research literature mental health

• Research article
• Open access
• Published: 01 May 2020

A systematic literature review of existing conceptualisation and measurement of mental health literacy in adolescent research: current challenges and inconsistencies

• Rosie Mansfield   ORCID: orcid.org/0000-0002-8703-5606 1 ,
• Praveetha Patalay 2 &
• Neil Humphrey 1  

BMC Public Health volume  20 , Article number:  607 ( 2020 ) Cite this article

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With an increased political interest in school-based mental health education, the dominant understanding and measurement of mental health literacy (MHL) in adolescent research should be critically appraised. This systematic literature review aimed to investigate the conceptualisation and measurement of MHL in adolescent research and the extent of methodological homogeneity in the field for meta-analyses.

Databases (PsycINFO, EMBASE, MEDLINE, ASSIA and ERIC) and grey literature were searched (1997–2017). Included articles used the term ‘mental health literacy’ and presented self-report data for at least one MHL domain with an adolescent sample (10–19 years). Definitions, methodological and contextual data were extracted and synthesised.

Ninety-one articles were identified. There was evidence of conceptual confusion, methodological inconsistency and a lack of measures developed and psychometrically tested with adolescents. The most commonly assessed domains were mental illness stigma and help-seeking beliefs; however, frequency of assessment varied by definition usage and study design. Recognition and knowledge of mental illnesses were assessed more frequently than help-seeking knowledge. A mental-ill health approach continues to dominate the field, with few articles assessing knowledge of mental health promotion.

Conclusions

MHL research with adolescent samples is increasing. Results suggest that a better understanding of what MHL means for this population is needed in order to develop reliable, valid and feasible adolescent measures, and explore mechanisms for change in improving adolescent mental health. We recommend a move away from ‘mental disorder literacy’ and towards critical ‘mental health literacy’. Future MHL research should apply integrated, culturally sensitive models of health literacy that account for life stage and acknowledge the interaction between individuals’ ability and social and contextual demands.

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Around 50% of mental health difficulties have their first onset by age 15 [ 1 , 2 ] and are associated with negative outcomes such as lower educational attainment and physical health problems [ 3 ]. Approximately 10–20% of young people are affected worldwide, and many more will experience impairing mental distress at varying degrees across the mental health continuum [ 4 , 5 , 6 , 7 , 8 ]. Adolescence is a critical period of transition, characterised by physical, cognitive, emotional, social and behavioural development [ 9 ]. It has therefore been identified as a particularly important developmental phase for improving ‘mental health literacy’ (MHL) and promoting access to mental health services [ 10 , 11 ]. However, better understanding of the conceptualisation and measurement of MHL in this population is needed.

MHL was first defined as ‘ knowledge and beliefs about mental disorders which aid their recognition, management or prevention’ ( [ 12 ] pp 182) and consisted of six domains: ‘1) the ability to recognise specific disorders or different types of psychological distress; 2) knowledge and beliefs about risk factors and causes; 3) knowledge and beliefs about self-help interventions; 4) knowledge and beliefs about professional help available; 5) attitudes which facilitate recognition and appropriate help-seeking, and 6) knowledge of how to seek mental health information’ ( [ 13 ] pp 396). Domains were later revised to include early recognition, prevention and mental health first aid skills [ 14 ]. The most recent definition comprises four broad domains aligned with current definitions of health literacy: ‘1) understanding how to obtain and maintain positive mental health; 2) understanding mental disorders and their treatments; 3) decreasing stigma related to mental disorders, and 4) enhancing help-seeking efficacy (knowing when and where to seek help and developing competencies designed to improve one’s mental health care and self-management capabilities’ ( [ 15 ] pp 155).

In a review of MHL measurement tools, O’Connor et al. revealed that the most commonly assessed domain was recognition of mental disorders. No studies assessed either knowledge of how to seek information or knowledge of self-help interventions [ 16 ]. The focus on recognition of mental disorders, along with knowledge about risk factors, causes and appropriate treatments, has been criticised for promoting the psychiatric and biogenetic conceptualisation of mental illness [ 17 , 18 ]. Despite being found to reduce blame, biogenetic explanations and attributions can lead to misconceptions about dangerousness and unpredictability and pessimism about recovery [ 19 ]. Early research also suggested that biogenetic causal theories increase a desire for social distance [ 20 , 21 ]. MHL modelled on recognition of psychiatric labels, and diagnostic language such as ‘disorder’, often leads to psychosocial predictors being ignored, and more negative attitudes towards individuals experiencing mental distress [ 22 , 23 ].

These criticisms, in line with broader socio-cultural approaches to literacy [ 24 ] understand MHL as a socio-political practice used to communicate, and make dominant, the psychiatric discourse. This appears to undermine attempts to reduce stigma, the most common outcome of school-based MHL interventions [ 25 ]. In their review of MHL measurement tools, O’Connor et al. excluded all disorder specific scales, claiming that ‘ MHL by definition should encompass knowledge and attitudes relating to a range of mental health disorders and concepts .’ ( [ 16 ] pp 199). Chambers et al. further criticised current MHL definitions for being narrow in focus with a predominantly mental-ill health approach, ignoring the complete mental health state that goes beyond the dichotomy of illness and wellness [ 26 , 27 ]. The difference between literacy about mental disorders and the ability to seek out, comprehend, appraise and apply information relating to the complete mental health state is an emerging point of discussion, and has seen MHL re-defined to include self-acquired knowledge and skills relating to positive psychology [ 28 , 29 ]. This aligns with the World Health Organisation’s (WHO) definition of mental health, which includes subjective wellbeing, optimal functioning and coping, and recognises mental health beyond the absence of disorder [ 30 ].

In response to increasingly inclusive definitions of MHL, Spiker and Hammer presented the argument for MHL as a ‘multi-construct theory, rather than a multi-dimensional construct’ ( [ 31 ] pp 3). The proposal suggested that by stretching the MHL construct, researchers have reduced the consistent use of the definition across studies, resulting in heterogeneous measurement [ 32 ]. Reviews of the psychometric properties of MHL measurement tools support this argument, and conclude that more consistent measurement with valid scales is needed [ 33 , 34 , 35 , 36 ]. Spiker and Hammer also outline problems with construct irrelevant variance [ 31 ], in which measures capture more than they intended to. Furthermore, they note that construct proliferation or the ‘jingle jangle fallacy’ [ 37 ], in which scales may have different labels but measure the same construct, and vice versa, increase problems with discriminant validity. Understanding MHL as a multi-construct theory could help delineate between its broad domains: recognition, knowledge, stigma and help-seeking beliefs, and acknowledge their complexity.

Internationally, there is growing political interest in child and adolescent mental health promotion and education [ 6 , 38 ]. Despite limited evidence, it is suggested that educating the public by improving their ability to recognise mental disorders, and increasing help-seeking knowledge, can promote population mental health [ 39 , 40 ]. Furthermore, a reduction in stigmatising attitudes is consistently reported to improve help-seeking [ 41 , 42 ]. MHL, by definition, includes these interacting domains. However, despite a comprehensive set of reviews that assess the psychometric properties of MHL measurement tools [ 33 , 34 , 35 , 36 ], there is no systematic literature review, to date, that assesses the current conceptualisation and measurement of MHL across adolescent research. Being able to clearly operationalise what is meant by a MHL intervention and meta-analyse their effectiveness, will have implications for the investment in school and population level initiatives. Similarly, being able to conduct time trend analyses that plot possible improvements in adolescents’ MHL against mental health outcomes, will reveal the extent to which population level improvements in MHL promote mental health. First though, we must have a clear picture of the understanding of MHL in adolescent research and how it is currently being measured.

Objectives and research questions

The aim of the current study was therefore to examine the ways in which MHL has been conceptualised and measured in adolescent research to date, and explore the extent of methodological homogeneity in the field for meta-analyses. We set out to answer the following research questions: 1) What are the most common study designs, contexts, and aims? 2) How is MHL conceptualised? 3) What are the most commonly measured domains of MHL, and do these vary by study design and definition usage? 4) To what extent do articles use measures that have evidence of validity for use with adolescent samples? 5) Is there enough methodological homogeneity in the field to conduct meta-analyses?

A protocol was published on PROSPERO in December 2017 (reference: CRD42017082021 ), and was updated periodically to reflect the progress of the review. Relevant PRISMA guidelines for reporting were followed [ 43 ].

Eligibility criteria

Articles were included with adolescent samples aged between 10 and 19 [ 44 ]. Samples with a mean age outside of this range were excluded. If no mean was presented and the age range fell outside of the criterion, articles were only included if results were presented for sub-groups (e.g. 12–17 years from a sample aged 12–25). General MHL and diagnosis-specific literacy research was included. Articles with quantitative study designs and extractable self-report data for at least one time point measurement of any MHL domain were eligible. These criteria ensured that only articles with extractable data from adolescents, who had not yet received any form of intervention were included. At the full text screening phase, articles published before 1997, based on the date of the first MHL definition [ 12 ], and those that did not explicitly use the term ‘mental health literacy’ or a diagnosis-specific equivalent (e.g. ‘depression literacy’) were excluded. By applying this criterion, the current study was able to present the number of articles that measured domains without referring to MHL. Identifying cases where researchers measure the same construct but use different labels is important when considering conceptualisation and meta-analyses.

Only articles available in English were included. Specific populations such as clinical/patient populations and juvenile offenders were excluded, as were university students. In contrast to schools in most countries, universities are not universal, with only a sub-set of young people entering higher education. University samples were therefore not seen as representative and often included participants outside the age criterion. Post-partum and later life neurocognitive disorders (e.g. Alzheimer’s disease) were removed given their limited relevance for this age group. In line with other MHL reviews [ 33 ], articles with a focus on substance abuse were excluded to avoid reviewing a large number of adolescent risk behaviour studies and substance abuse prevention programmes.

Search strategy

The search strategy was developed to include a number of combinations of terms to ensure that literature relating to different domains of MHL were captured. Population terms such as ‘adolescen*’ or ‘young people*’ had to be present and mental health related terms (e.g. ‘mental health’ and ‘mental disorders’) were exploded to capture general MHL and diagnosis-specific studies. Similarly, outcome terms (e.g. ‘health literacy’ and ‘health education’) were exploded, and domain specific terms included (e.g. ‘knowledge’, ‘recogni*’, ‘attitud*’, ‘stigma*’, ‘help-seek*’, ‘prevent*’ or ‘positive*’). See Additional File 1 . for an example search strategy.

Data sources

The following databases were searched from their start date to the search dates (November 2017): PsycINFO, EMBASE, MEDLINE, ASSIA, and ERIC. Key authors were also contacted to identify grey literature. References were harvested from related reviews and all papers identified in the search. Hand searches of key authors’ publication lists were also conducted, and Google Scholar was used to find studies known by the authors but not identified in the database searches.

Article selection

Results from the database searches were saved to Endnote and duplicates were removed. The lead author screened the article titles and abstracts to identify those that met the inclusion criteria. Full texts were then screened and reasons for exclusion were recorded. Any uncertainties were resolved through discussion with other members of the research team. A sub-set of 20 articles were screened at full text stage by the third author, and a strong level of agreement was found (k = .78, p  = .001).

Data extraction

Research was assessed on an article level (rather than by study) for the purposes of investigating the conceptualisation of MHL. The fact that authors break MHL down into component parts to write separate articles is support for identifying which domains are more commonly associated with the use of the term. Data on the following methodological factors were extracted from eligible articles using a uniform data extraction form: year of publication, country and setting (community (research conducted outside of the school setting e.g. population level surveys) vs. school-based research), study design (intervention vs. population-based), primary aims, MHL definition and use of the term, general MHL vs. diagnosis-specific literacy, number/types of MHL domains measured, and measurement tools (e.g. vignette, yes/no, Likert scales).

Data analysis

A content analysis was conducted using NVivo 12 to organise articles by their primary aim and understand the conceptualisation of MHL based on the definition presented and use of the term. Frequencies and percentages for each group were calculated and articles coded based on whether they included items related to general MHL or diagnosis-specific literacy. Existing definitions of MHL [ 12 , 13 , 14 , 15 , 28 ] were used to create a coding framework that clearly delineated its broad constituent domains (e.g. recognition, knowledge, stigma and beliefs), the object of these domains (e.g. mental illnesses, mental health prevention and promotion, and help-seeking), and their directionality (e.g. self vs. other) – see Fig.  1 .

MHL Coding Framework

Mental illness stigma was assessed using existing conceptualisation i.e. personal and perceived stigma relating to self (intra-personal) and others (inter-personal), and broad domains (e.g. attitudes and beliefs, emotional reactions, and social distancing) [ 45 ]. The coding of help-seeking beliefs was informed by the theory of planned behaviour [ 46 ], assessing not only help-seeking intentions but also help-seeking confidence and self-perceived help-seeking knowledge, perceived helpfulness of referrals, help-sources and treatments, help-seeking stigma and perceived help-seeking barriers. A distinction was also made between help-seeking beliefs for self (intra-personal) vs. others (inter-personal). Although not explicitly included in any MHL definition, help-seeking behaviour was also assessed as the term is sometimes confused with help-seeking intentions. Domains were coded at an item level due to many articles presenting this form of data (e.g. % of sample that answered each item correctly as opposed to a scale mean). Frequencies and percentages were produced across all articles and by study design and definition usage.

Assessment of measures

An assessment of all MHL related measurement tools was conducted in order to assess methodological homogeneity across articles, and whether there was evidence that the measures were psychometrically valid for adolescent samples. In order to present instruments with the most comprehensive psychometric assessments, measures were coded based on whether an article existed with the primary aim of establishing its psychometric properties with an adolescent sample.

Article selection and characteristics

In total, 206 articles were identified that presented extractable adolescent data on at least one MHL domain. Of these, 91 articles (44%) used the term ‘mental health literacy’. Those that did not use the term ( N  = 115, 56%), were therefore not perceived to have intended to explicitly measure the construct and were not included beyond this point. (see Fig.  2 . for a PRISMA flowchart of articles, Additional File 2 . for the full set of coded articles, and Additional File 3 . for the reference list of included articles).

PRISMA Flowchart of Included Studies

Synthesised findings

Design, context and aims.

Figure  3 shows the number of publications by year and country. Australian research dominated the field up until 2013, at which point there was an increase in research being published globally. Australia (34%), USA (15%), Canada (9%), Republic of Ireland (9%) and the UK (8%) have published the majority of research between 2003 and 2017.

Publication Count by Year and Country

Table  1 presents a summary of articles’ study design, context and primary aim. The majority of articles reported on school-based studies. Articles with the primary aim of describing levels of MHL also included variables such as age, school year, gender, education, socio-economic variables, occupation, urbanicity, mental health status and previous mental health service use.

• Conceptualisation

Of the 91 articles that used the term ‘mental health literacy’, only 41 (45%) defined it. The most common definition, presented by 29 out of 41 (71%) articles, was that coined by Jorm and colleagues [ 12 ]. A further 3 articles (7%) used a simplified or adapted version of this definition [ 47 , 48 , 49 ]. Four articles (10%) defined MHL as related to knowledge only (e.g. ‘knowledge of mental health problems as well as the sources of help available’ ; ( [ 50 ] pp. 485) . The full list of MHL domains presented by Jorm and colleagues [ 13 ], was included in over a third ( N  = 14, 34%) of articles that defined the term. However, there was some variation. For example, very few of these articles ( N  = 2, 14%) referred to different types of psychological distress as well as mental disorders when presenting the recognition domain. Furthermore, in most cases ( N  = 11, 79%), ‘knowledge and beliefs’ was replaced with ‘knowledge’ only, for domains relating to causes and risk factors, self-help strategies and professional help available.

A small number of articles that defined MHL ( N  = 5, 12%) presented Jorm’s additional domains relating to mental health first aid skills and advocacy [ 14 ]. Some articles ( N  = 4, 10%) provided examples of specific MHL domains, namely recognition of mental disorders and knowledge and beliefs about appropriate help-seeking and treatment, as opposed to presenting a comprehensive list. An emerging group of articles ( N  = 5, 12%) either acknowledged mental health promotion as a component of MHL or presented Kutcher and colleagues’ four broad domains including ‘understanding how to obtain and maintain good mental health’ ( [ 15 ] pp 155).

Regardless of whether a definition was provided, approximately one third of identified articles ( N  = 31, 34%) referred to MHL as a construct separate to mental illness stigma, with some suggesting that MHL predicts stigma. For example, articles described the measurement of these constructs as separate (e.g. ‘All respondents were then asked a series of questions that assessed sociodemographic characteristics, mental health literacy, stigma …’; ([ 51 ] pp. 941), and referred to or presented a relationship between the two constructs (e.g. ‘Participants with higher MHL displayed more negative attitudes to mental illness’ ; ( [ 52 ] pp. 100) . There were also instances where articles presented MHL as a predictor of help-seeking intentions and attitudes (e.g. ‘Studies indicate that in general, mental health literacy improves help seeking attitudes’ ; [ 53 ] (pp. 2), or used the term MHL to refer only to improved knowledge (e.g. ‘to assess the extent to which the students had learned the curriculum and developed what we called ‘depression literacy’ ; ([ 54 ] pp. 230).

• Measurement

Thirty-nine (43%) articles included items relating to general MHL. The exact terminology varied across studies e.g. mental disorder [ 55 ], mental illness [ 56 ], mental health problem [ 57 ], and mental health issue [ 58 ]. Few articles included items relating to mental health as opposed to mental ill-health. Bjørnsen et al. developed and validated a scale to assess adolescents' knowledge of how to obtain and maintain good mental health [ 28 ]. Kutcher et al. and McLuckie et al. also included an individual knowledge item that assessed an understanding of the complete mental health state (e.g. ‘People who have mental illness can at the same time have mental health’ ) [ 59 , 60 ].

Table  2 . presents the frequency and percentage of articles that assessed different types of diagnosis-specific literacy. In line with this focus, 57 (63%) articles utilized a vignette methodology, basing questions on descriptions, stories and scenarios relating to an individual meeting diagnostic criteria for a given mental disorder. Of these articles, 12 (21%) used comparator vignettes describing individuals with physical health problems (e.g. asthma or diabetes), control characters with good academic attainment, or ‘normal issues’ or mental health problems relating to stressful life events (e.g. the death of an elderly relative or the end of a romantic relationship). Table  3 . presents the frequency and percentage of articles that assessed different domains of MHL.

Measurement tools were too heterogeneous to conduct meta-analyses. As noted in Table 1 , four articles (4%) had the primary aim of validating MHL related measures with adolescent samples [ 28 , 55 , 61 , 62 ]. The scales assessed in Bjørnsen et al. and Pang et al. measured only one broad domain of MHL; knowledge of mental health promotion and mental illness stigma respectively [ 28 , 62 ]. Hart et al. assessed the psychometric properties of a depression knowledge questionnaire and found a one factor general knowledge latent structure to be the best fit to the data [ 61 ]. Campos et al. aimed to provide a more comprehensive assessment of MHL, and by psychometrically assessing a pool of items, developed a 33-item tool with three latent factors: first aid skills and help seeking, knowledge/stereotypes, and self-help strategies [ 55 ]. A further 22 articles (24%), stated that some items or scales had been developed for the purpose of the study.

Thirty-nine articles (43%) stated that they based their items on Jorm and colleagues original MHL survey or later 2006 and 2011 versions [ 12 , 63 ]. Furthermore, two articles (2%) included items from the Mental Health First Aid Questionnaire (MHFAQ) as detailed by Hart et al. [ 64 ]. However, there is no evidence of the validity of these surveys as whole scales, and researchers commonly selected and modified items. The Friend in Need Questionnaire, similar to Jorm and colleagues MHL survey in that it covers multiple MHL domains, was developed by Burns and Rapee to avoid leading multiple-choice answers. Instead, open-ended responses were coded in order to quantify levels of MHL [ 65 ]. Despite finding six articles (7%) that utilised a version of this questionnaire, no published validation paper was found. As part of the Adolescent Depression Awareness Programme (ADAP), an Adolescent Depression Knowledge Questionnaire (ADKQ) was developed and later validated [ 61 ]. Six articles (7%), including the validation paper, presented data using versions of the ADKQ.

Due to the multi-faceted nature of stigma, a range of measurement tools were identified across articles. The Attribution Questionnaire (AQ-27) was originally developed by Corrigan and colleagues [ 66 , 67 ] along with a brief 9-item scale (r-AQ) covering the following emotional reactions: blame, anger, pity, help, dangerousness, fear, avoidance, segregation and coercion. A similar 8-item version (AQ-8-C) was also developed for children [ 68 ]. The r-AQ was adapted by Watson et al. for use with middle school aged adolescents [ 69 ], and a 5-item version was more recently validated by Pinto et al. [ 70 ]. Four articles (4%) identified in this review used variations of the r-AQ.

Link et al. developed the 5-item Social Distance Scale (SDS) [ 71 ], which was later adapted for young people [ 72 ]. This version was more recently validated with a large sample aged 15–25 [ 73 ]. Five articles (5%) cited this version of the SDS. Seven articles (8%) used variations of the World Psychiatric Association’s (WPA) social distance items [ 74 ]; however, no adolescent validation paper was found. This review also found factual and attitudinal WPA scales presented by Pinfold et al. including the Myths and Facts About Schizophrenia Questionnaire. In total, these scales, or modified versions, were used in eight articles (9%), but no validation papers were found. The Reported and Intended Behaviour Scale (RIBS) [ 75 ] was utilised in three articles (3%). This scale has been translated into Japanese and Italian, and there is evidence of its validity with adult and university student samples [ 76 , 77 ]. The evidence of its validity with an adolescent sample was mixed [ 78 ].

The Depression Stigma Scale (DSS) was developed by Griffiths et al. to measure personal and perceived depression stigma [ 79 ]. Yap et al. later validated the DSS and confirmed that personal and perceived stigma were distinct constructs comprised of ‘weak-not-sick’ and ‘dangerous/unpredictable’ factors in a sample aged 15–25 [ 73 ]. Six articles (7%) utilised a version of the DSS, more commonly the items relating to personal stigma. Items from the Opinions about Mental Illness Scale (OMI) were used in two articles (2%). The original scale was cited by both [ 80 ], however, a Chinese version of the OMI has been tested for validity with a sample of secondary school students [ 81 ]. Other validated stigma scales identified included: the Attitudes Toward Serious Mental Illness Scale–Adolescent Version (ATSMI-AV) [ 82 ] ( N  = 1, 1%) and the Subjective Social Status Loss Scale [ 83 ] ( N  = 1, 1%). Measures of help-seeking attitudes and intentions were often not validated with adolescent samples. Two articles (2%) modified the General Help Seeking Questionnaire (GHSQ), previously validated for use with high school students [ 84 ]. A further two articles (2%) utilised the Self-Stigma of Seeking Help (SSOSH) scale; however, tests of its validity have only been conducted with college students [ 85 ].

The aims of this review were to investigate the conceptualisation and measurement of MHL in adolescent research, and scope the extent of methodological homogeneity for possible meta-analyses. The review clearly shows an increase in school-based MHL research with adolescent samples in recent years. This makes sense given that adolescence is increasingly identified as an important period for improving MHL and access to mental health services [ 6 , 10 , 11 , 38 ]. However, the field is still dominated by research from Western, developed countries and takes a predominantly mental-ill health approach. Furthermore, numerous challenges and inconsistencies have emerged in the field over the past 20 years.

Included articles were required to use the term ‘mental health literacy’ or a diagnosis-specific equivalent. However, by first including all articles that presented data for at least one MHL domain, a large number of articles that measured domains without referring to MHL were revealed. Researchers were measuring the same constructs but providing different labels indicating problems with discriminant validity [ 31 , 37 ]. It must be acknowledged that some of the articles included in the final set may have used the term without intending to measure the whole construct, and some articles were removed that measured multiple domains. For example, 16 intervention studies, previously included in a systematic literature review of the effectiveness of MHL interventions [ 25 ], were excluded from this current review because they did not use the term. Despite the exclusion of some potentially relevant data on a domain level, this criterion was considered most appropriate given one of the aims was to assess the conceptualisation of MHL.

Although under half of the articles identified defined MHL, those that did predominantly used definitions from Jorm and colleagues [ 12 , 13 , 14 ]. However, the various adaptations and interpretations of the original definition has clearly led to a lack of construct travelling in the field, in particular, confusion about the inclusion of beliefs and stigma related constructs as MHL domains. Furthermore, few articles referred to mental health and varying degrees of psychological distress in addition to mental illness, supporting the argument that current MHL definitions take a predominantly mental-ill health approach [ 16 , 26 ].

Although an adolescent specific definition of MHL may not be necessary, definitions frequently adopted by articles in this review were developed for adults. It is important for future research to consider not only cognitive development but also the unique social structures and vulnerabilities of adolescents in the conceptualisation and assessment of MHL. Given that the definition of adolescence in the current study ranges from 10 to 19 years, it is clear that even within this age range, different developmental factors could be considered. Applying integrated models of generic health literacy to MHL that acknowledge the life course and social and environmental determinants should therefore be a future priority [ 86 , 87 ].

Around a third of articles measured recognition of specific mental illnesses, with the majority using open-ended questions such as ‘ What, if anything, do you think is wrong …’, and calculating the % of correct responses. Knowledge of mental illnesses was measured more frequently than knowledge of prevention and promotion, therefore an understanding of the complete mental health state was often neglected [ 27 ]. More research is needed to develop and validate measures that assess the ability to seek out, comprehend, appraise and apply information relating to the complete mental health state as opposed to only assessing literacy of mental disorders. By using measurement tools that predominantly focus on psychiatric labels, there is evidence to suggest that stigma could be increased [ 22 , 23 ]. Given that over three quarters of intervention studies identified in this review included a measure of stigma, future research should consider the way in which mental-ill health approaches to MHL, in terms of intervention content and study measures, may influence stigma related outcomes.

It is perhaps unsurprising that the MHL field continues to be modelled on psychiatric labelling given the influence of Jorm and colleagues early work in Australia that came out of the National Health and Medical Research Council (NHMRC) Social Psychiatry Research Unit [ 12 ]. Kutcher and colleagues MHL definition also has its origins in psychiatry, but more explicitly includes understanding of mental health promotion and stigma reduction [ 15 ]. A growing body of research relating to eating disorders literacy also emphasises the need to distinguish between health promotion, prevention and early intervention initiatives in reducing the population health burden of eating-disordered behaviour and to prioritise mental health promotion programs, including those targeting stigma reduction [ 88 , 89 , 90 ]. This review identified an emerging group of articles that included understanding of how to obtain and maintain good mental health in their conceptualisation of MHL. However, this domain was rarely measured.

Just under half of the articles included items relating to general MHL. However, terminology was varied (e.g. mental illness, mental disorder, mental health problem, mental health issue). Leighton revealed that young people have a lack of conceptual clarity when it comes to these mental health related terms, unsurprising given the lack of consistent definitions in practice [ 91 ]. The range and subjectivity of mental health related terms reduces the meaningfulness of comparisons across MHL studies. Similarly, over half of the articles identified in this review assessed mental illness stigma, but the complexity of the construct caused heterogeneity in measurement. Intentions to seek help were the most commonly measured help-seeking belief; these findings support previous assessments of MHL measurement tools [ 16 ]. Measuring only intentions to seek help, without capturing knowledge of what help is available, will not provide a true picture of actual behaviour change. Findings also suggested that recognition and help-seeking related beliefs may be more directly associated with the MHL construct and, in line with previous literature [ 25 ], mental illness stigma was found to be a common outcome measure in MHL related interventions.

It is worth considering whether the MHL construct should continue to be stretched or whether we should accept that the multiple domains exist in their own right. For example, self-acquired knowledge and skills relating to positive psychology are being investigated, but are only just starting to emerge under the MHL construct [ 28 , 29 ]. Similarly, stigma and help-seeking knowledge and beliefs are assessed as part of, and independently from, the MHL framework. Adopting a multi-construct theory approach to MHL, as suggested by Spiker and Hammer [ 31 ], would see increased focus on developing and validating measures of specific MHL domains in order to better understand the way in which these domains relate to each other.

Developing better MHL theory will help provide clear logic models and theories of change for MHL interventions aiming to improve adolescent mental health, something currently lacking in the field. Although it should be acknowledged that the aims of MHL interventions will vary based on the scope, setting and cultural context, an increased number of validated measures as well as improved MHL theory could inform decisions about the most appropriate domain to measure as the outcome i.e. is the main aim of the intervention to reduce stigma or improve help-seeking. This is particularly important for school-based evaluations of MHL interventions for which respondent burden is often a concern.

We acknowledge that there were some articles in this review that adapted adult measures and tested for face and content validity with child and adolescent mental health professionals, and internal reliability and comprehension with adolescent samples. However, in general there was a lack of psychometric work to assess factor structure of scale-based measures in this age group, with large numbers of articles presenting data on an item level. More research should be conducted like that of Campos et al., working with young people to develop and psychometrically test pools of MHL items to identify latent factors [ 55 ]. This will help to inform future conceptualisation and measurement in this age group.

Even when there was evidence of a measure’s validity for use with adolescents, many articles selected only the items relevant for their study or adapted the scale to fit the cultural context. This may, in part, be an attempt to reduce the number of items and therefore the response burden. However, adaptation to measures based on the cultural discourse around mental health aligns with school-based mental health promotion approaches that account for children’s social, cultural and political contexts [ 92 ]. This raises the important question as to whether we should be trying to test and compare mental health related knowledge across cultures, particularly given the ongoing levels of disagreement amongst mental health professions between and within countries. A previous review of cross-cultural conceptualisations of positive mental health concluded that future definitions should be inclusive and culturally sensitive, and that more work was needed to empirically validate criteria for mental health [ 93 ]. Future research should consider conducting measurement invariance on existing MHL measures across different cultures. A comparison of knowledge items and their pre-defined correct answers, could help understand cultural differences in the discourse around mental health and what it means to be mental health literate across contexts.

Given the increased political interest in mental health promotion and education [ 6 , 38 ], we recommend that MHL research focuses on increasing understanding of ways to promote and maintain positive mental health, including subjective wellbeing, optimal functioning, coping and resilience [ 30 , 94 ]. Examples of knowledge items with true/false responses were identified in the current review and many aligned with a biogenetic conceptualisation of mental illness. Not only could these ‘truths’ cause more negative attitudes towards individuals experiencing mental health difficulties [ 19 ], many mapped directly onto the content of interventions and therefore do not provide any evidence of adolescents’ ability to critically appraise mental health information. To enhance individual and community level critical mental health literacy, the MHL field should apply models of public health literacy that aim to increase empowerment and control over health decisions, and acknowledge the interaction between an individual’s ability and their social and contextual demands [ 86 , 95 , 96 , 97 ]. Given that mental health is a key component of health, it is also worth questioning the usefulness of this separation moving forward; a MHL field that is playing catch up with more developed health literacy approaches could further exaggerate the existing lack of parity of esteem.

MHL research with adolescent populations is on the rise, but this review has highlighted some important areas for future consideration. Increasingly stretched definitions of MHL have led to conceptual confusion and methodological inconsistency, and there is a lack of measures developed and psychometrically tested with adolescents. Furthermore, the field is still dominated by a mental-ill health approach, with limited measures assessing the promotion of positive mental health. We suggest that the MHL field moves away from assessing ‘mental disorder literacy’ and towards critical ‘mental health literacy’. A better understanding of what MHL means for adolescents is needed in order to develop reliable, valid and feasible measures that acknowledge their developmental stage and unique social and contextual demands. In conclusion, by treating MHL as a multi-construct theory, more could be understood about the mechanisms for change in improving adolescent mental health.

Availability of data and materials

Link to PROSPERO review protocol included in the manuscript, example search strategy included as supplementary material.

Abbreviations

• Mental health literacy

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Mansfield, R., Patalay, P. & Humphrey, N. A systematic literature review of existing conceptualisation and measurement of mental health literacy in adolescent research: current challenges and inconsistencies. BMC Public Health 20 , 607 (2020). https://doi.org/10.1186/s12889-020-08734-1

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• Published: 10 May 2023

Mental health awareness: uniting advocacy and research

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Mental Health Month has been observed to reduce the stigma that is associated with mental illness and to educate the public and encourage individuals to make their mental health and wellbeing a priority. It is an important moment to bring the strengths of advocacy groups and researchers together to promote mental health awareness and to improve equity.

Observances have become a popular tool to garner media and notice for topics deserving attention, from medical conditions to public health concerns, commemoration of notable events, or celebration of cultural groups. Codifying the scope and needs connected to an issue or illness through awareness campaigns can provide opportunities for imparting useful information, reducing stigma and marshalling support for policy change. The impact of awareness campaigns can be difficult to measure beyond tallying social media mentions or news stories. Effective advocacy, however, extends beyond traffic and paves the way for the creation of knowledge and partnerships among allies and with those whose interests are being represented. When the magnitude of an issue and the potential for improvement are great and are matched by broad involvement and recognition by stakeholders, the possibility for impact is also great.

Held annually in May, Mental Health Month , also called Mental Health Awareness Month, is an observance with such reach, resonating with many people. Nearly everyone has experience with the challenges that are associated with mental health, either first-hand or through loved ones or in their community. There is a need for education, support and initiative to improve our understanding of the causes of mental health disorders and to increase the availability of resources for prevention and treatment. Mental Health Month also offers the possibility of bringing together groups who often work in parallel, such as mental health advocates and mental health research organizations, that can mutually benefit from each other’s functions and expertise.

Mental Health Month was first established in the US in 1949 by the National Mental Health Association, now known as Mental Health America . At a time more often associated with the outset of the Cold War and Marshall Plan than setting an agenda for domestic mental health and wellbeing advocacy, in the more than 70 years since, Mental Health Month has grown into an international event designed to reduce exclusion, stigma and discrimination against people with mental health conditions or disorders. Mental Health America are joined by other prominent mental health advocacy groups to sponsor related observances: Mental Health Awareness Week Canada (1–7 May, 2023) and Europe (22–28 May, 2023); and federal agencies such as the Substance Use Abuse and Mental Health Services Administration ( SAMSHA ) in the US, promoting related public education platforms, including National Prevention Week (7–13 May, 2023).

Observances and awareness campaigns also provide occasions to put mental health in context. Increasing acknowledgment of the role of social determinants, for example, as mechanisms that can increase vulnerability for developing disorders and that drive disparities in mental health are an important framework to underscore as part of promoting mental health awareness. Given the complex and broad scope of people, disorders, conditions and issues under the umbrella of mental health, observances also give us the chance to focus more closely on specific problems or experiences. The theme for Mental Health Month in 2023 is ‘Look Around, Look Within’, which emphasizes the interdependence of mental health and wellness with an individual’s internal and external experiences and environments.

“The ‘Look Around, Look Within’ theme builds on the growing recognition that all humans have mental health needs and that our available resources to build resilience and heal come in many forms — including in the natural world,” explains Jennifer Bright, Mental Health America Board Chair and President of Momentum Health Strategies. “Mental Health America’s strategic plan, focused on NextGen Prevention, carries a similar theme — that the social factors supporting mental health are essential building blocks. These encompass basic needs like healthy food, stable housing, and access to treatment and supports, but they also include spirituality, connection with peers with lived experience, and safe and natural spaces.”

Overlapping with Mental Health Month, Mental Health Foundation sponsors Mental Health Week in the UK (15–21 May, 2023), dedicating this year to raising awareness around anxiety. It shares an individual-centered approach to advocacy. In addition to providing toolkits and resources that point to how prevalent stress and anxiety can be to reduce stigma, it also promotes the accessibility of coping strategies for managing anxiety. As part of the Mental Health Awareness Week campaign, Mental Health Foundation and others use the international symbol of wearing a green ribbon or clothing to physically raise awareness around mental health. Nature Mental Health also incorporates the symbol of the green ribbon on the cover of this month’s issue and as our journal theme color. Green evokes the ideas of vitality, growth, new beginnings and hope — powerful imagery in mental health awareness.

Alongside stories, sponsorships and social media resources, mental health advocacy toolkits and strategy documents include fact sheets and messaging that are shaped and informed by research. Yet, there is often a perception that a divide exists between the mental health advocacy and research spaces, but observances such as Mental Health Month can bridge the two.

According to Lea Milligan, Chief Executive Officer of MQ: Transforming Mental Health , an international mental health research organization, there are complementary approaches and priorities in advocacy and research: “Mental health research can be used to bolster awareness by providing evidence-based information and resources that can help individuals and communities better understand mental health and the factors that contribute to mental health problems. This can include information on risk factors, prevention strategies, and available treatments.”

In addition, increased efforts to involve people with lived experience of mental illness in the research enterprise is a goal that is well-served through connection with advocacy. “While MQ is primarily focused on promoting mental health research, it also recognizes the importance of advocacy in advancing the mental health agenda” suggests Milligan. “MQ advocates for increased funding and support for mental health research, as well as policies that promote mental health and wellbeing. Additionally, MQ seeks to empower individuals with lived experience of mental health conditions to be involved in research and advocacy efforts, and to have their voices heard in the development of policies and programs that affect their lives. MQ provides resources and support for individuals with lived experience who wish to be involved in research or advocacy efforts, including training programs, research grants, and opportunities to participate in research studies.”

Involvement or engagement is certainly one of the most important metrics of advocacy. By strengthening collaboration between advocacy and research organizations and identifying the mutual areas of benefit, such as engagement and increased funding, we may find new ways to green light mental health awareness and action toward mental health equity.

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Mental health awareness: uniting advocacy and research. Nat. Mental Health 1 , 295–296 (2023). https://doi.org/10.1038/s44220-023-00072-6

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Research Article

Five studies evaluating the impact on mental health and mood of recalling, reading, and discussing fiction

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation The London Interdisciplinary School, London, United Kingdom

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – review & editing

Affiliation Center for Language Studies, Radboud University, Radboud, Netherlands

• James Carney, 
• Cole Robertson

• Published: April 8, 2022
• https://doi.org/10.1371/journal.pone.0266323
• Reader Comments

Does reading fiction improve mental health and well-being? We present the results of five studies that evaluated the impact of five forms of exposure to fiction. These included the effects of recalling reading fiction, of being prescribed fiction, of discussing fiction relative to non-fiction, and of discussing literary fiction relative to best-seller fiction. The first three studies directly recruited participants; the final two relied on scraped social media data from Reddit and Twitter. Results show that fiction can have a positive impact on measures of mood and emotion, but that a process of mnemonic or cognitive consolidation is required first: exposure to fiction does not, on its own, have an immediate impact on well-being.

Citation: Carney J, Robertson C (2022) Five studies evaluating the impact on mental health and mood of recalling, reading, and discussing fiction. PLoS ONE 17(4): e0266323. https://doi.org/10.1371/journal.pone.0266323

Editor: Barbara Dritschel, University of St Andrews, UNITED KINGDOM

Received: September 2, 2020; Accepted: March 20, 2022; Published: April 8, 2022

Copyright: © 2022 Carney, Robertson. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data associated with all five studies can be accessed at 10.6084/m9.figshare.17087135

Funding: This work was supported by fellowship no. 205493/Z/19/A awarded to JC from the Wellcome Trust ( wellcome.ac.uk ) The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The claim that exposure to literature can have a positive impact on mental well-being has been visible for some time now. ‘Creative bibliotherapy’, as this view has come to be known, argues that the cognitive effects engendered by poetry, fiction, and drama may be of value in treating mental health conditions [ 1 – 6 ]. In one formulation, ‘attentive immersion in great literature can help relieve, restore, and reinvigorate the troubled mind—and can play a part in relieving stress and anxiety, as well as other troubled states of mind’ [ 7 ]. In a world where the need for affordable mental health resources outstrips the ability to supply them, this is an attractive proposition. It is unsurprising, therefore, that numerous popular authors have been enthusiastic in their endorsement of reading literature as a therapeutic intervention [ 8 – 14 ], or that services such as ReLit, The Reading Agency, and The School of Life seek to pair troubled readers with literature that will ostensibly improve their state of mind.

But enthusiasm for an intervention is not an argument in its favour. If anything, such enthusiasm mandates that one should even more circumspect than usual in the assessment of the evidence in support of the intervention. ‘The first principle’, as Richard Feynman observed, ‘is that you must not fool yourself—and you are the easiest person to fool’ [ 15 ]. A programme like creative bibliotherapy, which promises improvements to mental health by way of a high-prestige, hedonic activity like reading literature, needs a solid evidence base if we are to guard against its subjective attractiveness. As the evidence revolution in medicine has made clear, arguments from experience and expert-led judgment—however well-intentioned they may be—come a poor second to statistical rigour and data-driven conclusions [ 16 ]. If creative bibliotherapy is to be credited with genuine therapeutic efficacy, therefore, it needs to be tested using the full resources of experimental evaluation.

This is especially needful given the current state of the field. Though creative bibliotherapy has been sporadically subjected to empirical assessment, the results do not yield a consistent picture and hypotheses have, in general, not been well formulated (see Troscianko [ 17 ] for the best appraisal of the literature). To start with the issue of evidence, it is certainly true that a reasonable number of studies attribute therapeutic change to the experience of reading literature. For example, group-based studies record positive impact on measures of cognitive performance like concentration, memory, social skills, and creativity, as well as affective change in the direction of increased confidence, fewer feelings of isolation, and improvement on markers of depression [ 6 , 18 – 20 ]. Paralleling this, studies focused on individual reading argue for positive impacts on adolescent aggression [ 21 , 22 ], expressiveness in ill children [ 23 ], self-confidence and functioning [ 5 ], interpersonal empathy [ 24 , 25 ], and theory of mind [ 24 ] However, results do not seem to generalise, with a meta-analysis by Montgomery and Maunders [ 26 ] finding only minor evidence for the efficacy of creative bibliotherapy in addressing PTSD, and Glavin and Montgomery [ 27 ] finding no therapeutic effects at all. Perhaps most worryingly, Troscianko [ 17 ] presents evidence that readers with eating disorders recall having their symptoms exacerbated by fiction that thematises the experience of having an eating disorder. If so, creative bibliotherapy violates the very first injunction of therapeutic intervention—to do no harm.

But the problem is not solely evidential; difficulties also emerge at the conceptual level. Most obviously, terms like ‘literature’ and ‘mental health’ need to be clearly defined. It is not at all clear, for instance, that there is any common feature underlying the heterogenous collection of works, genres and individual styles that comprise what is generally accepted as literature. Even if this were not the case, it would remain unlikely that literature would impact in the same way upon the 297 or so disorders that the DSM 5 defines as constituting the repertoire of mental illness [ 28 ]. Finally, even conceding that literature (by whatever definition) has a positive impact on mental health, there remains an explanatory gap concerning what causal mechanisms may meditate or moderate this impact. So far as it has been theorised at all, the main approaches seem to volunteer literature as a form of cognitive behaviour therapy (CBT), such that literary texts allow readers to re-frame their orientation to the world by allowing the self to be refracted through identification with a third-party perspective [ 29 , 30 ]. Though such ideas have an intuitive appeal, the fact is that they often better resemble the hard-to-test constructions of psychoanalysis than they do the pragmatic paradigm of CBT. While this does not make them wrong, it does foreclose the possibility of other (possibly more mundane) causal mechanisms being identified.

These considerations, in combination with the intellectual importance of establishing the relation between culture and mental health, are what motivated us to assess the therapeutic value of literature by way of the five studies presented here. While no authors can claim to exhaust a topic, our goal was to conduct as systematic an evaluation as possible of how one form of literature—fiction—impacts on mental health, while allowing for the different modes of encounter that characterise exposure to fiction. We chose fiction for the simple reason that most people experience literature through fiction, so any results would have the widest applicability. This is not to deny that fiction can attracts problems of definition in the same way as literature [ 31 , 32 ], but for our purposes we take fiction to be the linguistically mediated evocation of a counterfactual reality in narrative form. The principal mental health conditions we evaluated were depression and anxiety—once more for the simple reason that these conditions, whether individually or in co-morbid form, are the most common mental health presentations [ 33 ]. Usefully, however, both conditions are also associated with psychometrically validated tests that allow for them be easily measured. With that said, two of the studies did not use such tests due to the fact that their data was scraped from social media, and relied instead on linguistic measures of mental state using the valence-arousal-dominance model of emotion [ 34 ] and an absolute words measure of mental distress [ 35 ].

Where our main innovation lay was with respect to the mode of encounter with fiction. Fiction can be experienced in many different contexts, and it is at least prima facie plausible that any cognitive or emotional impact it might have will be shaped by the form of this experience. For instance, being required to read a novel as part of one’s high school education will result in a very different experience from freely choosing to read that novel for personal pleasure. Any thorough appraisal of creative bibliotherapy should therefore take some account of this variation. We did this by identifying five different modes of encounter with fiction and implementing an experimental design that reflected each mode.

• Recalled impact of reading fiction : The fiction we are reading right now is always dwarfed by the amount fiction we have previously read. Moreover, the impact of fiction may involve periods of reflective consolidation that last months or even years [ 36 ]. This means that there are good grounds for evaluating fiction with respect to its recalled effects, as well as its immediate effects.
• Impact of prescribed fiction : Most people first encounter literary fiction in a classroom context, where texts are prescribed for mandatory reading from a canon of classics. The assumption here seems to be that forced exposure will have an improving effect, though this is by no means empirically established. Any assessment of creative bibliotherapy should therefore investigate the effects of prescribed fiction.
• Impact of chosen fiction : Habitual readers of fiction—i.e. those who gain most hedonic value from reading—will have well-developed tastes that guide what they choose to read. If fiction has a therapeutic effect, then it is to be expected that the act of choosing a text will impact on its effectiveness. This gives a third modality of encounter that needs to be contrasted with prescribed fiction.
• Impact of discussing fiction : Reading is typically seen as a solitary exercise, but it is also particularly effective at stimulating collective discussion. This happens at a professional level in the form of cultural journalism and academic criticism, but it is no less present in informal reading groups and online forums. As in-person reading groups are explored by one of us in another study [ 37 ], we here look exclusively at the effects of discussing reading in an online context.
• Impact of fiction quality : Judgments of artistic quality are notoriously subjective, but most readers are prepared to distinguish between fiction as entertainment and fiction as an aesthetic phenomenon. As exposure to different types of fiction may have an impact on therapeutic effects, any thorough evaluation needs to allow for variation in fiction quality.

As not all of these forms of encounter with fiction could be assessed using the same methods, our first three studies were performed by directly recruiting online participants using Amazon’s Mechanical Turk platform, while the last two relied on social media data from Twitter and Reddit. The Reddit data was accessed through the Reddit API; the Twitter data was obtained using data scraping methods. As all usernames were cryptographically hashed at point of acquisition and no text data published, we cannot make inferences about the mental states of individual users and are therefore compliant with the terms of use of both platforms. Inevitably, presenting methodologically distinct studies together in this way means there must be some compression of information. Our view is that this compression is a price worth paying, given that the creative bibliotherapy research is widely dispersed across the academic literature on account of not obviously belonging to either the humanities or the experimental social sciences. By the same token, we recognise that these studies may be of interest to readers who do not have training in quantitative methods; every effort will therefore be made to keep them accessible, consistent with accurately reporting the relevant results.

All studies that involved the collection and retention of unpublished data received ethics clearance from the Brunel University London College of Business, Arts, and Social Sciences Research Ethics Committee (Ref. 7863-A-Jan/2018–10690–1). Where study participants were directly recruited, they were paid the UK living wage on a pro-rata basis.

Study 1—Impact of recalling fiction

Our first study evaluated the hypothesis that recalling literary fiction has a therapeutic impact. The problem it poses is that different texts may not impact in the same way, due to variations between the texts; as already noted, ‘literature’ is not a well-defined phenomenon. As there is no way to entirely resolve this problem, we compromised by prompting responses around 12 well-known novels and measuring the emotional character of the language they use by way of word norm data. However, though this provided useful pilot data, our aim was not to establish the effect of these specific novels, so we also allowed participants to answer on other texts that we did not directly mention. Therapeutic change was measured using CORE-OM and PHQ scales, as well as a search for meaning measure. Given that both the word norm data and therapeutic measures feature in the subsequent studies, we deliver the background exposition for all of them in the present study.

Materials and methods

Participants..

Participants were recruited online using TurkPrime, an implementation of Amazon’s Mechanical Turk platform [ 38 ] on the basis of having read at least one of the twelve experimental texts. With a view to ensuring quality of response, only those participants who had at least a 97% approval rating from a minimum of 500 previous tasks were admitted. A total of 151 participants were recruited. Three participants were excluded: one who entered their sex as ‘other’ (because estimating effects of sex with only one observation in the ‘other’ category was not reliable) and two because their global distress change scores were more than 4.4 standard deviations from the mean and their inclusion in later regression analyses was exerting disproportionate influence on the estimation of effects. This left a final sample of N = 148 (76 females).

Participants were asked to answer on two texts. The first involved participants in selecting a text from a list and estimate how long it had been since they had read it; a validity check was included by asking them to name two characters from the chosen text in a free-text field. After doing this, they were invited to recall their mental state before encountering the text, and then complete the CORE-OM inventory for the first time (note that we were less interested in the actual mental state than in their reconstruction of that that mental state might have been). Upon completion, participants were requested to rehearse the events and world of the text and immerse themselves as much as they could in the experiences they had when they were reading. After this, they once more completed the CORE-OM—though this time with reference to their recalled mental state after reading. This procedure was repeated for a second text, with an open text field—’None of the above’—provided if the participant had read only one text on the list. Participants were then required to answer the PHQ-4 inventory for depression and anxiety, complete the search for/presence of meaning question inventory, and give a Likert-scale rating of how important they felt fiction to be in their personal lives. (Note that this study centred on the effects of recalling reading the text and not actually reading the text).

A control condition was not included due to the difficulty in identifying a meaningful comparator. Neutral textual prompts—such as the Wikipedia articles on factual topics used in Study 2 and Study 3—are inherently unmemorable, and unlikely to prompt any recollection. Non-textual prompts (such as thinking about a recalled event or experience), on the other hand, cannot be guaranteed to be neutral due to variation in personal experience. As these reasons preclude the inclusion of a meaningful control, our study took the null hypothesis—that recalling fiction has no effect on well-being as our comparator.

Study materials consisted of twelve novel-length fictional narratives, selected from an undergraduate reading list in English literature at Brunel University London. The texts referenced were Charlotte Brontë’s Jane Eyre (1847), George Eliot’s Adam Bede (1859), Mary Shelley’s Frankenstein (1818), Emily Brontë’s Wuthering Heights (1847), Mary Elizabeth Braddon’s Lady Audley’s Secret (1862), Elizabeth Gaskell’s North and South (1855), H.G. Wells’s The Island of Doctor Moreau (1896), Thomas Hardy’s Tess of the D’Urbervilles (1891), Charles Dickens’s Great Expectations (1860), Joseph Conrad’s Heart of Darkness (1899), and Charles Dickens’s Hard Times (1854). In the event that participants had read only one of these texts, they were allowed to answer on a different text of their choosing.

Independent variables.

Linguistic variation between texts was measured using word norms for valence, arousal, dominance (VAD) and concreteness (C). In this connection, a word norm is the average response to a particular word on a given dimension. Typically, word norms are the result of mega-studies, where large corpuses of words are assessed for the response that individual words evoke [ 39 , 40 ]. Here, we used the VAD norms established in Warriner, Kuperman, & Brysbaert [ 41 ] and the concreteness norms published in Brysbaert, Warriner, & Kuperman [ 42 ].

The value of word norms is that they provide a low dimensional proxy for emotional variation. That is, according to dimensional models of emotion, each discrete emotion can be represented in terms of an underlying set of finite components [ 34 , 43 ]. The VAD model identifies these components as valence, arousal, and dominance, where valence measures how positive (or negative) an emotion is felt to be, arousal measures how energising (or sedating) an emotion is felt to be, and dominance measures how in control (or controlled) and emotion is felt to be. Thus, anger is negatively valent, positively arousing, and negatively dominant, while happiness is positively valent, neutrally arousing and positively dominant.

Here, we used the VAD norms established in Warriner, Kuperman, & Brysbaert [ 41 ] and the concreteness norms published in Brysbaert, Warriner, & Kuperman [ 42 ]. Warriner et al. (2013) present VAD ratings for 13,914 common English words, thereby providing an empirically validated way of assessing the overall emotional impact of a word, making mean VAD easy to calculate. The concreteness norms published in Brysbaert et al. [ 42 ] provide ratings of 37,058 English words with respect to how concrete or abstract they are felt to be.

VAD+C levels were calculated by processing electronic copies of each text sourced at Project Gutenberg. In detail, this involved tokenizing each text into words, removing stop words (e.g. ‘to’, ‘from’, ‘for’, ‘the’, etc.), lemmatizing the remaining words into their root form (i.e. ‘running’, ‘ran’, ‘runs’ all reduce to ‘run’), and calculating the mean scores using values from word norm databases. This process was automated for future use by creating a custom process function built using the python spaCy natural language processing (NLP) library [ 44 ] Fig 1 shows the relative proportions of VAD+C in each text, normalized between 0 and 1, meaning that the text with the lowest value for a variable shows that variable as absent: i.e. Tess of the d’Urbervilles has the lowest value for arousal, while the Island of Doctor Moreau has the lowest values for valence and dominance.

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Dependent and moderating variables.

Therapeutic impact . Change in recalled pre- and post-reading states was measured using the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM)—a 34-item inventory that is typically used in the evaluation of psychotherapeutic interventions [ 45 ]. This battery of questions establishes change on four dimensions: well-being (W), problems or symptoms (P), functioning (F), and risk (R)—with the mean of these scores being used to define a compound variable called ‘global distress’. Typical questions include ‘Over the last week I have felt like crying’ (W), ‘Over the last week I have felt tense, anxious or nervous’ (P), ‘Over the last week I have felt able to cope when things go wrong’ (F), ‘Over the last week I have felt like hurting myself’ (R). Small changes were made in the wording of the CORE-OM to make it consistent with being applied to the pre- and post-reading state. The change in score between one completion of the survey and another can be taken as a measure of therapeutic impact. As a positive change score would have indicated an increase in distress, change scores were reverse coded such that positive scores always denote an improvement in symptoms.

Depression and anxiety . As a key item of inquiry concerns how literary materials might differentially impact on mental health conditions, interpersonal variation with respect to the two most common conditions—anxiety and depression—was recorded. This was done using the PHQ-4 screening scale for anxiety and depression [ 46 ]. The objective of this scale is to establish underlying propensity towards anxiety or depression (or both) for screening purposes. Participants are asked to score how much over the last two weeks they have been bothered by problems like ‘Not being able to stop or control worrying’ (anxiety) or having ‘Little pleasure or interest in doing things’ (depression).

Search for/presence of meaning . In a previous study, we showed that the tendency to search for meaning in one’s life moderated responsiveness to a literary text—with individuals scoring highly being more receptive to the text [ 47 ]. This suggests that search for meaning may play an important role in susceptibility to any therapeutic impacts that literary texts may have. Search for/presence of meaning was measured using the questionnaire developed in Steger, Frazier, Oishi, & Kaler [ 48 ]. This asks respondents to rate questions like ‘I am always looking to find my life’s purpose’ or ‘I understand my life’s meaning’, with a view to establishing whether they experience meaning as absent or present in their lives (and care about the fact). It outputs two scores: ‘search for meaning’ and ‘presence of meaning’, with there being a typically inverse relation between the two.

Main hypothesis.

Changes scores were calculated by subtracting post- from pre-recalled-reading state scores of the four dimensions of the CORE-OM (wellbeing, problems or symptoms, functioning, and risk), as well as the compound of these, global distress. Following Connell & Barkham (2007), CORE-OM scores are usually calculated such that increase in distress/negative symptoms are positively coded, so higher scores on the CORE-OM indicate poorer wellbeing. By subtracting post- from pre-recalled-reading scores, we reverse this convention such that in the subsequent analyses, positive change scores indicate increase (and negative change scores indicate decreases) in positive mental states in the post-recalled-reading state compared to the pre-recalled-reading state. To test our hypothesis, we conducted one-way, one-sample t -tests for all of these variables, where the null hypothesis is that there is no change (i.e. mean change score of zero). Results are reported in Table 1 and Fig 2 , which also breaks results down by gender. In all cases, unadjusted change scores across the whole sample were significantly above zero, indicating that reported positive impact in every factor of the CORE-OM was higher in the recalled post-recalled-reading state than in the pre-recalled-reading state. Applying a Bonferroni correction for multiple tests resulted in significance drop to trend level for problems or symptoms, and to become non-significant for wellbeing—but significance levels remained highly significant for the other variables, including global distress, which is a compound of the other factors, and which was tested first.

Horizontal line at zero indicates no change. Plots represent Mean +/- 2*S.E.

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Exploratory analysis.

In order to test whether any of the independent or moderating variables related to recalled change in wellbeing, we regressed global distress change on the following variables, as well as all two-way interactions between them: valence, arousal, dominance, concreteness, search for meaning, presence of meaning, propensity to anxiety, propensity to depression, personal importance fiction, social importance fiction, age, and sex. We also allowed intercepts to randomly vary, grouped within participant; this procedure allowed for the effects of grouping variables (like reading the same book) to be accounted for in the analysis. (Participants answered the CORE-OM measure for before and after reading two different books, so change scores on multiple books were grouped within participant.) To reduce the complexity of this model, we then performed a backwards stepwise model selection procedure, where α crit = .05. As such a procedure increases the likelihood of Type I errors (i.e. false positives), these results should be considered exploratory in nature. The model fitting procedure resulted in the model reported in Table 2 and Fig 3 . There are significant effects for valence, arousal, dominance, and concreteness ( Fig 4 ), as well as numerous significant interactions. Specifically, increasing valence, dominance, and concreteness engenders an improvement in the global distress measure, while increasing arousal decreases it. In other words, the more ’sensational’ and negative a text was, the more it was likely to have a negative impact when recalled. As omnibus tests of model fit like R 2 are not possible with multilevel models, we instead report the log likelihood ratio test for our model compared to a model with only the intercept randomly varied by participant. Results are highly significant at χ 2 (87.18) = 1629.8, p < .001.

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Results suggested that being prompted to remember the experience of being immersed in the fictional world can impact positively on psychometrically validated measures of distress, problems or symptoms, and ability to function, with the balance of probability suggesting that this is also the case for well-being. These results provided support for the investigated hypothesis. The exploratory analysis revealed several interactions that may explain this effect, but the model fitting procedure makes inferences unreliable. It did, however, point to VAD values being of interest in subsequent testing. In particular, the analysis indicates that VAD variation should be systematically incorporated into text selection so as to assess any causal role on text impact, particularly with respect to the differential impact of arousal relative to valence, dominance, and concreteness.

Limitations

The two principal weaknesses of this study were the lack of a control condition and the fact that each answered-on text involved taking the CORE-OM twice in close succession. This means results may not be specific to the recall of fiction and that the pre- and post-intervention measures may not be sufficiently independent of each other.

Study 2—Impact of prescribed fiction

Our second study evaluated the effect of prescribed fiction. However, it also took cognizance of the limitations of the first study by incorporating a control condition and staggering the first and second administrations of the CORE-OM over several days. In place of the less precise PHQ anxiety and depression battery, we used the Depression Anxiety Stress Scales (DASS) to measure propensity to each condition; we also assessed participants on the ‘Big Five’ personality scale. Another change came in the texts evaluated. Though novels are by far the most common vehicle of narrative fiction, these are too long to be used in an experimental setting. We used short stories instead, which can be read in a single session.

Consistent with the results of the first study, our hypothesis was that reading fiction would lead to improved outcomes on the CORE-OM relative to the control condition However, our expectation was that better diagnostic tools, a larger number of texts, and improved study design would give better insight into the causal mechanisms behind any detected change.

Participants were recruited online using TurkPrime with same approval ratings as in Study 1. There were 158 participants in total for the first stage of the experiment; 140 of these completed the second stage. One further participant who entered their sex as ‘other’ was excluded due the difficulty of drawing statistical inferences from a sample of one. This gave a usable N of 139 participants (55 females).

In the first step of the experiment, participants completed the CORE-OM, DASS, ‘Big 5’, and Search for Meaning questionnaires. Six days later, they were contacted and invited to participate in the second stage. On doing so, they were presented with a random story or a control text and asked to read it. Time controls were imposed so that participants could not continue to the next section until enough time had passed for several re-reads of the assigned text. Subsequent to reading, they were asked to complete the CORE-OM again. Participants were paid separately for each arm of the study, with payment for the first arm not requiring completion of the second arm—although participants were strongly exhorted to complete both.

Texts for the test condition were scraped from the American Literature database of 4,000 short stories using a python script written for the purpose. Although described as an American literature website, these stories offered a generic selection from world literature with no obvious bias in favour of American authors. The advantage of this database is that it offered an accessible and independent source of classic literary narratives that were of short duration and out of copyright. One disadvantage is that many of its selections seem dated to the modern reader; another is that the decision to sample the entire space of VAD variation (see below) meant that some children’s stories were included. Though a case could be made for excluding the latter, we felt that methodological rigour was better served by including them.

For the control condition, we used eight Wikipedia articles on neutral topics. There were ‘paint’, ‘dime’, ‘snow’, ‘benzene’, ‘metal’, ‘sand’, ‘ammonia’, and ‘chair’. These were chosen so as to provide an emotionally neutral experience of reading other than fiction. Table 3 summarises the presented texts.

https://doi.org/10.1371/journal.pone.0266323.t003

All texts were processed and assigned a VAD+C score using the spaCy function created in Study 1. With a view to providing a balanced sample, each story was also assigned a category designation that showed where it sat in the three-dimensional space of VAD variation. The eight categories used corresponded to whether the V, A, and D measures associated with each story were higher or lower than the zero-centred mean of each dimension for the whole corpus. With a view to maximising variance, the Euclidean distance associated with each story was taken and used to rank it relative to other stories in the same category, with the story furthest from the origin being given a rank of 1. A second constraint was imposed by word count. Allowing that each story would need to be read several times, this meant an estimated reading time of 1 minute for 238 words gave an exposure time of 18 minutes for three readings of a 1,500 word story [ 49 ]. This giving an upper limit, we placed the lower limit at 600 words so as to avoid acutely dissimilar experiences of reading time across participants. Within the word count constraint, we selected the four stories in each of the eight categories that had the greatest Euclidean distance, giving 32 stories in total. Combined with the eight control condition articles, this gave 40 test items. (The entire dataset of 4k processed stories can be downloaded from X.)

CORE-OM and SM . Following the procedures established in Study 1, the CORE-OM and Search for Meaning scales were used to measure therapeutic impact and propensity to search for meaning respectively. See previous study above for details of these questionnaires.

Depression and anxiety . Instead of the PHQ4 measure for anxiety and depression that we used in Study 1, we chose here to use the Depression Anxiety Stress Scales (DASS) questionnaire [ 50 ]. Though the DASS and the PHQ correlate strongly with each other, the DASS offers a more probing inventory of 21 questions that subdivide into three factors of anxiety, depression, and stress. As such, our view was that the DASS would perform greater explanatory work were propensity towards depression or anxiety discovered to have an effect.

Big 5 personality scale . The Big 5 model of interpersonal variation suggests that human beings differ from each other with respect to the traits of openness to new experience, conscientiousness, extraversion, agreeableness, and neuroticism [ 51 , 52 ]. There is a mixed literature on the relationship between the Big 5 and cultural preferences. Djikic, Oatley, & Carland (2012) [ 53 ], for instance, suggest that exposure to fiction can cause changes in self-assessment with respect to the Big 5; other studies argue that personality, far from being shaped by cultural objects, determines the cultural objects that are found to be engaging and how they are engaged with [ 54 – 56 ]. Give the plausibility of claims that personality variation may moderate cultural taste (and vice versa), we included the 44-item inventory for measuring the five personality factors from John & Srivastrava [ 57 ].

As with Study 1, change scores were calculated on the CORE-OM by subtracting scores at the different time points. Change scores on the test condition were then compared with scores in the control condition using an independent samples t-test on global distress , problems or symptoms , distress , well-being , and functioning . No statistically significant differences were detected on any dependent variable ( Table 4 ). Subsequent tests that compared responses in each text category with the control condition also yielded no significant results.

https://doi.org/10.1371/journal.pone.0266323.t004

The lack of significant results here challenges the outcome of Study 1. However, the grounds of the challenge are not clear. One possibility is that the design of Study 1 created an artefact and the detected effects were not real. A second is that the constraints imposed by VAD sampling and word limits created an ecologically unrealistic sample of texts (i.e. the texts, taken collectively, are not a good representation of fiction). Thirdly, it could be reasonably argued that the CORE-OM outcome measure—designed for measuring face-to-face therapeutic interventions for distressed individuals—is inappropriate to the measurement of subtle changes in affective and cognitive state brought about by reading fiction. Finally, it may be that prescribing fiction independently of individual preferences nullifies any therapeutic impact it may have. Testing the impact of chosen fiction using more sensitive measures than the CORE-OM allows us to adjudicate between these outcomes by giving a second methodological contrast to Study 1 that avoids prescribing fiction to participants and is not subject to the same exacting sampling constraints.

Study 3—Impact of choosing fiction

If fiction has a therapeutic impact, it may be that this impact is partly delivered by the act of choosing the fictional text. That is, independently of the character of the text itself, individuals may respond to it more positively when the experience of reading is felt to be congruent with an autonomous choice. Support for this idea comes from the large literature documenting how individuals denied a choice in an activity experience less hedonic return relative to individuals allowed to exercise a choice [ 58 – 60 ]. In the specific area of cultural choices, for instance, Lewis [ 61 ] shows that the same TV programmes are enjoyed more by viewers who choose them over viewers who are involuntarily exposed to them, an effect that is (with some qualifications) also visible in advertising [ 62 , 63 ].

Our third study evaluated whether these ideas can be extended to fiction. It did this by reproducing the two-arm design of Study 2, but instead of assigning fiction, it allowed participants to choose the texts they wished to read. However, though we followed the overall design of Study 2, we changed several of the dependent variables. Most significantly, we used the Profile of Mood States (POMS) measure to capture affective change between the first and the second timepoints of the study [ 64 ]. We also swapped the CORE-OM for the GP-CORE (a subset of the CORE-OM questions that is intended for use with a general population instead of a clinical one) and used the GP-CORE score as a trait rather than a state measure. These changes are explained in more detail below.

Participants were recruited online using TurkPrime, using the same approval ratings as the previous two studies. There were 219 participants in total for the first stage of the experiment; 154 of these completed the second stage. One participant who entered their sex as ‘other’ was excluded due the difficulty of drawing statistical inferences from a sample of one. Two further participants were excluded on account of being mistakenly served the blurb text for a Gabriel García Márquez story instead of the story itself. This gave a usable N of 151 participants (69 females). As the duration of the task assigned to each participant varied widely, a three-tier payment structure was adopted, such that participants who chose longer tasks were paid more.

In the first step of the experiment, participants completed the GP-CORE, Search for Meaning and Profile of Mood States (POMS) questionnaires. Six days later, they were contacted and invited to participate in the second stage. In the test condition, they were invited to select a short story from a dropdown list and asked to read it, where the list text gave the name of the story and the name of the author. Time controls were imposed so that participants could not continue to the next section until enough time had passed for several re-reads of the selected text. In the control condition, they were randomly assigned one of the eight Wikipedia articles that made up the control texts in Study 2. Subsequent to reading, they were asked to complete the POMS questionnaire again. Participants were paid separately for each arm of the study, with payment for the first arm not requiring completion of the second arm.

Texts were taken from the American Literature database of 4,000 short stories used in Study 2. Unlike Study 2, however, there was no requirement to balance the selection across VAD+C. This meant that the primary considerations were word count and the challenge of loading the story text into the survey software, which required manual text formatting using html tags. In the interests of realistic reading times, word count was capped at 20k words and the 32 stories from Study 2 were increased to 67 so as to provide greater story choice. The control texts were once more the Wikipedia articles for ‘paint’, ‘dime’, ‘snow’, ‘benzene’, ‘metal’, ‘sand’, ‘ammonia’, and ‘chair’. Participants from Study 2 were excluded from Study 3.

The hypothesis informing this study was that choosing a fictional text would have a stronger impact on well-being than reading a randomly assigned alternative text. For this reason, the independent variable was categorical, and consisted of whether the participant chose (or did not choose) the text they were exposed to. In the test condition, this involved being exposed to a voluntarily chosen piece of fiction; in the control condition, they were randomly exposed to a Wikipedia article. As Study 2 already indicates that prescribing fiction does not seem to have a therapeutic effect, any positive result in the test condition in the present study favours the hypothesis that choosing a text has an impact on well-being. We acknowledge that this leaves undecided the question of whether a similar effect would also be achieved by choosing a non-fiction text. However, as our aim was to establish the result of choosing fiction relative to prescribing fiction compared to the same control, the best procedure was to retain the control texts from Study 2.

In contrast to Study 2, we used the POMS inventory rather than the CORE-OM as the dependant variable. On consideration, we felt that the CORE-OM, as an inventory designed to test structured therapeutic interventions, may not have the sensitivity to capture improvements to well-being that did not reach the threshold of clinical significance. By contrast, the POMS inventory is explicitly designed to capture transient changes in mood states that load onto the dimensions of tension, depression, anger, vigour, fatigue, and confusion [ 64 ]. In the interests of brevity, we used the reduced 39-item scale validated in Grove & Prapavessis [ 65 ] rather than the original 64-item questionnaire. Questions ask participants to quantify how they are feeling at the time of testing by presenting a mood word—‘Tense’, ‘Sad’, ‘Energetic’, etc.—and requiring them to circle an option on a scale that runs from ‘Not at all’ to ‘Extremely’. Several precedents exist for using POMS to capture affective and cognitive change following interventions designed to improve well-being [ 66 – 68 ].

Paralleling this movement away from measures designed to capture clinical variation, we took the GP-CORE as a moderating variable instead of the DASS. This is a subset of 14 questions from the CORE-OM that are selected for use in mental health assessment outside of clinical settings [ 69 ]. The chief difference is that extreme questions like ‘I have been physically violent to others’ or ‘I have felt panic or terror’ are omitted in favour of questions that pick out non-clinically relevant emotional variation.

The other included moderating variable, the Search for Meaning measure, was included due to it predicting receptivity to literary effects in Carney & Robertson [ 47 ]. The Big 5 personality scale was not used as analysis of Study 2 results showed no significant variation in responses across the five personality factors.

Change scores were calculated for POMS on two dimensions: total mood disturbance (TMD) and esteem-related affect (ERA). The first is the sum of the scores on the negatively valent dimensions minus the sum of the positively valent ones; the second is the specific subset of questions that pertain to positive mood states. An independent samples t-test was used to compare change scores between the test and control conditions. No statistically significant results were recorded on either dimension (TMD: t = -0.382, DF = 48.01, lower CI = -9.32, p = .703; ERA: t = -1.04, DF = 56.53, lower CI = -2.09, p = .301).

The lack of statistically significant differences between groups in this study challenges the hypothesis that choosing fiction impacts on wellbeing. Given that this matches the results achieved for prescribing fiction, the bigger question it raises concerns whether any positive results can be expected from direct exposure to fiction. It may be, for instance, that fiction needs to be cognitively or emotionally processed before positive effects can be accessed. This means that the testing programme needs to incorporate these dimensions if fiction is to be properly assessed for its impact on well-being.

Study 4—Impact of discussing fiction

One of the most common ways in which fiction is processed is through group discussion. In the first instance, most comprehensive education programmes will include a component that involves reading and discussing fiction, meaning that even individuals who do not enjoy fiction will have experience discussing it. Beyond educationally mandated discussions of fiction, books clubs provide popular forums in which like-minded individuals can discuss named titles. Typically, such groups are independent of each other, but they are occasionally coordinated in a top-down way by public libraries or TV shows. Finally, evaluations of fiction by academic researchers and professional journalists constitute a type of collective cultural discussion that individuals participate in to greater and lesser degrees, just as groups of friends who associate for social reasons may discuss fiction as part of general conversation.

Our fourth study evaluated the impact on mood and emotion of discussing book-related topics (mostly fiction) relative to the discussion of non-book-related topics. We chose to use the VAD word norms explored in the previous studies to measure mood and emotion. However, we supplemented this with an ‘absolute word’ measure, which has previously been used to assess linguistically mediated mental distress. In practice, this involved testing four claims.

• Valence : Discourse on books should be more positively valent, on average, than discourse on other topics. This follows directly from bibliotherapeutic claims that reading has positive impacts on well-being. Though this does not imply that discourse on reading will be the most positively valent of all surveyed discourse, it should score significantly higher than a random selection of other topics.
• Arousal : Discourse on books should be lower in arousal, on average, than discourse on other topics. While it is certainly true that high arousal is consistent with both positive and negative experiences, states of high physiological excitement are particularly associated with stress [ 70 , 71 ]. Thus, if discourse about books has a therapeutic effect, it is to be expected that it would exhibit lower arousal than other topics of discussion.
• Dominance : The conviction that one is the author of one’s own actions is often cited as a feature of psychological well-being [ 72 – 74 ]. Any positive impact of discourse on books on well-being should therefore be characterised by higher mean levels of dominance, which measures how in-control a stimulus makes its experiencer feel. Thus, we predict that dominance levels should be higher in book-related topics than in other topics.
• Absolute words : Al-Mosaiwi and Johnstone [ 35 ] argue that the use of what they call ‘absolute words’ is a linguistic covariate of anxiety, depression, and suicidal ideation. These are words that express magnitudes or probabilities without nuance or qualification, such as ‘always’, ‘totally,’ or ‘entire’. The supposition is that mental distress results in over- or underestimation of threats and rewards and the use of absolute words characterises this. We therefore predict that that the probability of encountering absolute words should be higher in non-book-related subreddits.

Given that one of the present authors was already involved in a long-term, in-person study that evaluated the impact of reading and discussing fiction [ 37 ], we chose here to focus on online discussions of fiction from the Reddit social media platform. While it is only fair to acknowledge from the outset that how people talk about a topic online may differ from offline interactions, it is unlikely to be wholly dissimilar. Moreover, given the role of social media in present-day social interactions, any results will be of equivalent importance to those from in-person studies.

Participants were not directly recruited. As per the procedure outlined below, they were selected when Reddit was accessed using the Reddit API in accordance with specific search criteria. This produced 286 participants. All scraped data were already in the public domain, but Reddit usernames were nevertheless hashed so as to protect the identity of users who may have been using their actual name.

Reddit is an open platform that allows users to create and participate in themed forums; its functionality allows for users (‘redditors’) to post original content, links, or other media and comment on it. Specific comments and posts can be voted up or down by individual users, with upvoted content remaining visible for longer. At the time of writing, Reddit has over 330 million users and approximately 180 thousand active subreddits, with the latter covering every major articulation of human activity. What makes Reddit useful in the present connection is that it can be accessed via an API that makes it possible to quickly and efficiently aggregate large bodies of text data. This makes it ideal for comparing the different ways in which people talk about different activities.

Using the Python Reddit API Wrapper (PRAW), the authors wrote scripts for extracting content from Reddit. For any specific subreddit, the scripts extracted the most upvoted submissions. With respect to an individual submission, the relevant script scraped all the comments associated with that submission. Two scripts dealt with individual redditors: one of these extracted the comments of a particular redditor on other redditors’ submissions in order of most upvoted comments; the other pulled their own submissions in order of upvotes. The scrape was initiated by scraping the top-rated 1,000 submissions in the books subreddit, with the ratings attaching to the number of upvotes received. The authors of these posts were identified, and all of their other submissions and comments were extracted up to a maximum value of 1,000 items. Each script generated a dataframe with the same columns—namely, ‘text’, ‘datetime’, ‘score’, ‘title’, ‘subreddit’, ‘type’, and ‘redditor’. Where a given script did not return a value for column field, a ‘NaN’ (‘not a number’) value was recorded. Using the same columns allowed for the output of one script to be easily concatenated with the results of every other. In all cases, content extraction was capped by PRAW rate limits, which return a maximum of 1,000 items for any Reddit listing and only allow a finite number of API calls in a given session.

Data were extracted on the 20 th of May 2019. This generated a dataset of 251,403 observations. Of these, 22,803 were generated by the AutoModerator Reddit bot and were removed, as were occasional duplicate entries. The result was a dataset of 228,600 items, spread across 5,942 subreddits.

Experimental variables.

Clean text and VAD values were extracted using a spaCy process function built in Study 1; an absolute words metric was also calculated for each text item. As processed texts were on average relatively short ( M = 40.14 words), this meant that a taking a mean across words for each of valence, arousal, and dominance gave an accurate measure of the emotional components of each item. (This is because longer linguistic samples tend to regress towards the mean VAD of English as a whole.). However, it should be noted that there was high variability in item length ( SD = 94.45), so internal VAD variation in longer texts may not have been captured. The absolute word metric was calculated by determining the probability of a randomly selected word being an absolute word for every text item.

With a view to distinguishing between books-themed subreddits and non-book-themed subreddits, the ‘subreddit’ column was analysed. Using string matching methods, any subreddit that contained ‘book’ or ‘fiction’ in its name was identified. Manual examination of these identified 30 subreddits that were directly concerned with the discussion of fiction or with reading generally. These were distinguished from other subreddits by adding a further ‘genre’ column to the dataframe that grouped books-related subreddits and non-book-related subreddits (here the word ‘genre’ is used in the loosest possible sense as a grouping variable). This gave 198,464 non-reading related items relative to 30,136 reading-related items.

Valence, arousal, dominance, and absolute words were regressed on multilevel mixed models with random intercepts and random slopes for redditor and subreddit (this allowed for the effects of autocorrelation within multiple posts by the same user and within multiple posts in the same subreddit). Fixed effects were included for whether or not the genre was related to books. This initial model failed to converge so the random slopes stipulation was removed in favour of a model with random intercepts only, which reached convergence. Results are summarised in Table 5 , but genre had a statistically significant impact on all variables with the exception of arousal. Effects were in the predicted directions for valence, arousal, and dominance, but in the opposite direction for absolute words ( Fig 5 ). As Study 5 also used the same variables as this study, a Bonferroni correction was made to allow for multiple comparisons on the same dependent variable; this had the effect of making absolute words statistically non-significant.

https://doi.org/10.1371/journal.pone.0266323.g005

https://doi.org/10.1371/journal.pone.0266323.t005

Of the three VAD variables, dominance is probably the one most explicitly connected with well-being. Valence and arousal, though obviously central to affective experiences, are nevertheless more directly associated with changes in physiological states. Dominance, by contrast, attaches to the sense of agency: it relates to how autonomous a stimulus makes a person feel. As attested in the literature, autonomy is a signal of both positive mental health and, where mental illness has previously supervened, recovery from such illness [ 75 , 76 ]. In one formulation, ‘recovery is a journey, characterized by a growing sense of agency and autonomy’ [ 77 ]. Thus, the significant result for dominance counts as a useful item of evidence in favour of the view that discussing books can have a positive effect on mental health. What is less clear is why discussing books should foster dominance to a greater degree than other topics. Though we did not disambiguate between fiction and books more generally in this study, the predominance of fiction in the data means that the answer may lay in the effects of narrative on identity construction. Several theorists argue that individuals frame their personal and collective identities using narrative modes of thinking [ 78 – 81 ]; if so, discussing recently consumed fictional narratives may activate a high dominance stance.

The significant result for valence also points to the value for mental health in discussing books. That a positive frame of mind should be associated with mental health is unsurprising; where the puzzle arises is why books should systematically impact on valence. Many books, whether factual or fictional, deal with unpleasant subject matter and challenging experiences, which would lead one to expect wide variation in valence in discussions of these books. Instead, the discussions have a positive valence that is significantly higher than the mean for other topics. It would seem, therefore, that reading has the effect of allowing readers to access and talk about low valence content in a way that is not itself negatively valent.

It is worth noting that this effect of valence replicates results for in-person, group discussions of fiction in Troscianko, Carney, and Holman [ 82 ], which show that low valence in a text does not mandate that the discussions of text are recalled as being unpleasant. It also aligns with a long-standing view that assigns a cathartic or functional value to being exposed to third-party experiences, for example via fiction. Aristotle first mooted the idea that drama has the effect of purging powerful emotions in the audience [ 83 ]. Twenty-first century scholarship has taken up this idea, with Glavin & Montgomery (2017) hypothesising that fictional worlds make anxiety inducing experiences salient while removing their threatening immediacy, thereby allowing them to be processed in a safe way. Similar ideas are also advanced for fiction by Troscianko [ 17 ] and Koopman [ 84 ]; Khoo & Oliver [ 85 ] make equivalent claims for cinema. Moving on to the functional advantages of representations of others’ experiences, Pinker [ 86 ] argues for the view that fiction may have evolved to allow for the offline processing of challenging scenarios. Clasen [ 87 , 88 ], takes up this idea with respect to negatively valent content in genres like horror; his claim is that the enjoyment of this disturbing content can be explained as an incentive for processing evolutionarily relevant threats like predation. Thus, there are several mechanisms that can explain why discussing books, in particular, should be associated with positive valence when their content may often have a negative valence.

The result on arousal prima facie challenges the hypothesis that discussing books improves mental well-being. It is notable, however, that the distribution of values found here for arousal is strongly bimodal—an effect that is also visible for dominance and (to a much smaller extent) for valence ( Fig 6 ). This suggests that books-related discussion does not exhibit uniform variance, but that people tend to use language that peaks either higher or lower than the mean for arousal and dominance. For dominance, the lower peak is still greater than the mean dominance for non-books discussion; for arousal, the higher peak is close to the non-books mean, while the lower peak gives a smaller value than the non-books mean. It would seem, therefore, that, in books-themed discussion there is a latent variable systematically pulling discourse into high-dominance, low-arousal and into low-dominance, high-arousal states. As much of books-related discussion is evaluative, we conjecture that this hidden variable is the quality of a book, with low quality books driving the low-dominance, high-arousal responses and high-quality books informing the high-dominance, low-arousal responses. We recognise, however, that these kernel-density estimate plots do not account for the autocorrelation of errors in the data, and thus make Type I errors of interpretation more likely.

https://doi.org/10.1371/journal.pone.0266323.g006

Our hypothesis is challenged by the result on absolute words, even if this effect becomes non-significant after correction for multiple comparisons. We note, however, that evaluative language uses many of the words in the absolute word lexicon, so it may be that absolute words and evaluative language are both forms of assessment applied to different things (i.e. cultural objects and one’s own mental state). Regardless, it does suggest caution in interpreting the overall set of results as being supportive of the idea that discussing books improves wellbeing.

One limitation of this study is that it did not systematically account for variation within books discussed. Though the majority of book-themed discussion concerns fiction, we did not control for how much. As our overall hypothesis concerns how fiction impacts on wellbeing, a more precise focus on fiction is needed. A second limitation is that the high variability in the length of reddit posts means that taking a per-item VAD average may conceal VAD variation within items. Limiting the length of items is needed to prevent this.

Study 5—Impact of discussing literary and non-literary fiction

One assumption of creative bibliotherapy is that any therapeutic efficacy fiction may have will scale with the quality of that fiction. That is, literary fiction will have a more salutary effect than non-literary fiction. This assumption is challenging to test because ‘literary’ is not an objective designation: it usually functions to identify what a historically shaped interpretive community nominates as literature rather than any feature of the text itself [ 89 ]. In Studies 1–3, this was side-stepped by using classic texts that have already been selected by critical opinion as exemplars of literature. The fact that two of these three studies showed no change means we must question the claim that the experience of reading literature has therapeutic effects. However, Study 4 did find effects, and gave evidence to think that there may be a latent variable to do with quality affecting discussions of books. This possibility justifies a study that evaluates the differential impact on wellbeing of literary fiction relative to non-literary fiction in a context that relates to community discussion.

Our fifth study did this by evaluating fiction-themed discourse on Twitter. Specifically, we compared the VAD and absolute words profile of the language surrounding best-seller fiction relative to that surrounding fiction that has won or been shortlisted for a literary award. There were three reasons for choosing to use Twitter as the source of data for this study. The first is that it gives access to the judgments of an interpretive community in an accessible way. Literary awards are explicitly offered as the outcome of informed critical opinion, so winners of these awards can with reasonable confidence be identified as ‘literary’ by the standards of present-day judgment. This contrasts with best-seller lists, which capture titles that are popular without necessarily being literary (allowing that the two can sometimes coincide). The second reason for using Twitter responses to literary awards is that it gives access to opinions on long-form contemporary fiction. Two limitations of earlier studies were that texts were required to be older than 70 years (due to copyright law) and, for Study 2 and Study 3, needed to be short enough to be presented in an experimental setting. As the effect of both limitations was to exclude much of the fiction read by present-day audiences, it challenges the relevance of these studies for contemporary readers. By contrast, Twitter responses to literary rewards and best-sellers directly connect with longer instances of contemporary fiction. Our third reason for using Twitter is that Twitter responses are limited to 280 characters. Tweets do not allow much scope for emotional equivocation, so they resolve the problem of VAD variability presented by long Reddit posts in Study 4.

With respect to hypotheses, we make the same predictions as made in Study 4, but with ‘book-related’ and ‘non-book-related’ replaced by ‘best-seller’ and ‘literary award’. That is, we predict that posts about books on the literary award category will (1) be higher in valence, (2) be lower in arousal, (3) be higher in dominance, and (4) have a lower probability of featuring absolute words.

Participants were not directly recruited. As per the procedure outlined below, they were selected when Twitter was scraped in accordance with specific search criteria. This produced 129,134 participants. All scraped data were already in the public domain, but Twitter usernames were nevertheless hashed so as to protect the identity of users who may have been using their actual name.

We identified six well-known literary awards for contemporary fiction: the Booker International, the Walter Scott Prize, the National Book Critics’ Award, the Man Booker, the Pulitzer, and the American Book Award. We then recorded the titles that these awards had either shortlisted or selected for these awards in the year from December 2017 to December 2018, which produced 40 titles in total. We then took a sample of the books that occupied the number one position in the New York Times best-seller list over the same time period; this gave 35 titles.

Using these 75 titles as search terms, we scraped Twitter from December 2017 to December 2018. This was performed using the Twint library, which is a python package that accesses with Twitter via the html public web interface. The advantage of Twint is that it does not impose rate limits, though as an open source project it is less reliable than the official Twitter API. This produced a total of 233,360 tweets that were authored by 128,134 users. Of the scraped tweets, 46,895 belonged to the ‘literary awards’ category and 186,465 belonged to the ‘best-seller’ category. Using the spaCy text cleaning function developed for the previous studies, tweet text was extracted and regularised. This text was then scored for VAD and absolute words. As anticipated, there was low variation in processed tweet length in words relative to the mean ( M = 11.87; SD = 6.59).

Valence, arousal, dominance, and absolute words were regressed on multilevel mixed models with random intercepts and random slopes for book title and user. This allowed for the effects of autocorrelation in tweets about the same title and in tweets by the same user. Fixed effects were included for whether or not the category was best-seller or literary award. This initial model failed to converge so the random slopes stipulation was removed in favour of a model with random intercepts only, which reached convergence (see Table 6 ). Effects were in the predicted directions for valence, arousal, and dominance, but in the opposite direction for absolute words ( Fig 7 ). Since Study 4 also used the same variables as this study, however, a Bonferroni correction was made to allow for multiple comparisons on the same dependent variable; this had the effect of also making arousal statistically non-significant.

https://doi.org/10.1371/journal.pone.0266323.g007

https://doi.org/10.1371/journal.pone.0266323.t006

As always, evidence against the null hypothesis is not necessarily evidence in favour of a competing hypothesis. Nevertheless, the fact that tweets about books featured in literary awards should evince a healthier mood profile with respect to valence and dominance than tweets about best-sellers is a provocative result. In particular, it supports the results for valence and dominance presented in Study 4, as well as validating the supposition that the Study 4 result for arousal is caused by a bimodal latent variable concerned with quality. The result on absolute words was not significant in this case, though the fact that it was in the same direction as in Study 4 indicates that it may be a factor in need of explanation.

In terms of the statistically significant results, we acknowledge that ‘literary award’ and ‘best-seller’ do not map onto ‘book-related’ and ‘non-book-related’, and thus the congruence of results between Study 4 and Study 5 is not a replication. With that said, the categories do cohere with respect to their status as test and control conditions relating to exposure to fiction; in this sense, ‘book-related’ and ‘literary award’ seem to be exercising a similar effect. Across the two studies, the Twitter and Reddit test conditions all have statistically significant differences between each other for valence and dominance, though it is not clear what conclusions should be drawn from this, except perhaps that Reddit and Twitter discourse simply have different emotional profiles.

More generally, the results for the most part support the claim that tweets about literary fiction have a more salutary character than tweets about best-sellers. The reasons why this might be so for valence and dominance have already been explored in the discussion for Study 4 so we will not repeat them here. Though arousal loses significance after the application of a Bonferroni correction, it remains in the predicted direction and no longer exhibits the bimodal distribution found in Study 4. Once again, the absolute words measure is not statistically significant, but this time in the opposite direction to Study 4. On reviewing the absolute words measure in both studies, we note that most comments or tweets had no absolute words in both studies, meaning that a great deal of variation is mapped onto a value of zero for absolute words. This does not invalidate absolute words as a measure of mental distress, but it does contrast unfavourably with the resolution provided by the VAD values, which assign a measure to all observations. It may be, for instance, that high levels of distress are needed to trigger the use of many absolute words, and lower levels are therefore undetected. However, the general point remains that tweets about literary fiction evince a profile more consistent with mental wellbeing than tweets about bestsellers.

Tweeting is not a neutral process; it introduces several confounds that may challenge the results presented here. It is likely, for instance, that social media users who tweet about literary awards are in a relatively secure economic position and well educated—two factors that would impact on well-being. Similarly, as explored in Murray [ 90 ], the digital environment selects for certain types of readers and reading experiences that may systematically impact on the kinds of tweets that are produced. The nature of twitter data means it is not possible to control for these issues, but they should still be borne in mind as important considerations.

General discussion

Across all five studies, a mixed pattern of results emerges. For the two studies in which there was a direct exposure to fiction, no results were recorded; in the three studies that dealt with the recall and discussion of fiction, results were on the whole supportive of the view that engaging with fiction has positive impacts on well-being. For Study 1, this relates to the outcome measures associated with the CORE instrument; in Study 4 and Study 5, the measure was mean change on valence, arousal, and dominance affect measures. How are we to make sense of these results?

At the broadest level, the implication of the five studies is to disconfirm what we might term the ‘pharmaceutical’ model of creative bibliotherapy. This is the view that fiction, in virtue of some intrinsic property, has salutary effects on well-being, and can thus be dose-prescribed in much the same way as, say, an antidepressant or a vitamin supplement. Though no authoritative proponent of creative bibliotherapy holds to so simplistic a view as this, it is nevertheless the intuition behind journalistic claims that ‘reading strengthens your brain’ [ 91 ], or that ‘books may have as many health benefits as running or eating broccoli’ [ 92 ]. But whether one subscribes to the pharmaceutical view or not, our results suggest that direct exposure to fiction does not seem to confer any measurable benefit in the time adjacent to exposure, at least with respect to common standardised test instruments. (Note that Troscianko [2018b] indicates that individuals with eating disorders recall being harmed by reading eating-disorder-themed fiction, but her study does not capture whether this was immediate or required reflective consolidation.) We suggest, therefore, that prescribing fiction to bring about a quick amelioration of symptoms is unlikely to work.

What does seem to have an effect, however, are modes of presentation that require indirect engagement with fiction. Study 1 showed this with respect to the effect of recalling reading fiction, Study 4 indicates that discussing books has more salutary effects than discussing non-book-related topics, and Study 5 gives evidence that discussing literary fiction has more positive effects than best-seller fiction. What is common in all cases is an opportunity to reflect on the material that has been read, whether by way of ordinary mnemonic integration or as a necessary preliminary to engaging with the opinions of others. And even in the case of mnemonic integration, this result was demonstrated only for classic literary texts that are the subject of sustained cultural discussion—potentially allowing that there is a social component at work here, too. The question that emerges is why these modes of encounter with fiction should engender positive effects when more direct encounters do not. We propose three explanations, all of which are consistent with each other.

The first explanation is that reading, when conducted on different time horizons, has different effects. Brysbaert (2019) challenges the view that readers have different mental ’gears’ that cause them to read faster or slower, depending on the reading aims. Nevertheless, his results do show that scanning a text and reading a text occurs in give very different results in words-per-minute metrics. As the experimental presentation of texts in Studies 2 and 3 may well have resulted in readers scanning or skimming them instead of attentively reading them, this may have affected the cognitive impact of the relevant texts. In a similar vein, Fabry and Kokkonen [ 93 ] make the case for mind wandering as a form on engagement with the text. That is, the reader’s successful engagement with a text is achieved by bringing to bear predictions generated from enculturated knowledge in a dynamical way in response to textual prompts. The failure of Studies 2 and 3 to produce results may therefore be because the experimental design inhibited this process. If so, new designs that respect the potential effects of long-term reading processes are mandated.

One such design would involve a long-term, three condition study, where participants are assigned to a fiction condition and a non-fiction condition, with the fiction condition being subdivided into literary and non-literary categories. All groups would be provided with the same set of interpretive prompts, which would be congruent with all three texts. Control groups would be generated by creating a second arm of the study with the same design but a substantially shorted duration (e.g. 1 year vs 2 weeks). At fixed points over each arm’s duration, participants would be prompted to interpretively engage with their text and a measure of well-being taken. The first prediction is that, in the long term arm, well-being would improve in the fiction condition relative to the non-fiction condition, and that within the fiction condition, participants in the literary category would improve most. The second prediction is that improvements would only occur in the long-term arm of the study and not the short term one.

Our second explanation of our results centres on social processing; it claims that fiction is an intrinsically social phenomenon, and thus that the positive impacts of fiction on well-being will most visibly manifest in social contexts. That fiction may be intrinsically social arises from evolutionary arguments concerning its utility. One of the more puzzling aspects of fiction from an evolutionary perspective has always been that it should exist at all. Fiction not alone communicates explicitly false information—it does so in a way that uses up temporal, cognitive, and material resources, such as by causing us to care about characters that do not, and often could not, exist. Known as the paradox of fiction [ 94 ], this problem has directly or indirectly exercised a number of evolutionary and cognitive theorists [ 86 , 87 , 95 – 100 ]. One proposed solution is that stories exist as a cultural tool for facilitating large-group living [ 101 – 103 ]. In this view, the performance and discussion of fictional narratives can create prosocial dispositions by activating shared frames of reference and a collective orientation towards the future [ 81 , 104 ]. In Terence Cave’s words, ‘literature promotes its own downstream conversation, where it becomes mingled with the everyday, the social, the ethical, the political’ [ 105 ]. Where this potentially impacts on mood state is through the opioid system. The brain opioid theory maintains that social bonding is experienced as positively valent because it stimulates the endogenous production of μ -opioids during affiliative behaviour [ 106 – 108 ]. If so, the positive impact of fiction on well-being and mood derives from the activation of endogenous opioid production through the mechanism of social bonding. Evidence that narratives in general can activate the opioid system is already provided in Dunbar et al. (2016), which shows that group exposure to an emotionally arresting short film can increase pain thresholds relative to less febrile narratives (increased pain threshold is a proxy for opioid system activation). The specific efficacy of literary fiction can, on this basis, be explained as the result of literary fiction providing a better focus for social bonding, possibly by way of its status as a culturally prestigious aesthetic form.

A useful paradigm for testing the social processing explanation is offered in Tarr, Launay, Benson, & Dunbar [ 109 ], where administration of naltrexone is used to blockade the endogenous opioid system. That is, Tarr and colleagues conducted a naltrexone-placebo double blind trial to determine whether increases in positive mood, pain threshold and self-reported social closeness between strangers following synchronised dance is suppressed in the test condition. A methodologically straightforward extension of this method would involve exposing matching cohorts to the same fictional materials and subsequently inviting both to participate in separate group discussions of this fiction, with the test group being administered naltrexone before each session. The social processing explanation predicts that discussions in the naltrexone condition should score lower on valence and dominance, as well as on other measures of affect like POMS.

Our second explanation centres on the distinction between lived experience and recalled experience. Specifically, Kahneman & Riis [ 110 ] make the useful theoretical distinction between the experiencing self and the evaluating self, with the experiencing self comprehending the moment-to-moment flux of phenomenal experience and the evaluating self taking in the retrospective summation of these experiences. Though the evaluating and experiencing selves often align, there are also many circumstances when they do not—and in these circumstances is typically the judgments of the evaluative self that persist. For instance, the predicted, experienced, and recalled enjoyment of a vacation often differ [ 111 ]—but it is the recalled enjoyment that makes choosing to repeat the experience most likely [ 112 ]. These systematic differences suggest that the findings generated here may be explicable as the result of the evaluating self extracting therapeutic value from an experience in a way that was not possible for the experiencing self. Literature, it has often been suggested, combines sensorimotor effects with intellectual patterns in a way that secures cognitive engagement that is greater than would result from either factor alone [ 105 , 113 – 115 ]. If so, then time-dependent cognitive processes will have had no opportunity to take effect upon immediate exposure; instead, there will be a minimum period of reflective processing that allows for these processes to supervene. (Or it may be that these processes are accelerated by discussion, which makes the reflective processing of others available.) Whatever the precise mechanism, the general point is that literature seems especially engaging of the evaluative rather than the experiencing self, and that this may account for the results presented here.

With respect to testing the experience-evaluation hypothesis, we propose a multiple cohort, staggered timeline experiment. This would involve n experimental groups, where each group is divided into test and control conditions. Individuals in the test condition would be exposed to one of a set of fictional literary texts; individuals in the control condition to a neutral textual stimulus. At timepoint t 0 , all groups will be exposed to their relevant text and a measure of impact on wellbeing taken. At t 1 , all groups will be prompted to interpretively elaborate on same text, except for one group which will be dropped; at t 2 , another prompt will be issued, and a second group dropped; this procedure will continue until timepoint t n is reached, when only one group remains. At timepoint t n+1 all participants will be asked to evaluate the impact on wellbeing of the text they have been exposed to using the same instrument as at t 0 . The experience-evaluation hypothesis predicts (1) that impact on wellbeing will be greater in the test over the control conditions, and (2) that wellbeing will scale positively with the number of interpretive engagements.

In proposing these studies, our first intention is to gain clarity on the results outlined here. However, we are also conscious of the fact that there is paucity of designs in experimental literary studies. As noted by van Peer and Pander Maat [ 116 ], “The problem with literary studies is that the given assumptions are usually vague and general—though often strong and unqualified—and have not been tested with real readers”.

To conclude, we maintain that our studies offer evidence in support of the view that fiction can have a positive impact in well-being. However, these effects do not seem to be realised in peculiarly modern models of reading, where the primary response of the reader is assumed to occur during the privacy of the reading process. Instead, fiction’s positive impact on well-being seems to require processes of mnemonic or social evaluation before it can occur. This result is less important for its positive content—that discussion and reflection amplify the impact of fiction was always known to educators and readers—than it is for what it rules out. If fiction is to be leveraged for therapeutic value, then it cannot be operationalised as a type of cultural pharmacy or—worse—as a cultic object that cures through mere exposure. Instead, it needs to be supported by an infrastructure that systematically and patiently encourages readers to evaluate their experiences by way of reflection and discussion. Inevitably, more research is needed, both with respect to fiction and other modes of literature not discussed here, before more concrete recommendations can be offered. However, we hope to have pointed towards some of the directions this research might take.

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• DOI: 10.35631/ijepc.954032
• Corpus ID: 271260659

REVIEWING THE INFLUENCE OF MENTAL HEALTH AND COPING STRATEGIES ON ACADEMIC PERFORMANCE

• Noraida Saidi , Nik Zam Nik Wan , +4 authors Normaizatul Akma Saidi
• Published in International Journal of… 30 June 2024
• Psychology, Education

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FROM INSTITUTIONAL CARE TO FAMILY SUPPORT: DEVELOPMENT OF AN EFFECTIVE EARLY INTERVENTION NETWORK IN THE NIZHNY NOVGOROD REGION, RUSSIAN FEDERATION, TO SUPPORT FAMILY CARE FOR CHILDREN AT RISK FOR INSTITUTIONALIZATION

Despite efforts of the government to reform child protection, Russia continues to rely on institutional care due to the lack of support services for families in crisis, children with disabilities, and foster and adoptive parents.The project goal was to establish a replicable professional model that would direct the child welfare system in the Nizhny Novgorod Region away from institutional care and toward services for young children and their families that reduce the risk of institutionalization. The program was carried out over a 3-year period through a public-private partnership, which included the Ministries of Social Policy and Health of the Nizhny Novgorod Region, Firefly, and KPMG with partial funding by the United States Agency for International Development (USAID). Participation of professionals was excellent, attitudinal changes were extensive, and there were significant improvements in the understanding and utilization of early intervention concepts. The number of visits to program sites increased from essentially none to almost 1,000/month during the course of the project. Difficulties employing standardized child-based measures of success and developing ministry data-collection systems were encountered. Changes within the child welfare system in Russia are possible, but require a knowledgeable and adequately funded and supported program within regions receptive to change.

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Journal of Infant Mental Health

Niels P E T E R Rygaard , Christina Groark

This Special Issue includes articles that contribute to (a) the global research base pertaining to the development of infants and toddlers at risk, primarily those who are institutionalized in lower resource countries; (b) interventions in institutions and to promote family alternatives to institutionalization; and (c) attempts to create modern child welfare systems emphasizing family care in entire states and countries. This introduction places these articles into the broader contexts of the literature in these three domains of interest. Across the world, urbanization, migration, armed conflict, epidemics, and famine disrupt families. Add poverty, abuse, neglect, and parental incapacity due to substance abuse and mental health problems, and the result is millions of children without parental care who come under governmental responsibility, often to be reared in institutions, and at risk for long-term developmental deficiencies and problems. Over the last 2 decades and especially recently, national and international governments and nongovernment organizations have increased efforts to help such children, especially those in low-resource countries. Two types of efforts have been made: one to improve the quality of care provided by institutions and the other to minimize the use of institutions and promote family residential care alternatives. The latter effort includes preventing family separations in the first place, reunification of children with birth families, and developing systems of kinship care, foster care, and adoption. This Special Issue of IMHJ is devoted to reports pertaining to issues in the research knowledge base, program practices, and countrywide policies for infants and young children at risk. We attempt in this introduction to place these reports in the broader context of this field, identify their unique contributions, and highlight lessons learned that can contribute to improved care practices and better child welfare systems. RESUMEN: Esta Edición Especial incluye artículos que contribuyen a 1) la base de la investigación global que concierne al desarrollo de niños pequeños e infantes bajo riesgo, primariamente aquellos que se encuentran bajo el cuidado de una institución en países de bajos recursos, 2) las intervenciones en las instituciones y el promover en las familias alternativas a la institucionalización, y 3) tratar de crear sistemas modernos de bienestar infantil que enfaticen el cuidado familiar en estados y países enteros. Esta introducción coloca estos artículos dentro contextos más amplios en las literaturas de estos tres dominios de interés. R ´ ESUM´ E: Ce numéro spécial comprend des articles qui contribuentà 1) une base de recherches globale ayant trait au développement des nourrissons et des jeunes enfantsà risque, surtout ceux qui sont placés en institutions dans des pays n'ayant que de faibles resources, 2) des interventions en institutions et pour promouvoir des alternatives familialesà l'institutionnalisation en orphelinat, et 3) les tentatives pour créer des systèmes modernes de soutienà l'enfance et mettant l'accent sur le soinà la famille dans desétats et des pays entiers. Cette introduction replace ces articles dans les contextes plus grand des recherches dans ces trois domaines d'intérêt. ZUSAMMENFASSUNG: Diese Sonderausgabe enthält Artikel, die einen Beitrag leisten 1) zur globalen Grundlagenforschung in Bezug auf die Entwicklung von gefährdeten Säuglingen und Kleinkindern, vor allem von denjenigen, die in Ländern mit begrenzten Ressourcen institutionalisiert sind, 2) für Interventionen in Institutionen und für die Förderung von Familienalternativen statt Institutionalisierung und 3) die Sonderausgabe versucht moderne Kinderschutzsysteme zu schaffen, indem die Familienpflege in allen Staaten und Ländern betont wird. Diese Einführung setzt die Artikel in den Kontext der zu diesen drei Interessensgebieten vorliegenden Literatur. ABSTRACT: This Special Issue includes articles that contribute to 1) the global research base pertaining to the development of infants and toddlers at risk, primarily those who are institutionalized in lower-resource countries, : 1) 2

Trauma, Violence, & Abuse

Niels P E T E R Rygaard

Quality of child care has been shown to have a crucial impact on children's development and psychological adjustment, particularly for orphans with a history of maltreatment and trauma. However, adequate care for orphans is often impacted by unfavorable caregiver–child ratios and poorly trained, overburdened personnel, especially in institutional care in countries with limited resources and large numbers of orphans. This systematic review investigated the effects of structural interventions and caregiver trainings on child development in institutional environments. The 24 intervention studies included in this systematic review reported beneficial effects on the children's emotional, social, and cognitive development. Yet, few studies focused on effects of interventions on the child–caregiver relationship or the general institutional environment. Moreover, our review revealed that interventions aimed at improving institutional care settings have largely neglected violence and abuse prevention. Unfortunately, our findings are partially limited by constraints of study design and methodology. In sum, this systematic review sheds light on obstacles and possibilities for the improvement in institutional care. There must be greater efforts at preventing violence, abuse, and neglect of children living in institutional care. Therefore, we advocate for combining attachment theory-based models with maltreatment prevention approaches and then testing them using rigorous scientific standards. By using approaches grounded in the evidence, it could be possible to enable more children to grow up in supportive and nonviolent environments. Authors: K. Hermenau, K. Goessmann, M. A. Landolt, T. Hecker, Rygaard, N.P.

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John Sergeev

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Svetlana Stephenson

Placement of Orphans

Sven HESSLE

Infant Mental Health Journal

Charles Zeanah

Adriana Sampaio

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Identifying Research Gaps and Prioritizing Psychological Health Evidence Synthesis Needs

Susanne hempel.

* RAND Corporation, Evidence-based Practice Center (EPC), Santa Monica

† University of Southern California, Keck School of Medicine, Los Angeles, CA

Kristie Gore

‡ RAND, National Security Research Division, Arlington

Bradley Belsher

§ Defense Health Agency, Psychological Health Center of Excellence (PHCoE), Falls Church, VA

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Background:

Evidence synthesis is key in promoting evidence-based health care, but it is resource-intense. Methods are needed to identify and prioritize evidence synthesis needs within health care systems. We describe a collaboration between an agency charged with facilitating the implementation of evidence-based research and practices across the Military Health System and a research center specializing in evidence synthesis.

Scoping searches targeted 15 sources, including the Veterans Affairs/Department of Defense Guidelines and National Defense Authorization Acts. We screened for evidence gaps in psychological health management approaches relevant to the target population. We translated gaps into potential topics for evidence maps and/or systematic reviews. Gaps amenable to evidence synthesis format provided the basis for stakeholder input. Stakeholders rated topics for their potential to inform psychological health care in the military health system. Feasibility scans determined whether topics were ready to be pursued, that is, sufficient literature exists, and duplicative efforts are avoided.

We identified 58 intervention, 9 diagnostics, 12 outcome, 19 population, and 24 health services evidence synthesis gaps. Areas included: posttraumatic stress disorder (PTSD) (19), suicide prevention (14), depression (9), bipolar disorder (9), substance use (24), traumatic brain injury (20), anxiety (1), and cross-cutting (14) synthesis topics. Stakeholder input helped prioritize 19 potential PTSD topics and 22 other psychological health topics. To date, 46 topics have undergone feasibility scans. We document lessons learned across clinical topics and research methods.

Conclusion:

We describe a transparent and structured approach to evidence synthesis topic selection for a health care system using scoping searches, translation into evidence synthesis format, stakeholder input, and feasibility scans.

Evidence synthesis is an essential step in promoting evidence-based medicine across health systems; it facilitates the translation of research to practice. A systematic review of the research literature on focused review questions is a key evidence synthesis approach that can inform practice and policy decisions. 1 However, systematic reviews are resource-intense undertakings. In a resource-constrained environment, before an evidence review is commissioned, the need and the feasibility of the review must be established.

Establishing the need for the review can be achieved through a research gap analysis or needs assessment. Identification of a gap serves as the first step in developing a new research question. 2 Research gaps in health care do not necessarily align directly with research needs. Research gaps are only critical where knowledge gaps substantially inhibit the decision-making ability of stakeholders such as patients, health care providers, and policymakers, thus creating a need to fill the knowledge gap. Evidence synthesis enables the assessment of whether a research gap continues to exist or whether there is adequate evidence to close the knowledge gap.

Furthermore, a gap analysis often identifies multiple, competing gaps that are worthwhile to be pursued. Given the resource requirements of formal evidence reviews, topic prioritization is needed to best allocate resources to those areas deemed the most relevant for the health system. Regardless of the topic, the prioritization process is likely to be stakeholder-dependent. Priorities for evidence synthesis will vary depending on the mission of the health care system and the local needs of the health care stakeholders. A process of stakeholder input is an important mechanism to ensure that the evidence review will meet local needs as well to identify a receptive audience of the review findings.

In addition to establishing the need for an evidence review, the feasibility of conducting the review must also be established. In conducting primary research, feasibility is often mainly a question of available resources. For evidence reviews, the resources, the availability of primary research, and the presence of existing evidence reviews on the topic need to be explored. Not all topics are amenable for a systematic review which focus on a specific range of research questions and rely heavily on published literature. Furthermore, evidence review synthesizes the existing evidence; hence, if there is insufficient evidence in the primary research literature, an evidence review is not useful. Establishing a lack of evidence is a worthwhile exercise since it identifies the need for further research. However, most health care delivery organizations will be keen to prioritize areas that can be synthesized, that is, investing in synthesizing a body of research sizable enough to derive meaningful results. For evidence reviews, the presence of existing evidence syntheses is also an important consideration, in particular, to determine the incremental validity of a new review. Although primary research benefits profoundly by replication, secondary literature, in particular in the context of existing high-quality reviews and/or limited evidence, may not add anything to our knowledge base. 3

This work describes a structured and transparent approach to identify and prioritize areas of psychological health that are important and that can be feasibly addressed by a synthesis of the research literature. It describes a collaboration between an agency charged with facilitating the implementation of evidence-based research and practices across the Military Health System (MHS) and a research center specializing in evidence synthesis.

This project is anchored in the relationship between the Defense Health Agency Psychological Health Center of Excellence (PHCoE) and the RAND Corporation’s National Defense Research Institute (NDRI), one of the Federally Funded Research and Development Centers (FFRDC) dedicated to providing long-term analytic support to the Defense Health Agency. PHCoE, an agency charged with facilitating the implementation of evidence-based research and practices across the Military Health System funded a series of systematic reviews and evidence maps synthesizing psychological research. The project draws on the expertise of the Southern California Evidence-based Practice Center (EPC) located at RAND, a center specializing in evidence synthesis. The project included scoping searches, stakeholder input, and feasibility scans. The project is ongoing; this manuscript describes methods and results from June 2016 to September 2018. The project was assessed by our Human Subject Protection staff and determined to be exempt (date July 7, 2016, ID ND3621; August 6, 2017, ID ND3714).

The following describes the process, Figure ​ Figure1 1 provides a visual overview.

Process of identifying research gaps and prioritizing psychological health evidence synthesis needs.

Scoping Searches to Identify Evidence Synthesis Gaps

Scoping searches targeted pertinent sources for evidence gaps. The searches focused on clinical conditions and interventions relevant to psychological health, including biological psychiatry, health care services research, and mental health comorbidity. Proposed topics and study populations were not limited by deployment status or deployment eligibility, but the topic section considered the prevalence of clinical conditions among Department of Defense active duty military personnel managed by the MHS. The scoping searches excluded evidence gaps addressing children and adolescents and clinical conditions exclusively relevant to veterans managed by the Department of Veterans Affairs.

Scoping Search Sources

We screened 15 sources in total for evidence synthesis gaps.

Veterans Affairs/Department of Defense clinical practice guidelines were a key source for documented evidence gaps. 4 – 9 Recently updated guidelines were screened only for evidence gaps that indicated a lack of synthesis of existing research or content areas that were outside the scope of that guideline (guidelines rely primarily on published systematic reviews and can only review a limited number of topic areas).

We consulted the current report of the committee on armed services of the House of Representatives regarding the proposed National Defense Authorization Act (NDAA) and the report for the upcoming fiscal year. 10 , 11 We specifically screened the report for research priorities identified for psychological health. We also screened the published National Research Action Plan designed to improve access to mental health services for veterans, service members, and military families. 12

We conducted a literature search for publications dedicated to identifying evidence gaps and research needs for psychological health and traumatic brain injury. We searched for publications published since 2000–2016 in the most relevant databases, PubMed and PsycINFO, that had the words research gap, knowledge gap, or research priority in the title and addressed psychological health (Supplemental Digital Content, http://links.lww.com/MLR/B836 ). The search retrieved 203 citations. Six publications were considered potentially relevant and obtained as full text, 1 source was subsequently excluded because the authors conducted a literature search <3 years ago and it was deemed unlikely that a new review would identify substantially more eligible studies. 13 – 19

We also used an analysis of the utilization of complementary and alternative medicine in the MHS 20 to identify interventions that were popular with patients but for which potentially little evidence-based guidance exists. We focused our scoping efforts on complementary approaches such as stress management, hypnotherapy, massage, biofeedback, chiropractic, and music therapy to align with the funding scope. In the next step, we reviewed the existing clinical practice guidelines to determine whether clinicians have guidance regarding these approaches. The Department of Defense Health Related Behaviors Survey of Active Duty Military Personnel 21 is an anonymous survey conducted every 3 years on service members with the aim of identifying interventions or health behaviors patients currently use. To address evidence gaps most relevant to patients, we screened the survey results, and then matched the more prevalent needs identified with guidance provided in relevant clinical practice guidelines.

We consulted the priority review list assembled by the Cochrane group to identify research needs for systematic reviews. We screened the 2015–2017 lists for mental health topics that are open to new authors, that is, those that do not have an author team currently dedicated to the topic. None of the currently available topics appeared relevant to psychological health and no topics were added to the table. We also consulted with ongoing federally funded projects to identify evidence gaps that were beyond the scope of the other projects. In addition, we screened a list of psychological health research priorities developed at PHCoE for knowledge gaps that could be addressed in systematic reviews or evidence maps. Finally, we screened resources available on MHS web sites for evidence gaps.

Gap Analysis Procedure and Approach to Translating Gaps into Evidence Review Format

We first screened these sources for knowledge gaps, regardless of considerations of whether the gap is amenable to evidence review. However, we did not include research gaps where the source explicitly indicated that the knowledge gap is due to the lack of primary research. We distinguished 5 evidence gap domains and abstracted gaps across pertinent areas: interventions or diagnostic questions, treatment outcomes or specific populations, and health services research and health care delivery models.

We then translated the evidence gaps into potential topics for evidence maps and/or systematic reviews. Evidence maps provide a broad overview of large research areas using data visualizations to document the presence and absence of evidence. 22 Similar to scoping reviews, evidence maps do not necessarily address the effects of interventions but can be broader in scope. Systematic reviews are a standardized research methodology designed to answer clinical and policy questions with published research using meta-analysis to estimate effect sizes and formal grading of the quality of evidence. We considered systematic reviews for effectiveness and comparative effectiveness questions regarding specific intervention and diagnostic approaches.

Stakeholder Input

Evidence synthesis gaps that were determined to be amenable to systematic review or evidence map methods provided the basis for stakeholder input. Although all topics were reviewed by project personnel, we also identified psychological health service leads for Army, Navy, Air Force, and Marines within the Defense Health Agency as key stakeholders to be included in the topic selection process. To date, 2 rounds of formal ratings by stakeholders have been undertaken.

The first round focused on the need for systematic review covering issues related to posttraumatic stress disorder (PTSD). The second round focused on other potential psychological health topics determined to be compatible with the MHS mission. Represented clinical areas were suicide prevention and aftercare, depressive disorders, anxiety disorders, traumatic brain injury, substance use disorder including alcohol and opioid use disorder, and chronic pain. All of the potential topics addressed either the effects of clinical interventions or health service research questions.

Stakeholders rated the topics based on their potential to inform psychological health care in the military health system. The raters used a scale 5-point rating scale ranging from “No impact” to “Very high impact.” In addition, stakeholders were able to add additional suggestions for evidence review. We analyzed the mean, the mode, and individual stakeholder rating indicating “high impact” for individual topics.

Feasibility Scans

Feasibility scans provided an estimate of the volume and the type of existing research literature which is informative for 3 reasons. First, this process determined whether sufficient research was available to inform a systematic review or an evidence map. Second, feasibility scans can provide an estimate of the required resources for an evidence review by establishing whether only a small literature base or a large number of research studies exists. Finally, feasibility scans identify existing high-profile evidence synthesis reports that could make a new synthesis obsolete.

Feasibility scans for potential evidence maps concentrated on the size of the body of research that would need to be screened and the relevant synthesis questions that can inform how this research should be organized in the evidence map. Feasibility scans for systematic reviews aimed to determine the number of relevant studies, existing high-quality reviews, and the number of studies not covered in existing reviews. Randomized controlled trials (RCTs) are the focus of most of the systematic review topics, that is, strong research evidence that could inform clinical practice guideline committees to recommend either for or against interventions. An experienced systematic reviewer used PubMed, a very well-maintained and user-friendly database for biomedical literature, developed preliminary search strategies, and applied database search filters (eg, for RCTs or systematic reviews) in preliminary literature searches to estimate the research volume for each topic.

Scans also identified any existing high-quality evidence review published by agencies specializing in unbiased evidence syntheses such as the Agency for Healthcare Research and Quality (AHRQ)’s Evidence-based Practice Center program, the Cochrane Collaboration, the Campbell Collaboration, the Evidence Synthesis Program of the Department of Veterans Affairs, and the Federal Health Technology Assessment program. We used the databases PubMed and PubMed Health to identify reports. We appraised the scope, relevance and publication year of the existing high-profile evidence reviews. The research base for psychological health develops rapidly and evidence syntheses need to ensure that current clinical policies reflect the best available evidence. When determining the feasibility and appropriateness of a new systematic review, we took the results of the original review and any new studies that had been published subsequent to the systematic review on the same topic into account.

The following results are described: the results of the scoping searches and gap analysis, the translation of gaps into evidence synthesis format, the stakeholder input ratings, and the feasibility scans.

Scoping Searches and Gap Analysis Results

The scoping search and gap analysis identified a large number of evidence gaps as documented in the gap analysis table in the Appendix (Supplemental Digital Content, http://links.lww.com/MLR/B836 ). Across sources, we identified 58 intervention, 9 diagnostics, 12 outcome, 19 population, and 24 health services evidence synthesis gaps. The evidence gaps varied considerably with regard to scope and specificity, for example, highlighting knowledge gaps in recommendations for medications for specific clinical indications or treatment combinations 4 to pointing out to gaps in supporting caregivers. 11 The largest group of evidence gaps were documented for interventions. This included open questions for individual interventions (eg, ketamine) 12 as well as the best format and modality within an intervention domain (eg, use of telehealth). 6 Diagnostic evidence gaps included open questions regarding predictive risk factors that could be used in suicide prevention 8 and the need for personalized treatments. 12 Outcome evidence gaps often pointed to the lack of measured outcomes to include cost-effectiveness as well as the lack of knowledge on hypothesized effects, such as increased access or decreased stigma associated with technology-based modalities. 23 Population evidence gaps addressed specific patient populations such as complex patients 5 and family members of service members. 11 The health services evidence gaps addressed care support through technology (eg, videoconferencing 23 ) as well as treatment coordination within health care organizations such as how treatment for substance use disorder should be coordinated with treatment for co-occurring conditions. 4

Potential Evidence Synthesis Topics

The gaps were translated into potential evidence map or systematic review topics. This translation process took into account that some topics cannot easily be operationalized as an evidence review. For example, knowledge gaps regarding prevalence or utilization estimates were hindered by the lack of publicly available data. In addition, we noted that some review questions may require an exhaustive search and a full-text review of the literature because the information cannot be searched for directly, and hence were outside the budget restraints.

The clinical areas and number of topics were: PTSD (n=19), suicide prevention (n=14), depression (n=9), bipolar disorder (n=9), substance use (n=24), traumatic brain injury (n=20), anxiety (n=1), and cross-cutting (n=14) evidence synthesis topics. All topic areas are documented in the Appendix (Supplemental Digital Content, http://links.lww.com/MLR/B836 ).

Stakeholder Input Results

Stakeholders rated 19 PTSD-related research gaps and suggested an additional 5 topics for evidence review, addressing both preventions as well as treatment topics. Mean ratings for topics ranged from 1.75 to 3.5 on a scale from 0 (no impact potential) to 4 (high potential for impact). Thus, although identified as research gaps, the potential of an evidence review to have an important impact on the MHS varied across the topics. Only 2 topics received a mean score of ≥3 (high potential), including predictors of PTSD treatment retention and response and PTSD treatment dosing, duration, and sequencing . In addition, raters’ opinions varied considerably across some topics with SDs ranging from 0.5 to 1.5 across all topics.

The stakeholders rated 22 other psychological health topics, suggested 2 additional topics for evidence review, and revised 2 original topics indicating which aspect of the research gap would be most important to address. Mean scores for the rated topics ranged from 0.25 to 3.75, with the SDs for each item ranging from 0 to 1.4. Six topics received an average score of ≥3, primarily focused on the topics of suicide prevention, substance use disorders, and telehealth interventions. Opinions on other topics varied widely across service leads.

Feasibility Scan Results

Evidence review topics that were rated by stakeholders as having some potential for impact (using a rating cutoff score>1) within the MHS were selected for formal feasibility scans. To date, 46 topics have been subjected to feasibility scans. Of these, 11 were evaluated as potential evidence map, 17 as a systematic review, and 18 as either at the time of the topic suggestion. The results of the feasibility scans are documented in the table in the Appendix (Supplemental Digital Content, http://links.lww.com/MLR/B836 ).

The feasibility scan result table shows the topic, topic modification suggestions based on literature reviews, and the mean stakeholder impact rating. The table shows the employed search strategy to determine the feasibility; the estimated number of RCTs in the database PubMed; the number and citation of Cochrane, Evidence Synthesis Program, and Health Technology Assessment reviews, that is, high-quality syntheses; and the estimated number of RCTs published after the latest existing systematic review that had been published on the topic.

Each potential evidence review topic was discussed in a narrative review report that documented the reason for determining the topic to be feasible or not feasible. Reasons for determining the topic to be not feasible included the lack of primary research for an evidence map or systematic review, the presence of an ongoing research project that may influence the evidence review scope, and the presence of an existing high-quality evidence review. Some topics were shown to be feasible upon further modification; this included topics that were partially addressed in existing reviews or topics where the review scope would need to be substantially changed to result in a high-impact evidence review. Topics to be judged feasible met all outlined criteria, that is, the topic could be addressed in a systematic review or evidence map, there were sufficient studies to justify a review, and the review would not merely replicate an existing review but make a novel contribution to the evidence base.

The project describes a transparent and structured approach to identify and prioritize evidence synthesis topics using scoping reviews, stakeholder input, and feasibility scans.

The work demonstrates an approach to establishing and evaluating evidence synthesis gaps. It has been repeatedly noted that research gap analyses often lack transparency with little information on analytic criteria and selection processes. 24 , 25 In addition, research need identification may not be informed by systematic literature searches documenting gaps but primarily rely on often unstructured content expert input. 26 , 27 Evidence synthesis needs assessment is a new field that to date has received very little attention. However, as health care delivery organizations move towards providing evidence-based treatments and the existing research continue to grow, both evidence reviews and evidence review gap identification and prioritization will become more prominent.

One of the lessons learned is that the topic selection process added to the timeline and required additional resources. The scoping searches, translation into evidence synthesis topics, stakeholder input, and feasibility scans each added time and the project required a longer period of performance compared to previous evidence synthesis projects. The project components were undertaken sequentially and had to be divided into topic areas. For example, it was deemed too much to ask for stakeholder input for all 122 topics identified as potential evidence review topics. Furthermore, we needed to be flexible to be able to respond to unanticipated congressional requests for evidence reviews. However, our process of identifying synthesis gaps, checking whether topics can be translated into syntheses, obtaining stakeholder input to ensure that the gaps are meaningful and need filling, and estimating the feasibility and avoiding duplicative efforts, has merit considering the alternative. More targeted funding of evidence syntheses ensures relevance and while resources need to be spent on the steps we are describing, these are small investments compared to the resources required for a full systematic review or evidence map.

The documented stakeholder engagement approach was useful for many reasons, not just for ensuring that the selection of evidence synthesis topics was transparent and structured. The stakeholders were alerted to the evidence synthesis project and provided input for further topic refinement. This process also supported the identification of a ‘customer’ after the review was completed, that is, a stakeholder who is keen on using the evidence review is likely to take action on its results and ready to translate the findings into clinical practice. The research to practice gap is substantial and the challenges of translating research to practice are widely documented. 28 – 30 Inefficient research translation delays delivery of proven clinical practices and can lead to wasteful research and practice investments.

The project had several strengths and limitations. The project describes a successful, transparent, and structured process to engage stakeholders and identifies important and feasible evidence review topics. However, the approach was developed to address the specific military psychological health care system needs, and therefore the process may not be generalizable to all other health care delivery organizations. Source selection was tailored to psychological health synthesis needs and process modifications (ie, sources to identify gaps) are needed for organizations aiming to establish a similar procedure. To keep the approach manageable, feasibility scans used only 1 database and we developed only preliminary, not comprehensive searches. Hence, some uncertainty about the true evidence base for the different topics remained; feasibility scans can only estimate the available research. Furthermore, the selected stakeholders were limited to a small number of service leads. A broader panel of stakeholders would have likely provided additional input. In addition, all evaluations of the literature relied on the expertise of experienced systematic reviewers; any replication of the process will require some staff with expertise in the evidence review. Finally, as outlined, all described processes added to the project timeline compounding the challenges of providing timely systematic reviews for practitioners and policymakers. 31 , 32

We have described a transparent and structured approach to identify and prioritize areas of evidence synthesis for a health care system. Scoping searches and feasibility scans identified gaps in the literature that would benefit from evidence review. Stakeholder input helped ensure the relevance of review topics and created a receptive audience for targeted evidence synthesis. The approach aims to advance the field of evidence synthesis needs assessment.

Supplementary Material

Acknowledgments.

The authors thank Laura Raaen, Margaret Maglione, Gulrez Azhar, Margie Danz, and Thomas Concannon for content input and Aneesa Motala and Naemma Golshan for administrative assistance.

Supported by the Office of the Secretary of Defense, Psychological Health Center of Excellence. The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the views of the Psychological Health Center of Excellence, the Office of the Secretary of Defense, or the United States government.

The authors declare no conflict of interest.

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Nizhny Novgorod

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• Official Tourism Site of Nizhny Novgorod, Russia
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Nizhny Novgorod , city and administrative center of Nizhegorod oblast (region), western Russia . The city lies at the confluence of the Volga and Oka rivers, 260 miles (420 km) east of Moscow .

Although some authorities give an earlier date, the city was founded, according to a major chronicle, in 1221 by Yury Vsevolodovich, prince of Vladimir, as Russian colonization was advancing to the Volga into lands formerly occupied by the Mordvinians . Nizhny Novgorod’s strategic site on the great Volga route from the Baltic to Central Asia —with links via the navigable Oka River to the Vladimir-Moscow region and via the Kama River to the Ural Mountains and Siberia—ensured its importance. In 1392 the town was incorporated into the principality of Moscow and soon became a Russian stronghold against the Volga Tatars. From there, Ivan III the Great in 1469 and Ivan IV the Terrible in 1552 launched their expeditions against the Tatar capital of Kazan . The Russian conquest of the Volga in the mid-16th century brought about increased trade for Nizhny Novgorod. The annual fair that was established in that city in 1817 became the largest and most important in Russia, attracting traders and goods from across Europe and Asia. The fair continued until the Russian Revolution of 1917. The well-known writer Maxim Gorky was born in Nizhny Novgorod in 1868, and in 1932 the town was renamed in his honor by the Soviet regime, although its original name was restored in 1990.

The great volume of trade passing through the city led to the early utilization of serf labor in manufacturing, causing an earlier onset of factory industrialization than in much of Russia, especially in heavy industry and engineering. The town’s industrial importance grew steadily, stimulated in World Wars I and II by the destruction of plants to the west. Modern Nizhny Novgorod is one of the largest cities of Russia and the center of a large metropolitan area strung out along the Volga and lower Oka rivers. The city is home to the Gorky Automobile Plant (Gorkovsky Avtomobilny Zavod; GAZ), one of the largest in Russia, and also produces many types of ships and river craft, diesel engines, machinery and machine tools, and a wide range of chemical and consumer goods. Of its satellite towns, Bor, across the Volga, makes glass, notably safety glass for cars; Dzerzhinsk makes chemicals and fertilizers; Balakhna and Pravdinsk make paper; Bogorodsk produces leather goods and footwear; and Kstovo has a major oil refinery. Power for the metropolis comes from two thermal-electric plants in Nizhny Novgorod—the Balakhna peat-burning station and the hydroelectric station at Zavolzhye. During the general deindustrialization trend in Russia in the post-Soviet period, the city preserved its industrial profile, and, at the beginning of the 21st century, of the country’s cities with more than one million residents, it had the highest proportion of the working population employed in industry. Nizhny Novgorod is the focus of excellent communications by river, road, rail, and air. Railways connect it with Moscow, Kirov (on the Trans-Siberian line), and Arzamas , and electrified suburban lines serve the metropolitan area.

Nizhny Novgorod has numerous institutions of higher learning, including the N.I. Lobachevsky State University (founded 1918). There is also a state art museum and one of the oldest drama theaters in Russia (established 1798). The city’s historic buildings include the 16th-century kremlin and the 17th-century Archangel Cathedral. Pop. (2010) 1,250,619.