Screening questionnaire
The purpose of the screening was to ascertain mental health status and history of treatment contact for mental health problems. The questionnaire included demographic data, a self-report instrument rating symptoms of mental disorder, and questions about health care contact. The self-report instrument has previously been used in a population study of mental disorders in Stockholm, Sweden [
27,
28].
A respondent was defined as screening positive for symptoms of mental ill health if at least one of the following screening criteria were met:
* ≥ Six symptoms of anxiety and/or panic attacks with anticipatory fear of future attacks. The questions were based on Sheehan Patient-Rated (Panic) Scale [
29].
* ≥ One symptom of avoidance of agoraphobic or social phobic situations due to fear or anxiety. The symptoms were assessed using questions from Mark and Mathews brief standard rating for phobic patients [
30]. Three questions on agoraphobia including avoidance of transport vehicles, shops or cinemas, and open places. Avoidance of social situations due to fear or anxiety was investigated concerning the following circumstances: avoiding eating, drinking or writing in public, avoiding being in the centre of attention, avoiding being with other people due to a high level of self-criticism. One question concerning avoidance of other situations was included.
* ≥ One obsessive compulsive symptom during last 30 days and suffering due to this [
31]. Three screening questions recommended by the Swedish Psychiatric Association and the Swedish Institute for Health Service Development were included. These concerned obsessional washing, checking, and intrusive unpleasant thoughts. A question measuring severity of social impairment was added, in accordance with DSM-IV criteria.
* ≥ Five symptoms of depression lasting more than two weeks causing disability according a slightly modified Major Depression Inventory (MDI) (4 point-scale [
32] instead of the usual 6 point-scale) [
33,
34]. A question about significant distress during the last 14 days, caused by the symptoms, was included.
* Presence of suicidal thoughts some of the time or more often during the last two weeks, according to the MDI.
* Alcohol Use Disorder Identification Test score (AUDIT) ≥ 11 [
35].
* Any use of illicit drugs during last year.
* ≥ One symptom of social disability due to psychological problems measured according to WHO's brief Disability Assessment Schedule (WHO-DAS-S) [
36,
37].
* Self-report of an ongoing life-crisis, depression, "burn-out", or other mental disorder (according to a checklist).
* Current psychoactive drug prescription. (All respondents who had indicated present use of medication were asked to list their medications including doses. These lists were manually checked for psychoactive drugs).
The respondents were asked whether they had contacted health care for sleep disturbance, personal problem or mental health problems. In case of a positive answer, the respondents were asked to indicate present (last three months) and/or former contact from a checklist. The sources of care that could be indicated included specialised mental health care (psychiatric outpatient clinic of a psychiatric hospital; independent psychiatrist, psychologist or psychotherapist) and primary care (general practitioner, company physician, and non-psychiatric independent physicians). All respondents with health care contact during the past three months, as well as all those with a history of contact with specialised mental health care, were coded as having contact for a mental health problem. Subjects who were currently prescribed psychoactive drug were also considered to have contact with health care for mental health problems.
645 persons (18.2%) had mental ill health as defined above. Ten percent of the total sample (N = 353) had health care contact for mental health problems (group I: cases with contact). An additional 292 persons (8.3%) fulfilled above criteria but had no relevant health care contact (group II: cases without contact). Among the cases with contact, 37% reported depressive symptoms, 18% had symptoms of any anxiety syndrome (but no depressive symptoms) and 7% had harmful alcohol use (but no depressive symptoms, no anxiety symptoms). The remaining had either indicated disability due to psychological problems, ongoing mental disorder or current psychoactive drug prescription. The corresponding numbers for cases without contact is 36% with depressive symptoms, 20% with anxiety symptoms and 24% with harmful alcohol use. Respondents who did not meet the above stated criteria for "caseness" (n = 2 893) were classified as mentally healthy (group III: mentally healthy).
Stage II
A random sample from each of the three groups was invited to participate in a face-to-face interview. Among cases 'with contact' we approached 141 people; 125 (89%) agreed to participate in an interview. The corresponding figures for 'cases without contact' were 105/160 (66%). Of the mentally healthy, 252 persons were randomly chosen for an interview; 128 interviews were conducted (51%). Fifty per cent of the interviews took place in the homes of the respondents and the remainder were conducted at the research office.
Interview
The mean time between the screening questionnaire and the interview was 4 months (range 1–7 months). The interview began with a vignette developed by Jorm and colleagues [
38] designed to determine mental health literacy. The vignette depicted a diagnostically unlabelled case with major depressive disorder. Either a female (Anna) or a male (Magnus) version was presented, depending on the sex of the respondent.
"Anna is 30 years old. She has been feeling unusually sad and miserable for the last few weeks. Even though she is tired all the time, she has trouble sleeping almost every night. Anna doesn't feel like eating and has lost weight. She can't keep her mind on her work and puts off making decisions. Even day-to-day tasks seem too much for her. This has come to the attention of Anna's boss who is concerned about her lowered productivity."
After being presented with the vignette, respondents were questioned about what was wrong and how the person could be helped. Recognition was examined using an open-ended question: "What, if anything, do you think is wrong with Anna?" If multiple responses were given, only the label closest to the correct diagnosis (depression) was registered. Optimal form of help was assessed by asking the respondents how Anna/Magnus best could be helped.
After responding to these open-ended questions, participants were shown a list of different interventions (professionals and other potential helpers, medications and a variety of other treatments) and asked to rate each intervention as helpful, harmful or neither. Respondents were then asked about the prognosis (full recovery, full recovery with risk of relapse, partial recovery, partial recovery with risk of relapse, no improvement, or progression) were the person to receive the preferred intervention. Finally, they were asked to assess prognosis in a similar manner, were the person described in the vignette to receive no treatment at all.
Following the administration of the vignette based questions, the interviewer used the Schedule of Clinical Assessment in Neuropsychiatry (SCAN) version 2.1 PART 1, chapter 1–8 and 11 [
39,
40] to generate past month diagnoses in accordance with DSM-IV [
41].
The instrument including the vignette and the questions were translated to Swedish by the investigators and checked and edited by colleagues. The Ethical Committee of Karolinska Institute approved the study.