Mental health literacy: knowledge of depression among undergraduate students in Hanoi, Vietnam

According to the World Health Organization (WHO), there are approximately 450 million people with mental disorders and more than that with mental health problems. Mental disorders account for 13% global burden of disease, and its prevalence appears to be increasing [1]. The results from Global Burden of Disease study in 2015 showed that neurological conditions in Vietnam contributed 4.56% of total DALYs [2]. Mental health problems often arise for the first time in adolescents or young adults [3‐5] and affect more than one in four young people globally. In Vietnam, the prevalence of general mental health problems ranges from 8 to 29% for children and adolescents. This percentage among young people, including undergraduate students, is higher at about 25–60% [6, 7].

Depression is a common and serious mental health problem. According to WHO [8], there were at least 350 million people living with depression globally. Depression often starts at a young age, can be long-lasting or recurrent, and when most severe, can lead to suicide [9]. In Vietnam, depressive disorders have the second highest prevalence among mental disorders [10] with about 36,000–40,000 people losing their lives to depression per year [11]. Depression is treatable, but fewer than half of those affected in the world (in many countries, less than 10%) receive the care and support they need [9]. Shortage of resources, lack of psychiatric services, social stigma, and lack of mental health literacy (MHL) constitute major barriers in accessing treatment for mental disorders in general and for depression in particular [9, 12, 13]. Healthcare services in Vietnam are organized around a 4-tier system (central, province, district, commune) with two major types of services: community-based and hospital-based [10]. More mental health services are provided in hospitals than in community, but follow-up usually occurs at community general practice [14].

The term MHL was first used in 1997 by Jorm to describe “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” [15]. This definition emphasizes the role of recognition of mental health problems and help-seeking for management and prevention by young people and people close to them, e.g. family members, teachers, and friends. The MHL research to date has demonstrated that many young people do not seek help or postpone help-seeking due to various personal and structural barriers such as fear of stigma and discrimination associated with depression; inability to recognize symptoms of the problems; lack of knowledge about the availability of help; lack of appropriate responses from both peers and adults [16, 17].

Studies assessing MHL of depression of the population have been done in some countries. Jorm and his colleagues, in a study published in 1997, found that 39% (n = 1010) of Australians aged 18–74 could correctly recognize depression [18]. Another survey 15 years later among 1016 Australians aged 15 and older found that 73.7% of the respondents could recognize depression [19]. In a survey among 1004 Canadians aged 18–64, divided into two groups: 18–24 and 25–64, Marcus and Westra found that the ability to recognize depression among the two age groups were 80 and 79% respectively [20]. MHL was also studied in some Asian countries showing a lower percentage of respondents who could correctly recognize depression. Jingyi Wang et al. found that 34.6% (n = 1.953) of Shanghai residents selected the correct answer [21]. A study among a multiracial population in Singapore (2016) showed that 55.2% of this population (including Chinese, Malay, Indian and others) could correctly name a vignette as depression [22].

MHL of depression focused on young people has been studied elsewhere. Coles et al. found that 40% of high school students aged 14–19 (n = 1104) in New York, USA could correctly recognize depression symptoms described in a vignette [12]. A study in UK [23] found that among 1125 young people aged 16–24, 41.8% was able to correctly name a vignette as depression [17]. Reavley et al. estimated that 74% of higher education students in Australia could recognize depression in a vignette [3]. Sayarifard et al. [24] carried out a survey among 324 medical sciences students in Iran and the results showed only 35.6% of the participants selected the correct answer. In Sri Lanka, Amarasuriya et al. [25] examined depression literacy among 4671 undergraduates and only 17.4% of the respondents were able to recognize depression. Because mental health problems often arise at young age, such studies are needed for potential intervention to improve mental health for young people [26]. In Vietnam, there have been some studies estimating prevalence of depression [11, 27]. To the best of our knowledge, there is however no publication that describes young people’s knowledge of mental health. We aim to investigate the recognition of depression, help-seeking intentions, and knowledge to support people with depression among undergraduate Vietnamese students in Hanoi. Findings from our study can be used to inform interventions aiming to promote understanding of MHL of depression and improving mental health.

Among 350 students who completed the questionnaire, 213 (60.9%) were public health students and 137 (39.1%) were sociology/social science students. The majority of respondents were female (76.6%). Most students were living with housemates (51.4%), with parents (35.1%), and the rest were living with relatives, by themselves, with acquaintances or with their partners. The age of respondents ranged from 19 to 26 years with a mean age of 20.7 (SD = 1.3) (see Table 1 for more details).

Recognition of depression is a factor that can facilitate help-seeking [30]. The percentage of young Vietnamese people who could correctly detect depression is lower (32%) than that of developed countries [12], but higher than that of some other developing country [25]. Our result also showed a majority of respondents recognized the vignette as “stress” (49.1%), suggesting that the ability to identify mental health problems among undergraduate students needs to be improved.

Depression often starts at an early age and can be long lasting [9]. As Jorm and his colleagues have pointed out, good MHL in young people and their key supporters may lead to better outcomes for those with mental disorders, either by facilitating early help-seeking by young people themselves, or helping adults to identify early signs of mental disorder and to seek help for the young person [5]. As shown in Lam’s study [29], correct identification of depression and intention to seek help can be used to assess the level of MHL [29]. The low level of correct identification of depression in this study points to the need to improve both knowledge on disorder symptoms and the awareness of resourceful locations to seek help for people with depression.

Even though many respondents were unable to recognize the problem as depression, the majority of respondents (94.8%) did identify that Linh’s problem was a common mental health problem—stress, depression or anxiety. A very small proportion of respondents thought she had schizophrenia (2.9%) or unspecified disorder (1.1%). Only 1.1% of students chose “don’t know”.

It is not surprising that a substantial proportion of the respondents (81.4%) were willing to help. This result is consistent with that reported by Reavley [3] stating that regardless of the proper identification of the disorder, they understood the importance of the need to seek help. This finding indicates young people’s willingness to help those with depression, despite whether they can correctly recognize the specific problem.

In this study, participants showed confidence in informal sources such as family members and close friends when needing help. The bonding with families and friends as well as social network supports in Vietnam is typically strong. It seems people can seek help from their loved ones or from their social network whenever they need. Professional help from formal sources such as mental health professionals, general practitioners/family doctors, and psychiatrists, in this study was not deemed necessary as found in other studies [23, 24]. This is understandable in the context of Vietnam, where most people know very little about what roles mental health professionals and psychiatrists play. Moreover, there is still stigma in the community regarding mental health problems. This might have driven people’s decision to not see a mental health specialist.

Our results showed a high proportion of respondents identified the problem as one of the common mental health problems (stress, depression, anxiety) and they also rated a counselor or a psychologist as a helpful source of intervention. This means our respondents believed in the role of a counselor and a psychologist to help people with common mental health problems, including depression. In Vietnam, however, most psychologists are not practitioners. They mostly work in research or teaching environment. Only some provide counseling through helpline centers. Therefore, respondents’ choice of “talking to a counselor or a psychologist” may be referred to professional help from medical setting.

Telephone helplines provide easy access for those seeking mental health counselling. In Hanoi, there are several helplines that provide psychological counseling. These helplines are open 24/7 assisting people who need help any time. However, most young people are either unaware of helpline services or doubtful of their usefulness. This discrepancy is similar to a finding from Debra Rickwood’s study in Australia (2005) that when young people are seeking help, they want to talk to a professional whom they can trust and that person can maintain confidentiality [31].

In terms of knowledge about first-aid support, among the proposed possible actions that participants could potentially take to support people with depression, the option of “listening to the person who needs help” was chosen by a large percentage of respondents. This action is consistent with the guidelines of mental health first aid [32]. A majority of participants considered it useful to encourage individuals with mental health issues to become more physically active. They believed that the distraction may lead a person to forget about his/her mental health problem temporarily. Depression is a treatable disease; talking with people we trust is a first step towards recovery from depression [9]. WHO encourages people with symptoms of depression to consult professionals or recognize depression among family and friends and encourage them to seek help because depression can lead to suicide [9]. In this study, there was only a small number of respondents, 5.88% from group 1 (recognized depression) and 2.67% from group 2 (did not recognize depression), chose to ignore Linh until she gets over her problem (p < 0.05). This finding indicates that a majority of respondents believed that people with depression should not be left alone. However, 4.9% of 350 respondents with wrong knowledge about first-aid for depression was a considerable number. Young people should be educated that depressive people should not be left alone.

Concerning another component of mental health literacy—knowledge of interventions—self-help strategies (how to relax, physical exercise, consulting an online source, reading self-help book about the problem) received a high rate of endorsement by participants. Jorm and Griffiths [33] demonstrated the effectiveness of self-help strategies like exercise, relaxation and self-help book for depression. Our results also showed that the respondents in both groups believed joining a self-help group (p < 0.001) is a helpful intervention strategy. Our study again confirms that self-help strategies are essential [32] and suggests a need for public awareness campaigns on mental health problems. One interesting find in our study is that both groups (higher percentage in group 1 = 32.1% than group 2 = 26.4%) did think people with depression should be admitted to hospital for psychiatric services (p < 0.05).

A potential limitation of this study is the use of the adapted Australian questionnaire that has not been validated. However, the research team consulted mental health experts and piloted the instrument to ensure the questionnaire is understandable and relevant to the Vietnamese context. Another limitation is that our sample is a convenience one consisting of college students only. The findings are therefore not generalizable to all young adults in Vietnam. However, our study results could reflect an aspect of the “bigger picture” of Vietnamese young people’s MHL and thus, warrant future studies.

Mental health literacy of depression among the undergraduate students surveyed in this study was not as high as in other countries. Aside from the majority of respondents choosing stress to describe the depression vignette, our findings suggest a need to improve understanding of MHL of depression, especially depression detection and how-to seek help, for undergraduate students in Vietnam. Although mental health problems have become an increasing problem across all socio-demographic groups in Vietnam, there are currently not enough interventions to educate the public about them. Various interventions can be considered including the development of short mental health courses for students. Additional information on various mental health issues can also be posted through social media and internet-based resources. Challenges remain as mental health has never been considered a high priority in Vietnam. Future studies should focus on how to effectively disseminate mental health education among young people.