Strategies and future attempts to reduce stigmatization and increase awareness of mental health problems among young people: A narrative review of educational interventions

Authors


Sosei Yamaguchi, MSc, Department of Social Welfare, School of Humanities and Social Sciences, Osaka Prefecture University, 1-1 Naka-Ku, Gakuen-Cho, Sakai, Osaka 599-8531, Japan. Email: sosei.yama19@gmail.com

Abstract

There is a need to reduce stigma and increase awareness in order to prevent social exclusion of people with mental illness and to facilitate the use of mental health services in young people. The purpose of this review was to examine the effects of educational interventions to reduce stigmatization and improve awareness of mental health problems among young people. An electronic search using MEDLINE, PsycINFO and Academic Search Complete was carried out for studies that evaluated the effectiveness of educational interventions. Forty eligible studies were identified. There were three types of educational interventions (Educational condition, Video-based Contact condition and Contact condition). Eighteen of 23 studies reported significant improvements in knowledge, 27 of 34 studies yielded significant changes in attitudes towards people with mental illness. Significant effects in social distance were found in 16 of 20 studies. Two of five studies significantly improved young people's awareness of mental illness. However, six studies reported difficulties in maintaining improved knowledge, attitudes and social distance in young people. Furthermore, the majority of studies did not measure the actual behavioral change. From the comparison of the three types of educational interventions, direct contact with people with mental illness (Contact condition) seems to be key in reducing stigmatization, while the components of Education and Video-based contact conditions are still arguable. Despite the demonstration of the positive effects of each educational intervention, their long-term effects are still unclear. Further research needs to involve measuring actual behavioral change and performing a long-term follow up.

THERE IS A great need to pay attention to young people's stigmatizing attitudes towards mental illness and educational interventions that try to reduce stigmatization. The aims of reducing stigma seem to be twofold: prevention of social exclusion and facilitation of treatments for mental illness among young people.

With regard to the first aspect, the World Health Organization (WHO) and the World Psychiatric Association (WPA) have acknowledged that people's stigmatization of mental illness is a serious problem in our society, because it generates various disadvantages for people with mental illness that include infringement of their human rights and social exclusion.1,2 Social exclusion includes harmful discrimination, income inequality (poverty) and unemployment, which eventually lead to a reduction in social acceptance with regards to those with a mental illness.3–5 Therefore, there is a dire need to answer calls for a safer society by reducing this stigmatization. There is no doubt that young people need to participate in such a society in the future, but this group has a greater degree of negative attitudes than adults on the topic of perception of people with mental health.6

Second, there is an issue about the use of mental health services among young people, as many individuals experience the onset of psychiatric symptoms in their adolescent years.7 Past reports indicate that 10% of young people in the UK and 14–18% of young people across Europe have mental disorders.8,9 Nevertheless, young people are less likely to access mental health services because of stigma.10 Stigma in society can deter the initiation of help from an individual suffering from mental health problems because they are labeled as abnormal in society.11 Meanwhile, early detection and treatment of psychosis have attracted a high level of interest from mental health professionals at the next stage of treatment for mental illness. There is accumulating evidence that shows that the diminishment of the duration of the untreated period can contribute to improved outcome in individuals with mental illness, including total symptoms, overall functioning and social functioning.12,13 This may imply that reduction of stigma leads to better access to mental health services and better mental health among young people. In that context, it appears to be necessary for health professionals to focus on young people when they try to reduce stigma.

While many studies have sought better educational interventions to reduce stigma, there are various types of programs. Educational interventions are roughly classified into the following three methods: direct contact, indirect contact and an explanation about (people with) mental illness by professionals. As a number of studies have pointed out, direct contact with stigmatized people can often contribute to lessening stigma.14,15 However, recent efforts to combat stigma towards people with mental illness have produced several other ways. For example, some studies reported that videos or computer programs (indirect contact) that show the lives of people with mental illness were also useful in reducing stigmatization among young people.16–18 Furthermore, even a short lecture can sometimes change young people's stigmatization.19 However, it may be unclear for intervention providers to select which ways are most effective in reducing stigmatization in young people. Therefore, the purpose of the current study was to identify the key to reduction of stigma, classify the types of the programs, and point out potential future issues.

METHODS

Selection criteria

We included and examined the studies that have assessed the effects of educational interventions for reducing stigma and increasing awareness of mental health problems among young people. Educational interventions for children, adolescents or young people, including medical, nursing and psychology students, were included. However, the studies that assessed the effects of educational intervention on adults or that combined young people with adults were excluded. We focused on educational interventions performed in schools, classes, sessions, lectures, colleges or universities. National and media campaigns were excluded. We also excluded the studies that evaluated whole course curriculums and compulsory tasks for study participants, such as a practical training or a clerkship in medical and nursing departments. In addition, the studies that combined mental health and other health or social educational interventions were excluded. All randomized controlled trials (RCT), non-randomized controlled trials, and pre/post studies were included. The studies assessing participants' views only after intervention were excluded.

Search methods

MEDLINE (1950–2009), PsycINFO (1806–2009) and Academic Search Complete were searched using the terms ‘mental’, ‘psychiatric’, ‘schizophrenia’, ‘educational programme (program)’, ‘(educational) intervention’, ‘campaign’, ‘stigma’, ‘awareness’, ‘prejudice’, ‘discrimination’, ‘knowledge’, ‘attitude’, ‘social distance’, ‘young people’, ‘adolescence’, ‘student’ and ‘children’. The search included articles that could be gained as full texts at King's College London and Oxford Brookes University and had been published until September 2009. Only articles in English were included.

Definition of interventions and effects

In order to find key components of interventions, interventions were classified into the following three categories. (i) Contact condition (CC): intervention included an opportunity for young people to meet people with mental health problems. (ii) Video-based contact condition (VCC): intervention included any media that describes people with mental illness. (iii) Educational condition (EC): interventions only included a presentation by professionals and did not include CC or VCC.

When studies did not show the changes in means of overall results from measurements of intervention group and comparison group or between pre- and post-test, we decided each educational intervention was effective, if statistically significant differences in the means or proportions were observed in more than half of the items in each measurement.

RESULTS

Study design of evaluation

The combination of the above three methods found 40 studies.16–55 Comparisons of the studies are shown in Table 1. In 21 studies, the participants were university or college students, including those studying medicine, nursing and psychology17–37 and 18 studies included children or adolescents aged younger than 18 in schools.38–55 One study included both school students (under 18) and college students.55

Table 1.  Descriptions and effects of educational interventions included in this review
Authors (year), study designIntervention (length) and [types of education]*Types of participantsSample sizeLong-term follow upOutcomes
  • Intervention group/[comparison group]/control group: participants in comparison group took other form of educational intervention related to (people with) mental health problems, and participants in control group took no education or other educational intervention not related to (people with) mental health problems.

  • (+) significant positive change in each outcome measurement; (–) no significant positive effect; and (?) not mentioned in articles.

  • §

    There was no control group.

  • Anti-stigma computer-assisted education (Anti-Stigma COED) includes three components of stigma: cognitive, emotional and behavioral problems.

  • AB, actual behavior; AT, attitudes or attribute; AW, awareness of own mental health or help seeking intentions; CC, Contact condition; CCT, clinical controlled trial (non-randomized controlled trial); COED, computer-assisted education; EC, educational condition; K, knowledge; PP, pre–post test study; RCT, randomized controlled trial; S, social distance or acceptance; VCC, Video-based contact condition; WHO, World Health Organization; WPA, World Psychiatric Association.

Contact condition     
 Desforges et al.(1991), RCT25An educational workshop (50 min) (Scripted cooperative interaction [CC] or Jigsaw cooperative interaction [CC]) vs Individual study [EC]Undergraduate students33/[31]/[31]§ AT(+), S(+)
 Corrigan et al. (2001), RCT26A presentation by users [CC] vs An education presentation about myth [EC] or An educational presentation about suppressing stigmatizing attitudes [EC] (each 15 min, including discussion)Community college students152, including intervention, comparison and control groups AT(+)
 Corrigan et al. (2002), RCT27Contact with a person with serious mental illness and discussion about personal responsibility [CC] or Contact and discussion about dangerousness [CC] vs (each 15 min, including discussion) An educational session on personal responsibility [EC] or An educational session on dangerousness [EC]Community college students213, including intervention, comparison and control groups AT(+), S(+)
 Reinke et al. (2004), RCT28A presentation by users [CC] vs A video presentation highly disconfirming stereotypes [VCC] or A video moderately disconfirming stereotypes [VCC] or A video little disconfirming stereotypes [VCC] (each 15 min, including discussion)Community college students164, including intervention, comparison and control groups S(+)
 Wood & Wahl (2006), RCT29Educational sessions, including a presentation by users, video and discussion [CC]Undergraduate students57/57 K(+), AT(+), S(+)
 McConkey et al. (1983), Cluster-RCT396 educational sessions (each 40 min), including role-play, video, discussion, workshop, and visitation in a local centre for people with mental illness [CC]Secondary school students197/2133 monthsK(+), AT(+), AB(+)
 Husek (1965), CCT41A presentation by users (20 min) [CC]High school students498, including intervention and control groups AT(+)
 Ng & Chan (2002), CCT4210 educational sessions, a joint-school mental health promotion day, presentation by users, and visitation to mental health hospitals [CC]Secondary school students79/907 monthsK(−), AT(+), S(+)
 Schulze et al. (2003), CCT435 educational sessions, including artwork, games and discussions [CC]Secondary school students90/601 monthK(+), AT(+), S(+)
 Rickwood et al. (2004), CCT44An educational session, including a presentation by users, and discussion (50–90 min) [CC]High school students207/38 AT(+), S(+), AW(−)
 Altindag et al. (2006), CCT31A lecture, including a presentation by a user and famous video (Beautiful Mind) [CC]Medial students25/352 monthsK(–), AT(–), S(–)
 Sadow & Ryder (2008), CCT32Brief psychosocial education + a presentation by users [CC] vs Psychological education [EC]Nursing students30/[27]§ K(+), AT(+), S(+)
 Chovil (2004), PP47A presentation by users about the causes of mental illness and their painful experiences of mental illness (75 min) [CC]Mostly 16-year-old students1370 AW(+)
 Pinfold et al. (2005), PP53An educational workshop with people with mental illness [CC]Middle or secondary school students512 (UK), 634 (Canada) K(+), S(+)
 Twardzicki (2008), PP37Arts educational program [CC]Undergraduate students43 K(?), AT(?)
 Spagnolo et al. (2008), PP54A presentation by users (1 h) [CC]High school students277 AT(+)
 Brown (2009), PP35Educational sessions: faith-based initiatives [CC]Nursing students38 AT(+)
Video-based contact condition
 Penn et al. (2003), RCT22A documentary film about a person with schizophrenia [VCC] vs An animal film or A weight-fear film (each 43–70 min)Undergraduate students38/[41]/[40]/39 AT(+), S(–)
 Corrigan et al. (2007), RCT23A contact-video [VCC] vs An education-video [EC] (each 10 min)Community college students244, including intervention and comparison groups§1 weekAT(+)
 Finkelstein et al. (2007), RCT17A web-based anti-stigma program using COED[VCC] vs Reading the book by WHO [EC]Undergraduate students32/[36]/236 monthsAT(+), S(+)
 Finkelstein et al. (2008), RCT18A web-based anti-stigma program using COED[VCC] vs Reading the book by WHO [EC]Undergraduate students69/[76]/486 monthsK(+), AT(+), S(+)
 Mann & Himelein (2008), Cluster- RCT24Humanizing classes (6 h), including reading and video [VCC] vs Traditional psychological classes [EC]Undergraduate students on psychology course27/[26]§ S(+)
 Chan et al. (2009), Cluster- RCT16Education (30 min) + A video (15 min) [VCC] or A video + education [VCC] vs Education (30 min) [EC]Secondary school students94/[73]/[88]§1 monthK(+), AT(+), S(+)
 Naylor et al. (2009), CCT406 educational sessions, including films (each 50 min) [VCC]Secondary school students149/2076 monthsK(+), AT(+)
 Pinfold et al. (2003), PP502 educational sessions, including video and workshop [VCC]Secondary school students4726 monthsK(+), S(–)
 Watson et al. (2004), PP515 educational sessions (each 45 min), including video and discussion [VCC]Middle school students1566 K(+), AT(+)
 Stuart (2006), PP52A video-based educational program [VCC]High school students330 K(+), S(–)
 Lapshin et al. (2006), PP36Anti-stigma COED system [VCC]Medical students51 AT(+)
Educational condition     
 Rahman et al. (1998), RCT38Educational sessions, including speech, essay-writing, poster-painting competitions, and skits [EC]Secondary school students50/50 K(+), AT(+)
 Masuda (2007), RCT20Acceptance and commitment therapy [EC] vs Usual education about psychological disorder and stigma [EC] (each 2 h 30 min)Undergraduate students on psychology course47/[38]§1 monthAT(+), S(+)
 Boysen & Vogel (2008), RCT21Reading the textbook (Psychological causes [EC] vs Biological causes [EC])Undergraduate students on psychology course105/[108]§ AT(+)
 Mino et al. (2001), CCT19A lecture about Japanese mental health services and the importance of community care (1 h) [EC]Medical students95/94 AT(–), S(+)
 Lincoln et al. (2008), CCT30Biogenetic education [EC] vs Psychosocial education [EC]Psychology and medical students81/[39]§ K(+), AT(–), S(+)
 Morrison et al. (1979), PP45Educational session about causes and stereotypes (50 min) [EC]High school students245 weeksK(+), AT(+)
 Read et al. (1999). PP334 lectures about cause of mental illness [EC]Psychology students126 K(+), AT(+)
 Lauria-Horner (2004), PP46Educational sessions by school teachers [EC]Elementary school students158 K(+), AT(+), AW(?)
 Essler et al. (2006), PP48Educational sessions, including quiz, drama and game [EC]Secondary school students1041 monthK(+), AT(+)
 Roberts et al. (2007), PP553 educational sessions, including drama, discussion and feedback [EC]Age 14–2213676 monthsK(–), AT(–), AW(+)
 Schmetzer et al. (2008), PP34A presentation by families of people with mental illness (1 h) [EC]Medical students669 K(+), AT(–)
 Hoven et al. (2008), PP49Educational sessions using awareness manual by WPA and WHO [EC]Mean age: 14.224721 monthK(?), AT(?), AW(?)

In order to examine the effects of each educational intervention, fifteen studies performed random allocation between an intervention group and control or comparison groups (RCT and cluster RCT).16–18,20–29,38,39 Nine studies used a control group or comparison group that were provided different types of educational intervention (clinical controlled trial).19,30–32,40–44 Other studies were contacted pre- and post-test to assess young people's stigmatization without control or comparison groups (pre/post study).33–37,45–55 In addition, there were 14 studies that conducted long-term follow ups.16–18,20,31,37,38,42,43,45,48–50,55 Of those, nine studies performed both post-test and long-term follow ups.16–18,20,31,39,43,50,55

Educational intervention strategies

The interventions in 12 studies were composed of only education: providing information about people with mental health problems, psychiatric services or causes of mental illness (EC).19,21,22,30,33,34,38,45,46,48,49,55 Eleven studies included videos or other media instruments (e.g. computer- or web-based education) that introduced persons with mental health problems and showed their actual lives (VCC).16–18,22–24,36,40,50–52 With regards to two studies that used videos in their educational interventions, we could not identify from the articles whether videos introduced persons with mental health problems or just provided information about mental illness in the video.40,51 On the other hand, 17 studies attempted to give participants opportunities to have contact with people with mental health problems (CC).25–29,31,32,35,37,39,41–44,47,53,54

Three studies directly compared the effects of the CC and EC,26,27,32 and one study evaluated both the effects of the CC and the VCC.28 In addition, two studies tried to compare the effects of the VCC and the EC.16,23

Effects of educational interventions

Twenty-three studies measured participants' knowledge about (people with) mental health problems.16,18,29–34,37–40,42,43,45,46,48–53,55 Significant changes of knowledge by educational interventions were reported in 18 of those studies.16,18,29,30,32–34,38–40,43,45,46,48,50–53 Attitudes (or attributions) towards people with mental health problems were assessed by 34 studies.16–23,25–27,29–46,48,49,51,54,55 A total of 27 studies found significant improvements in young people's attitudes.16–18,20–23,25–27,29,32,33,35,36,38–46,48,51,54 Twenty studies measured the change in social distance,16–20,22,24,25,27–32,42–44,50,52,53 and 16 found significantly positive effects.16–20,24,25,27–30,32,42–44,53 Only one study measured actual behavioral changes, and reported that students voluntarily visited the local centre for people with mental illness after the educational intervention, including the CC.39 Five studies evaluated the participants' awareness of their own mental health or help-seeking intentions,44,46,47,49,55 and two of these studies had significant improvement.47,55 However, it was reported that there was a difficulty in maintaining participants' changed knowledge, attitudes and social distance between post-survey and follow up.16–18,20,43,50

Specific components of interventions and effects

In the CC and EC, two studies that were focused on perceived dangerousness or violence of people with mental illness had improved participants' attribution towards people with mental illness.26,27 A further two studies reported that information about psychosocial causes of mental disorders was effective in improving students' attitudes, although they partly acknowledged the positive effects of biological information.21,33 Specifically, in one study, a biological explanation led psychology students to have unfavorable views of patients' prognosis, but contributed to lessening the social distance and removing blame from patients for having a mental illness.30

Three studies that directly compared the EC and the CC showed favorable positive effects of reducing stigmatization in the CC.25,26,32 With regards to the VCC, there were varying effects where one study found that this condition could be more effective to promote positive attitudes and reduce social distance than the EC.16 However, other research has indicated that indirect contact using a video, which showed the lives of people with mental health problems, had slightly smaller effects in changing social distance, compared to direct contact.28 Penn et al. also highlighted this limited effect on improving social distance with regards to using a documentary film about a person with schizophrenia.22 On the other hand, three interventions that provided indirect contact through videos or the Internet displayed significant improvements in social distance.17,18,36 One study found that the video in which people with mental illness talked about symptomatology, successful events or recovery processes and daily life produced a significant improvement in young people's social distance, compared to the videos in which people with mental illness stressed their symptoms or triumphal events only.28 Another study compared the effects of two educational videos, one of which introduced patients (VCC), while the other just provided psychiatric information. The results of this study showed a more positive effect on improving attributions towards people with mental illness from the former condition.23

With self-awareness in mental illness, one study focusing on help-seeking behavior reported that the intervention with the CC had positive effects.47 Despite the significant improvement in stigmatization towards others with mental illness, one study did not find alterations in help-seeking intentions.44 An intervention including drama, discussion about mental illness and feedback (EC) had a positive effect on improving mental health awareness but not on knowledge and attitudes towards people with mental illness.55

DISCUSSION

The current review found that there were some effective strategies to reduce stigmatization and relatively weak evidence of the long-term effects and changes in behavior in most of the studies.

In terms of components of education, there are two types of possible educational components that focus on the perceived dangerousness of people with mental health problems and the causes of mental disorders in order to overcome misunderstanding of mental health problems.

Regarding the dangerousness of people with mental illness, both young people and older people in the general public are likely to link people with mental illness and the idea of violence.56,57 Some of the RCT in the current review tried to overcome this issue, and reported their success in reducing stigmatization.26,27 It seems to be necessary to remove misunderstandings regarding dangerousness from participants for an educational intervention. Thornicroft emphasizes that people with only depression or schizophrenia are not substantially dangerous, although the combination of schizophrenia and substance abuse increases the crime rates.3 We can provide students with the information that a single diagnosis of mental disorder is not always associated with dangerousness.

Other aspects of the components in interventions are more debatable. Some studies have emphasized the importance of dissemination of knowledge about the biological causes of mental health problems in order to improve people's perception and awareness.58,59 Nevertheless, sometimes, knowledge about brain disease as a cause of mental illness may have small effects in reducing stigma.60 Indeed, some studies in this review found small effects of biological information on improving attitudes towards people with mental illness.21,33 A review of association between biological or psychological information and attitudes towards people with mental illness found that biological information often labeled ‘illness’ as people with mental health problems, and so led people to have more negative attitudes.61 However, an unbalanced explanation only about biological or psychological information may be unfair, even though some people prefer psychosocial information about causes of mental disorder to biological information. It is also true that biological information can contribute to improving stigmatizaiton.30 Corrigan and Watson suggest that it could be better to keep balanced approaches between biological and psychosocial explanations about the causes of mental disorders.62 It is, therefore, recommended that the information include both the brain structures and the psychosocial risk factors.

Although the provision of accurate knowledge could be an essential first step to reducing stigmatization, numerous studies have consistently pointed out the importance of contact with minority groups, which seems to be key in reducing stigma.14,15 Some studies in this review directly compared the EC and the CC and showed more positive effects of reducing stigmatization in the CC.25,26,32 Moreover, one study involving the CC, interestingly, noted possible changes in actual behaviors, indicating that students voluntarily visited a center for people with mental illness after educational intervention.39 Therefore, involvement of people with mental health problems in educational intervention can be the most important and helpful way to ameliorate stigma.

In comparison to the CC, the effects of the VCC appear to be less explicit. The discrepancy effects of the VCC may derive from sample selection, sample size or methods of evaluation. Another possible assumption is that individuals in the videos may need to introduce their name and background, and focus more on their successful life events or recovery process, as made explicit in the CC.28,29 The evidence suggests the importance of a balanced presentation including patients' symptoms, their lives, and successful events. However, there are limitations to determining the effective components of the video, one example being that each study used different videos and achieved different outcomes in the VCC. There are few replicated studies that have used the same videos. There is also sometimes a lack of information about the video in each article, withholding vital information. The use of the video as an indirect contact in an educational intervention is obviously a brief and more cost-effective encounter than the settings of direct contact.52 There might be a need to examine the components of videos more in order to clarify the effective contents of the videos.

There are also discrepancy effects on improvement in awareness or help-seeking intentions. One explanation for the different effects of interventions is the material involved within that presentation, where Chovil's study particularly attempted to facilitate help-seeking intentions,47 while Rickwood et al. did not focus only on improvements in help-seeking intentions but also knowledge of and social distance towards people with mental illness.44 However, there is another possible consideration that stigmatization towards people with mental illness is not directly related to the awareness of one's own mental health and actual help-seeking behaviour.63 For another example, Roberts's study showed significant improvement in help-seeking intentions rather than knowledge and attitudes toward people with mental illness.55 Therefore, we may need to separate stigma reduction and health promotion, and perform other special interventions to improve help-seeking behavior. An intervention aimed at enhancing help-seeking behavior may consist of information about effects of psychotherapy for psychosis, therapeutic processes and possibility of recovery rather than about characteristics of people with mental health problems. Such interventions may help young people understand psychiatric remedy and the benefits of therapy, and encourage them to use services.

Limitation in evaluation of educational intervention and future issues

There are some limitations of educational interventions and the evaluation of these. First, most of the studies did not perform a long-term follow up, but conducted pre- and post-tests to assess the effectiveness of their educational interventions. In terms of RCT, only five studies measured the long-term effects of educational intervention.16–18,20,39 It might be more important to examine long-term improvements in young people's stigmatization rather than its temporary changes. Indeed, all studies that had both a post-test and a long-term follow up reported decreases in the effects of educational intervention in the long-term follow up, compared to the post-test.16–18,20,31,39,43,50,55 Therefore, further research is needed to plan the long-term study design, and concurrently address the development of an educational intervention enabling young people to maintain their improved stigmatization.

Second, although the term ‘stigma’ includes discrimination or discriminative behaviour,64,65 a few studies assessed behavior against people with mental health problems.66 One study assessed the number of visits to the local center for people with mental health problems as students' behavioral changes, although this did not directly evaluate discriminative behaviors.39 A possible assumption is that day-to-day contact with people with mental health problems can be effective in changing stigmatization.3 However, it is also assumed that there may be no link between the numbers of simple visits and actual discrimination. Furthermore, it is unclear whether students could maintain their attitudes or behavior towards service users in the local center without structured programs. In short, none of the studies in this review properly measured the actual behavior change.

However, it may be difficult to assess the changes in discriminatory behavior during short study periods, because behavioral changes usually take longer than knowledge and attitude changes. Social distance seems to be more proximate to discriminative behavior and to be more predictable for people's acceptance, at least, than knowledge and attitudes.4,67 However, it is still controversial whether social distance can predict future discriminative behavior. In other words, simple improvements in social distance may not lead participants to change their behavior in the real world. It is, therefore, suggested that the priority is given to assess discriminative behavior directly. Then, social distance or behavioral intentions scales can be used, when studies have difficulties in measuring actual behaviors.

Similarly, two studies have shown that their educational intervention improved awareness of one's own mental health problems in young people, but have not evaluated the changes in young people's actions.47,55 It is imperative that young people use services following educational interventions, if they themselves have mental health troubles. Thus, we need to evaluate not only awareness about one's own mental health and help-seeking intentions, but also the real use of services after educational interventions: for example, gathering of numbers for the use of counseling services in school or a psychiatric consultation rate among participants.

Study limitations

The current study was limited to published journal articles in English, and to those available as full texts at Oxford Brookes University and Kings College London databases. There could be other research assessing the reduction of stigma and the increase of awareness that was inaccessible. Additionally, we may have overlooked some studies involving educational interventions that could contain relevant information regarding the purpose of this study.

Conclusion

The current study attempts to find better strategies to reduce stigmatization towards people with mental health problems in young people. Each educational intervention could contribute to the enhancement, either or collectively, of knowledge, attitudes, social distance towards people with mental illness, and/or awareness of one's own mental health problems. We suggest that an educational program should have information that can remove a belief about the dangerousness of people with mental illness from young people, and components that include a balanced approach between biological and psychological causes of mental disorders. In particular, involvement of people with mental illness seems to be key to reducing stigmatization. It is, therefore, suggested that priority is given to set up the situation in which young people meet people with mental illness in an educational program. However, evidence on the effect of the VCC should be accumulated in the future, as certain components of the videos are still debatable. In addition, an intervention aimed at improving mental health awareness should be developed, for example, including information about psychotherapy for psychosis, therapeutic processes and the possibility of recovery. Despite the demonstration of positive effects of each educational intervention, the long-term effects may still be unclear because of the short study periods involved. Further research needs to measure actual discriminative behavior (at least social distance) and actual help-seeking behavior (e.g. the use of mental health services), and to perform a long-term follow up to achieve consistency in rating stigmatization.

Ancillary