and Economic Burdens of Depression' (SEBoD) movement in Asia.

As the SEBoD movement aims to improve depression literacy within general health workforces, we were interested to determine whether the instrument was sensitive to differences in mental health training. As many countries are not culturally homogeneous, we also sought to determine whether significant ethnic differences had impacts on depression literacy among persons residing in the same country. Therefore, in this Australian study we endeavoured to examine the utility of our instrument when it was completed by university students from different ethnic and health training backgrounds.

The study was a cross-sectional survey of four groups of Australian university students. There were two groups of general students (ethnic Chinese and non-ethnically selected students) and two groups of medical students (second and fourth year students of The University of Sydney Graduate Medical Program).

The English version of the International Depression Literacy Survey (IDLS) was administered to four student groups: medical students from The University of Sydney in second year (n = 103) and fourth year (n = 82); tertiary students from The ANU (n = 38); and Chinese students from The University of Sydney, The University of Technology (Sydney) and The University of New South Wales (n = 184). In total the survey was completed by N = 407 students. Eighty-two percent of the sample completed the entire survey (n = 333/407), 33 terminated after section B (i.e. only completed the first two sections), 17 after section C, 12 after section D, six after section E and six after section F.

The IDLS has been developed specifically to track understanding of depression as a general health condition. For the IDLS to be useful within ethnically diverse communities or groups of health professionals over time, it should first be sensitive to likely baseline differences between relevant groups residing in the same country. While there is little published research regarding the specifics of cross-cultural differences regarding attitudes and beliefs around depression, studies published to date suggest attitudes to mental illness in general differ between Asian and western cultures [18, 19]. The study reported here demonstrates that the IDLS does detect clear differences between medical students in second and fourth year courses, and between non-medical students from ethnic Chinese backgrounds and other undergraduates residing in Australia. These differences are obvious across all the key areas (depression within the context of major general health problems and major mental health problems, common psychological symptoms of depression, attitudes to the use of evidence-based treatments, patterns of health care utilisation and expectations of discrimination).

The basic utility of the instrument for potential use in wider epidemiological, cross-cultural, longitudinal or interventional studies is given preliminary support by the current results. However, it must be noted that convenience samples were utilised in this study, thus limiting the conclusions that can be drawn. The effect of health training on responses would ideally be confirmed by a longitudinal study, sampling the same individuals prior to and following mental health training. Another limitation was the age difference within each of the comparison student groups. While there did not appear to be a systematic effect with increasing age, the study would warrant repetition in age matched samples. While we acknowledge that a small proportion of the Chinese students had a medical or health care background, and that a small proportion of the other students (medical or from ANU) were Chinese, this would most probably reduce the likelihood of finding differences attributable to culture or training. As the instrument has been designed in consultation with professional leaders in a wide range of Asia-Pacific countries, we now encourage utilisation of at least the English version of the instrument in relevant studies among English-literate groups within those countries. A second set of studies will now address the utility of translated versions of the instrument for use in other population groups not literate in English within those countries.

Within the Australia setting, the differences detected between the student groups examined are perhaps unexpected and worthy of further comment. Specific health care training clearly has an association with increasing recognition of the general health burden due to depression. This association also appears to increase with the degree of that training and exposure to direct clinical experience of mental disorders (i.e. fourth versus second year medical students). The importance of medical courses increasing their commitment to this style of teaching in Australia and across the region needs to be emphasised [20, 21]. Secondly, those students from ethnic Chinese backgrounds in Australia have markedly different knowledge and attitudes towards depression. This does not simply reflect an unwillingness to discuss such difficulties as the relevant self-report instruments indicate moderately high levels of psychological distress among this cohort. The lack of recognition of depression as a general health problem, the tendency to recognise features more typically conceptualised as anxiety, the greater reliance on pharmacists and alternative practitioners rather than traditional medical services and the expectation of greater discrimination all appear to be consistent with attitudes expressed within other ethnic Chinese groups not residing in Australia [22, 23]. Such effects have major implications for current public awareness and health literacy interventions in Australia [4, 7]. While we are recording substantial shifts in public attitudes among the broad Australian public [12], we may need to deal more effectively with those specific attitudes held by key ethnic groups or those who have recently arrived in our country.

The IDLS does detect significant differences in understanding of depression among groups from different ethnic backgrounds and between those who differ in terms of prior health training. These results provide preliminary support for the suitability of the IDLS for use in a wider international context.