how to write a literature review on mental health

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Additional Online Resources

• How to: Literature reviews The Writing Center, University of North Carolina Chapel Hill
• The Literature Review A basic overview of the literature review process. (Courtesy of Virginia Commonwealth University)
• The Process: Search, Assess, Summarize, Synthesize Getting Started: Assessing Sources/Creating a Matrix/Writing a Literature Review (Courtesy of Virginia Commonwealth University)
• Review of Literature The Writing Center @ Univeristy of Wisconsin - Madison
• Tools for Preparing Literature Reviews George Washington University
• Write a Literature Review University Library, UC Santa Cruz

1. Introduction

Not to be confused with a book review, a  literature review  surveys scholarly articles, books and other sources (e.g. dissertations, conference proceedings) relevant to a particular issue, area of research, or theory, providing a description, summary, and critical evaluation of each work. The purpose is to offer an overview of significant literature published on a topic.

2. Components

Similar to primary research, development of the literature review requires four stages:

• Problem formulation—which topic or field is being examined and what are its component issues?
• Literature search—finding materials relevant to the subject being explored
• Data evaluation—determining which literature makes a significant contribution to the understanding of the topic
• Analysis and interpretation—discussing the findings and conclusions of pertinent literature

Literature reviews should comprise the following elements:

• An overview of the subject, issue or theory under consideration, along with the objectives of the literature review
• Division of works under review into categories (e.g. those in support of a particular position, those against, and those offering alternative theses entirely)
• Explanation of how each work is similar to and how it varies from the others
• Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research

In assessing each piece, consideration should be given to:

• Provenance—What are the author's credentials? Are the author's arguments supported by evidence (e.g. primary historical material, case studies, narratives, statistics, recent scientific findings)?
• Objectivity—Is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
• Persuasiveness—Which of the author's theses are most/least convincing?
• Value—Are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

  3. Definition and Use/Purpose

A literature review may constitute an essential chapter of a thesis or dissertation, or may be a self-contained review of writings on a subject. In either case, its purpose is to:

• Place each work in the context of its contribution to the understanding of the subject under review
• Describe the relationship of each work to the others under consideration
• Identify new ways to interpret, and shed light on any gaps in, previous research
• Resolve conflicts amongst seemingly contradictory previous studies
• Identify areas of prior scholarship to prevent duplication of effort
• Point the way forward for further research
• Place one's original work (in the case of theses or dissertations) in the context of existing literature

The literature review itself, however, does not present new  primary  scholarship.

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E-Mental Health: A Rapid Review of the Literature

• Shalini Lal , Ph.D. , and
• Carol E. Adair , Ph.D.

Search for more papers by this author

The authors conducted a review of the literature on e-mental health, including its applications, strengths, limitations, and evidence base.

The rapid review approach, an emerging type of knowledge synthesis, was used in response to a request for information from policy makers. MEDLINE was searched from 2005 to 2010 by using relevant terms. The search was supplemented with a general Internet search and a search focused on key authors.

A total of 115 documents were reviewed: 94% were peer-reviewed articles, and 51% described primary research. Most of the research (76%) originated in the United States, Australia, or the Netherlands. The review identified e-mental health applications addressing four areas of mental health service delivery: information provision; screening, assessment, and monitoring; intervention; and social support. Currently, applications are most frequently aimed at adults with depression or anxiety disorders. Some interventions have demonstrated effectiveness in early trials. Many believe that e-mental health has enormous potential to address the gap between the identified need for services and the limited capacity and resources to provide conventional treatment. Strengths of e-mental health initiatives noted in the literature include improved accessibility, reduced costs (although start-up and research and development costs are necessary), flexibility in terms of standardization and personalization, interactivity, and consumer engagement.

Conclusions

E-mental health applications are proliferating and hold promise to expand access to care. Further discussion and research are needed on how to effectively incorporate e-mental health into service systems and to apply it to diverse populations.

Innovations in information and communication technology (ICT) are transforming the landscape of health service delivery. This emerging field, often referred to as “e-health,” includes key features, such as electronic, efficient, enhancing quality, evidence based, empowering, encouraging, education, enabling, extending, ethics, and equity ( 1 ). E-health is a broader concept than telehealth (and telemedicine), which involves the use of ICT to connect patients and providers in real time across geographical distances ( 2 ) for the delivery of typical care and where the use of real-time video is the main modality ( 3 ).

Interest is also increasing in the application of ICT in mental health care. For example, the first international e-mental health summit was held in 2009 in Amsterdam, and a summit-specific issue of the Journal of Medical Internet Research was published ( 4 ). Christensen and colleagues ( 5 ) defined e-mental health as “mental health services and information delivered or enhanced through the Internet and related technologies.” However, there is no agreement on a field-specific definition. Some scholars consider e-mental health to include only initiatives delivered directly to mental health service users ( 6 ) and only on the Internet ( 6 , 7 ) (as opposed to, for example, delivery via stand-alone computers or video seminars). Others adopt a wider definition that includes frontline delivery activities related to screening, mental health promotion and prevention, provision of treatment, staff training, administrative support (for example, patient records), and research ( 4 ).

Because of the growth of the e-mental health field, it is difficult for policy makers and practitioners to stay abreast of available applications and the evidence for their effectiveness. In response to a request from a Canadian executive-level policy maker, we conducted a rapid review of the literature on e-mental health. In this article, we report briefly on the review methods and summarize key findings.

Rapid reviews are an emerging type of knowledge synthesis used to inform health-related policy decisions and discussions, especially when information needs are immediate ( 8 – 11 ). Rapid reviews streamline systematic review methods—for example, by focusing the literature search ( 8 ) while still aiming to produce valid conclusions. The requirements for the review, which was undertaken with a two-week deadline, were for a short (maximum eight pages) but in-depth synthesis of the current state of the science on the topic. The personnel available was one senior (doctoral-level) mental health services researcher (CEA). Later, a second (doctoral-level) mental health services researcher (SL) validated the conclusions by screening all titles and abstracts, extracting and synthesizing additional data, and reviewing the findings.

The overarching review question was: What is currently known on the topic of e-mental health? (Even though telepsychiatry is typically included in e-mental health definitions, we did not include this subtopic because its literature is already well developed with several systematic reviews and reviews of reviews.)

Several secondary questions were developed and refined as the review progressed: What types of e-mental health initiatives have been developed? What are the strengths and benefits of e-mental health? What are the concerns with and barriers to use of e-mental health? What is the state of the evidence for the effectiveness of e-mental health? How has e-mental health been integrated in service systems and policy?

The rapid review method used is similar to Khangura and colleagues’ ( 10 ) seven-step process. Briefly, the search focused on English, peer-reviewed full abstracts in MEDLINE from 2005 to 2010 and used the MESH terms mental disorders and internet and the following non-MESH key words: e-mental health, e-therapy, computer, computer-based therapy, computer-based treatment, web-based therapy, web-based treatment. We excluded search terms related to telehealth because that is a distinct, and well-established subset of the e-health field that mainly considers the use of telecommunications to connect service providers and patients across geographical distances ( 3 ) (as opposed to delivering automated, self-management interventions, for example). The search was run in MEDLINE because of time constraints and because it is the most widely searched database for health-related topics, has comprehensive coverage (more than 5,500 journals), and has substantial capture of the content of health services research and overlap with similar sources.

The initial search (December 2010) yielded 158 titles or abstracts. Similar keywords were also used in a brief on-line grey literature search, which retrieved additional relevant documents, such as a list of in-progress trials, a policy report, and recent conference proceedings. Two experts on e-mental health were also contacted by e-mail for comment on the appropriateness of the identified literature and additional articles. Final searches focused on the work of prominent authors (for example, Christensen, Hickie, and Titov). These searches yielded an additional 50 titles and abstracts, resulting in 208 titles and abstracts screened for duplicates and relevancy.

Further details on the rapid review method and our search and selection strategy are provided in an online data supplement to this article.

General description of the literature

The screening process resulted in 115 documents, which were reviewed. Of these, 108 (94%) had been peer reviewed. Publication dates were from 2000 to 2010, with most (N=91, 79%) published between 2007 and 2010, which confirmed an expected increase in the volume of literature on the topic over time. Of the 115 documents, 59 (51%) reported primary empirical studies, of which 25 (42%) were conducted in the United States, 13 (22%) in Australia, and seven (12%) in the Netherlands.

Types of e-mental health initiatives

The review identified e-mental health applications addressing four areas of mental health service delivery: information provision ( 6 , 12 ); screening, assessment, and monitoring ( 13 – 20 ); intervention ( 21 – 24 ); and social support ( 25 ). Many applications addressed several areas of mental health service delivery concurrently ( 26 – 29 ). [A table listing examples of these e-mental health programs and initiatives is provided in the online data supplement . It summarizes information on the purpose of the application, the health conditions and populations targeted, and the components and technologies used.]

With respect to information provision, there is an identified need to ensure the quality of information about mental health. Therefore, tools such as the Brief DISCERN ( 13 ) have been developed to help users assess the quality of mental health–related content on Web sites.

Screening and assessment tools have been available for many years on stand-alone computers, but more recent developments are Internet-based screening tools to provide broader access to individuals for self-assessment (particularly to underserved or hard-to-reach groups) or for use by professionals in specific settings (for example, primary care) ( 30 ). For example, Diamond and colleagues ( 16 ) described an Internet-based behavioral health screening tool for adolescents and young adults in primary care. It requires minimal time to complete; addresses a broad spectrum of psychiatric symptoms, risk behaviors, and patient strengths; is automatically scored online; and allows results to be integrated into the patient’s electronic medical record and into system-level performance measurement.

Social support in e-mental health occurs through several types of Web-based formats, including discussion groups, bulletin boards, chat rooms, blogs, and social media. For example, Scharer ( 25 ) reported on a pilot study that examined the effectiveness of an online electronic bulletin board to provide social support to parents of children with mental illness. Parents made use of the bulletin board over a four-month period, actively posting messages to each other about their children’s illness or about the group.

E-mental health interventions were classified in our review by stage (promotion, prevention, early intervention, active treatment, maintenance, and relapse prevention), type of relationship (for example, between a professional and a consumer, between consumers, and between professionals), and treatment or therapy modality (for example, cognitive-behavioral therapy [CBT] and psychoeducation). Treatments identified were self-led or led by a therapist or were a combination (for example, self-led and therapist guided). Interventions were provided as the primary therapy or adjunct to conventional in-person therapy and were delivered to individuals or groups or both. For example, MoodGYM is an exemplary Web-based, interactive intervention that has been developed and evaluated in several randomized controlled trials ( 27 , 31 – 33 ). Its purpose is to enhance coping skills in relation to depression, and it includes assessments, workbooks, games, online exercises, and feedback. MoodGYM is freely available to the public and has been translated into several languages.

Most of the interventions studied were situated on a specific point of the continuum of care (for example, prevention, mental health promotion, or intervention) and used a single format; however, a few incorporated several types of approaches. For example, Tillfors and colleagues ( 34 ) investigated whether an Internet-delivered self-help intervention in conjunction with minimal e-mail contact was as effective as adding in-person group sessions to the Internet intervention. They found that adding in-person group sessions did not result in significant differences in outcomes.

Typically, e-mental health interventions mimicked traditional treatment approaches in that they often addressed single disorders; none were designed for individuals with comorbid mental and substances use disorders. The most frequent disorders addressed by the 59 empirical studies were depression or anxiety (18 studies, 31%). Several interventions focused on mental health promotion or prevention, including early identification (eight studies, 14%). Most interventions were developed specifically for adults (40 studies, 68%), followed by interventions targeting adolescents or young adults (11 studies, 19%). Recent e-mental health initiatives reflect the shift in the mid-2000s to Web 2.0 technologies (that is, more interactive, multimedia, and user-driven technologies) ( 35 ).

Strengths and benefits

Many authors believe that e-mental health has enormous potential to address the gap between the identified need for mental health services in the population and the limited capacity and resources to provide conventional treatment services ( 13 , 30 ). Strengths of e-mental health initiatives noted in the literature include improved accessibility, reduced costs (although start-up and research and development costs are necessary), flexibility in terms of standardization and personalization, interactivity, and consumer engagement ( 5 , 30 , 34 – 38 ). E-health technologies are considered to be particularly promising for rural and remote populations. They are also promising for subpopulations that have other barriers to access (attitudinal, financial, or temporal) or that avoid treatment because of stigma. For example, by using Internet-based social support, individuals can share their perspectives freely while preserving their anonymity. Further details and examples of benefits are summarized in a box on the next page.

Concerns and barriers

Some concerns and barriers are associated with using e-mental health. There are concerns that e-mental health will replace important and needed conventional services; divert attention away from improvements to or funding for conventional services; and be costly to develop, deploy, and evaluate ( 5 ). Another issue raised in the literature is related to the financial interests of developers and researchers, which may produce a risk of publication bias ( 39 ). Others have highlighted the limited evidence base for interventions, lack of quality control and care standards, and slow uptake by or reluctance among health care professionals ( 39 , 40 ). Some question the ability of professionals to establish therapeutic relationships on line and the feasibility of online treatment for certain population groups (for example, patients with severe depression) ( 39 ). Emmelkamp ( 39 ) described “technological phobia,” whereby professionals may be unfamiliar with technology and anxious about its use in professional care. Concerns have also been expressed about the potential to further marginalize individuals who have physical, financial, or cognitive barriers in terms of access to conventional services. Finally, some are concerned that the availability of e-mental health services may lead some individuals to postpone seeking needed conventional care or that some will receive inappropriate or harmful care when there is insufficient quality control over content ( 7 ).

Ethical and liability concerns have been cited. For example, when participants are from outside the regulatory jurisdiction, ethical responsibilities cannot be met; other concerns are that participants cannot be reliably identified and that privacy cannot be guaranteed for typed or recorded communications ( 5 , 34 , 37 , 38 , 41 ). To address these issues, several professional organizations (for example, the American Psychological Association) have developed guidelines ( 38 ), and an international organization to set standards has been established—the International Society for Mental Health Online. Even so, adherence has been found to be lacking, and concerns remain ( 7 , 39 , 42 , 43 ). At the same time, remedies for the above-mentioned concerns are emerging. Technology for the protection of security and confidentiality has improved, and some efforts are being made to review Web site content for quality ( 35 , 44 , 45 ). In Australia, a Web portal called Beacon has been set up that provides quality ratings for mental health Web sites and recommends evidence-based interventions ( 46 ).

Consumer engagement, reach, and response

A handful of recent studies have shed some light on the role of e-mental health providing prevention or intervention programming for particular groups of individuals, such as youths, socioeconomically diverse populations, rural and remote populations, the general public, and patients. One study investigated the preferences for e-mental health services in an online Australian sample (N=218) ( 47 ). Among individuals in the general population who were already using the Internet, a large majority (77%) expressed a preference for face-to-face services, but less than 10% indicated that they would not use e-mental health services. The authors highlighted the importance of raising public awareness, knowledge, and understanding about e-mental health services. More than 50% of the sample expressed the need to learn more about e-mental health services and about issues related to confidentiality.

More than 90% of youths now use the Internet, and it is seen as a promising medium for reaching that age group ( 28 , 48 ). In a large population-based sample of 2,000 young people aged 12 to 25 in Australia, 77% reported seeking information about mental health problems whether or not they had the problem themselves ( 49 ). In another study among military personnel, who are predominantly younger males, one-third of 352 respondents who reported that they were not willing to talk to a counselor in person indicated that they would be willing to use technology to address their concerns ( 50 ).

Preliminary research has also indicated that mental health service users value the use of e-mental health. A qualitative study of 36 participants found that their primary motive for Internet use was to access social support and their secondary motive was for information ( 51 ). Respondents noted that hearing about other individuals’ experiences helped them to feel less isolated and more hopeful. Respondents also liked the convenience, privacy, and anonymity of the Internet. On the other hand, several authors have documented low access to and use of the Internet among persons with more serious mental illnesses, such as those with co-occurring substance use and serious mental illness ( 52 , 53 ). Cost, lack of training, and impairment (in cognition, concentration, executive function, and motor control) can present barriers for individuals with serious mental illness, further disenfranchising them from services ( 54 ). However, evidence is emerging that with a user-friendly interface, high levels of engagement and positive outcomes can be obtained in online interventions for individuals with serious mental illnesses such as schizophrenia and their families ( 26 ). Nonetheless, access to and attitudes toward technology, as well as socioeconomic factors, need to be taken into account in planning Internet-based interventions for specific population groups ( 55 ).

Evidence base for e-mental health

Although evaluation of some interventions is limited, an encouraging amount of rigorous research is available, depending on the developmental stage of the intervention. Research on Web-based interventions has both opportunities and challenges. Studies are relatively inexpensive to conduct, and large samples can be used. Interventions are easily standardized, randomized or controlled designs are feasible (often with wait list controls), and data are easily collected. Challenges include low rates of completion because of the relative ease with which participants can drop out of studies. In addition, it is difficult to study both the intervention and the mode of delivery; contamination of the control group is possible because participants can access similar services elsewhere on the Web; the ability to conduct double-blind studies is limited; and biases related to using self-report measures are a problem ( 56 – 58 ). Increasingly, resources for optimizing practice and evaluation are available; for example, guidelines for program design and for study methods have been published ( 36 , 59 ).

In the past five years, several reviews, including systematic reviews and meta-analyses of randomized controlled trials, have documented the progress made; effectiveness has been demonstrated in particular for interventions (both therapist assisted and self-directed) addressing depression and anxiety disorders ( 57 , 59 , 60 ). For example, a systematic review of meta-analyses of the efficacy of Internet-based self-help for depression and anxiety disorders reported that these interventions are effective and that effect sizes are comparable to those observed in similar interventions delivered in person ( 60 ). Systematic reviews of Internet-based CBT interventions (prevention and treatment) for anxiety and depression among adults have found that they are as effective as or more effective than treatment as usual ( 57 ). Preliminary evidence has also been reported for the effectiveness of Internet-based interventions to address issues such as stress, insomnia, and substance abuse ( 61 ). There are still some interventions for which evidence is weak or contrary, such as one CBT-based program for individuals with obsessive-compulsive disorder ( 62 ), and not all studies evaluating the effectiveness of Internet-based interventions for depression and anxiety have found positive results ( 62 , 63 ). Lower effect sizes have generally been found for interventions targeting alcohol and smoking cessation compared with those for anxiety and depression ( 61 ). There are some indications that programs work best for individuals with mild to moderate disorders; however, this group has been the focus of most research. Despite the popularity of online support groups, concerns about the encouragement of maladaptive behaviors, or support for continuing such behaviors, have surfaced—for example, in a recent survey of members of an eating disorders forum ( 64 ).

Systematic reviews are also beginning to appear that address e-health interventions for children and youths. For example, Stinson and colleagues ( 65 ) found that symptoms improved in seven of nine identified self-management interventions. A recent narrative review of Internet-based prevention and treatment programs for anxiety and depression among children and adolescents concluded that there was early support for effectiveness but a need for more rigorous research as well as interventions specifically targeting children ( 66 ). Recent innovations, such as those that embed prevention and early-intervention content in online games, need more evaluation. A study of one such program found a nonsignificant worsening effect on support seeking, avoidance, and resilience outcomes, especially among males ( 29 ). An interactive fantasy gaming approach has also been developed by Sally Merry, M.D., of Auckland, New Zealand (personal communication, Merry S, Dec. 2010). A recently published randomized controlled trial demonstrated its effectiveness among adolescents seeking help for depression in primary care settings ( 67 ).

In the area of substance use and abuse, a systematic review of Internet-based interventions for young people found small positive effects for programs aimed at alcohol abuse; the effects were of similar magnitude to those of brief in-person interventions, but the Internet-based interventions had the advantage of much broader delivery ( 68 ). However, programs aimed at preventing subsequent development of alcohol-related problems among those who were nondrinkers at baseline were generally not effective.

More research is needed on individual or subgroup predictors of differential outcomes of e-mental health interventions ( 21 , 69 ). Moreover, even though there is some preliminary evidence supporting the lower cost of using e-mental health approaches, true cost-effectiveness studies are just beginning to appear in the literature ( 70 ).

E-mental health, systems, and policy

Most of the literature reviewed described the development, implementation, and evaluation of single interventions in isolation. One very important question that has been given limited attention is how e-mental health interventions might best be situated in relation to an array of related services for a broad population. In a rare exception, van Straten and colleagues ( 71 ) discussed a stepped-care approach for depression in primary care wherein interventions advance from watchful waiting through self-guided but supported intervention (including Web-based formats), brief face-to-face psychotherapy, and finally longer-term face-to-face psychotherapy with consideration of antidepressant medication. To ensure continuity of care, a care manager monitors patient status at all levels and makes decisions about necessary transitions. Treatments at all levels are evidence based. These authors described trials of two different e-mental health interventions, including one for younger adults, and most important, how they fit within the full stepped-care model. Data on cost-effectiveness of the full model are unavailable, but the authors suggested that the incidence of new cases of depression and anxiety could be halved by introducing this model.

Andrews and Titov ( 72 ) described the promotion of Internet-based treatment programs (a virtual clinic) connected to a hospital in Sydney, Australia. The programs are considered to be cost-effective alternatives to medication or face-to-face CBT treatment. Programs are offered for major depression, social phobia, panic disorder, and generalized anxiety disorder. Programs are available free or at very low cost directly to the public; general practitioners and other mental health professionals can use these programs in addition to or instead of conventional care. Trial results show high levels of patient adherence and strong reductions in symptoms with very little investment of clinician time. The authors discuss how e-mental health programs might fit in a broader health service delivery context (for example, in U.S. health maintenance organizations, health care trusts in the United Kingdom, and regional health authorities in Canada). They suggest that the programs could be the first level of treatment for the proportion of the population that desires Internet-based treatment; however, with the support of a small team, individuals who need more support could be identified and referred for more intensive intervention.

An approach that reaches out to the total population but that is not fully connected to conventional services has been described by Bennett and colleagues ( 27 ). At its center is “e-hub,” which is an online self-help mental health service available free to the public. The service provides automated Web interventions for several needs, such as symptoms of depression, anxiety, and social anxiety, and an online bulletin board. Programs focus on the prevention and early-intervention end of the spectrum. There is no therapist involvement in the interventions, and the bulletin board is moderated by trained consumers under the supervision of a clinical psychologist. Interested individuals can contact the e-hub by e-mail. The organizers report a high volume of use by individuals with and without mental disorders, some over a lengthy period. The service is considered most suitable for those who prefer to receive help anonymously, prefer self-help, or reside in rural or remote areas. Quality control processes are included.

No peer-reviewed articles had a central focus on policy-level discussions about e-mental health. However, the gray literature search yielded one major report on the topic from Australia, E-Mental Health in Australia: Implications of the Internet and Related Technologies for Policy ( 5 ). Although the report was published in 2004, much of the content is relevant for other countries, because many are only at the beginning stages of e-mental health implementation. The report describes the advantages of e-mental health initiatives and barriers to implementation (as described above). Five major recommendations for moving forward are included related to access, ethical issues, quality and effectiveness, technology, and funding.

Articles and studies identified by the rapid review but not discussed here are listed in References ( 73 – 103 ).

The purpose of this rapid review was to synthesize and describe what is currently known on the topic of e-mental health. On the basis of the findings, several considerations for future research and practice in the field of e-mental health are evident. First, it is important to consider the fit of e-mental health initiatives within the context of the existing service system and to ensure that they complement—and not detract from—needs for direct care. Second, it is important to select interventions and initiatives on the basis of available evidence regarding both design features and effectiveness and to build research and evaluation into any new initiatives. Third, it is important to consider the needs of the population as well as the greatest potential for benefit when choosing or investing in e-mental health initiatives—for example, the intervention’s suitability for a diverse group of participants (in age, ethnocultural status, literacy, and disability) should be considered. Fourth, it is important to ensure that ethical and quality issues are addressed. Fifth, the extent to which interventions have or can be applied in cross-cultural and international contexts is an important consideration. Sixth, the involvement of consumers, as well as other relevant key stakeholder groups (such as families and caregivers, service providers, and policy makers), in the development and deployment of initiatives is paramount. Seventh, further research is needed in relation to conditions other than common disorders, such as psychotic disorders. Eighth, more rigorously conducted research is needed, such as randomized controlled trials, and it is important to understand which groups of individuals will benefit the most from such interventions and to take into account cross-cultural and international factors (for example, cultural adaptations).

It is important to acknowledge the limits of rapid review. They include focusing the search on one electronic database source (although we used the database that contains by far the largest number of health and medical journals). The search was also complemented by gray literature searches on the Internet, focused author searches, and brief key-informant consultations. A second limitation of our review is that only one author (CEA) initially screened the titles and abstracts from the total set of documents retrieved, although this author is knowledgeable about the content area and has experience conducting systematic reviews. However, the second author (SL) rescreened all extracted titles and abstracts from the total set. This rescreening uncovered additional nuances in various content areas, identified further studies for review, and provided the opportunity for incorporating more detailed information in this article (for example, technologies and components of e-mental health initiatives described in the online data supplement ). Some minor errors in the initial review were also uncovered. Although the initial review was well received by its sponsors and was reported to inform key policy discussions, the effectiveness of rapid reviews in terms of their ultimate impact on health policy decisions and service outcomes remains to be systematically considered.

This rapid review identified a small but rich set of information on the topic of e-mental health, which was found to be highly useful for its specific intended policy discussion. The apparent promise and pitfalls of e-mental health and the increasing interest of policy makers in its potential for service system transformation indicate that careful monitoring of the evidence base is warranted.

Acknowledgments and disclosures

While conducting this review, Dr. Lal was partially supported by a postdoctoral fellowship from Knowledge Translation Canada. Dr. Adair conducted the initial review while under contract with the Mental Health Commission of Canada. The authors acknowledge Jayne Barker, Ph.D., and Janice Popp, M.S.W., for their assistance in refining the research questions to serve a policy purpose. The views expressed herein are solely those of the authors.

The authors report no competing interests.

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A Systematic Review of Mental Health Literacy Measures for Children and Adolescents

• Systematic Review
• Published: 02 January 2023
• Volume 8 , pages 339–358, ( 2023 )

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• Matej Kucera   ORCID: orcid.org/0000-0003-3288-232X 1 , 3 , 4   na1 ,
• Hana Tomaskova 1 , 2 ,
• Marek Stodola 5   na1 &
• Anna Kagstrom 1  

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Mental health literacy is an essential part of preventing mental illnesses. However, the quality of mental health literacy measures remain unknown, as does its universality across various settings and populations. Few studies focus on measures aimed at assessing mental health literacy of children and adolescents that covers knowledge about mental health and mental disorders, strategies to decrease stigma, and enhancement of help-seeking efficacy. The present study aimed to conduct a systematic search to find available measures of mental health literacy of children and adolescents under the age of 19 years. The following databases were searched: Web of Science, PubMed, PsycINFO, MEDLINE, ERIC and CINAHL Plus. COSMIN checklist was applied to assess the methodological quality of each study. Twenty-one mental health literacy measures were identified in 18 studies. The quality of the studies ranged between very good and inadequate. Sixteen measures were universal, implying that they were not diagnostic specific. Two measures scored a full score of four on mental health literacy comprehensiveness. This review revealed that the overall quality of the measurement properties was mixed, that there are limited measures available to evaluate non-diagnostic-specific mental health literacy in universal populations of children and adolescents, and that measures fail to cover key mental health literacy components of knowledge of mental health, illness, stigma, and help-seeking. New measures should be developed to cover this gap in the field of child and adolescent mental health.

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This project is supported by EEA and Norway Funds Project: SUPREME Strengthening Universal Prevention, Resources, and Evaluation of Mental Health in Education, funded via the grant “Monitoring a posilování duševního zdraví dětí a adolescent,” grant number ZD-ZDOVA1-025. The funding bodies had no role whatsoever in the design of our program or study, methodology used, data collection, data analysis, data interpretation, or writing of this manuscript.

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Matej Kucera and Hana Tomaskova are first authorship.

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National Institute of Mental Health, Topolová 748, 250 67, Klecany, Czech Republic

Matej Kucera, Hana Tomaskova & Anna Kagstrom

Department of Psychology, Charles University, Prague, Czech Republic

Hana Tomaskova

Second Faculty of Medicine, Charles University, Prague, Czech Republic

Matej Kucera

Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1105, 1081 HV, Amsterdam, The Netherlands

Faculty of Social Sciences, Charles University, Prague, Czech Republic

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MK participated in the design and study quality assessment, interpretation of the data, and helped draft the manuscript; HT participated in the study design, data management and extraction, and helped draft the manuscript; MS participated in data management and extraction and reviewed the manuscript; AK conceived the study, participated in its design and interpretation of the data, and helped draft the manuscript. All authors read and approved the final manuscript.

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Search strategy applied across the databases

Appendix II

Standards and measurement properties and its taxonomy based on COSMIN

Appendix III

Updated criteria for good measurement properties

Appendix IV

Methodological quality of each study on a measurement properties

• V very good, A   adequate, D   doubtful, I  inadequate

Rating of results in each study on measurement properties against the updated criteria for good measurement properties

• + sufficient, ? indeterminate”, – insufficient, ± inconsistent

Appendix VI

MHL comprehensiveness across the scales

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Kucera, M., Tomaskova, H., Stodola, M. et al. A Systematic Review of Mental Health Literacy Measures for Children and Adolescents. Adolescent Res Rev 8 , 339–358 (2023). https://doi.org/10.1007/s40894-022-00202-8

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Recommendation 22 Literature Review Summary

• Mental health literacy encompasses knowledge about mental health symptoms, interventions, and resources available, as well as positive attitudes and willingness to intervene when others are struggling.
• Literacy campaigns targeted at mental health have been positively received in post-secondary institutions, though it is unclear how they might affect behavioural outcomes.
• Mental health training can improve knowledge, attitudes and self-efficacy. However, improvements often diminish over time, and it is unclear how actual gatekeeping behaviours are affected.
• Barriers to participating in training programs include lack of awareness, time constraints, resource limitations, and uncertainty about the benefits of training.

Literature Review Findings

Mental health literacy is broadly defined as knowledge of mental health symptoms, interventions, and resources available, as well as positive attitudes and self-efficacy toward helping others in need. Many students were aware of counselling services and symptoms related to depression, but fewer recognized other campus resources and types of mental health conditions. Health promotion and prevention of mental health issues were under-recognized; students only endorsed help-seeking actions when symptoms were severe. Additionally, students experiencing high levels of depression and distress were less likely to recognize symptoms of mental illness than others.

Various mental health literacy campaigns have been implemented in post-secondary settings. Feedback collected through focus groups and surveys tended to be positive, though response rates were often low and outcomes following exposure were minimal. Campaigns utilizing visual promotion materials are more effective when they are designed appealingly and with a student audience in mind. There is also a need for campaigns targeted at groups at higher risk of experiencing mental distress, such as LGBTQ+ and racialized student groups.

Mental health training programs are associated with short-term increases in self-reported knowledge, attitudes, and self-efficacy. However, there is mixed evidence supporting changes to actual behaviours; (quasi-)experimental studies found few differences in skills following training. Training programs that included components such as experiential learning exercises and scenarios tailored to post-secondary settings were the most effective at improving outcomes. Limitations of studies on training programs include low participation and response rates, lack of long-term follow-up assessments, and the use of instruments that have not been empirically validated.  

Faculty, staff and students described barriers to participating in training programs, such as lack of awareness about training opportunities, limited time and resources, and uncertainty about the benefits of training given the role of the person. Support from peers and leaders in the community was a strong enabling factor for participating in training.

Implications for Practice 

Mental health literacy campaigns need to be embedded into a larger policy and service framework that emphasizes health promotion and prevention as well as intervention and crisis management. Tailored campaigns for high risk groups, such as minority student populations and those experiencing high levels of mental distress, are recommended.

As part of a mental health literacy strategy, training programs need to be available to all members of the university community. Training programs that are specialized for post-secondary settings, incorporate experiential exercises, and which receive institutional resources and ongoing support, are likely to have the most impact.

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Clinical placements in mental health: a literature review

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Gaining experience in clinical mental health settings is central to the education of health practitioners. To facilitate the ongoing development of knowledge and practice in this area, we performed a review of the literature on clinical placements in mental health settings. Searches in Academic Search Complete, CINAHL, Medline and PsycINFO databases returned 244 records, of which 36 met the selection criteria for this review. Five additional papers were obtained through scanning the reference lists of those papers included from the initial search. The evidence suggests that clinical placements may have multiple benefits (e.g. improving students' skills, knowledge, attitudes towards people with mental health issues and confidence, as well as reducing their fears and anxieties about working in mental health). The location and structure of placements may affect outcomes, with mental health placements in non-mental health settings appearing to have minimal impact on key outcomes. The availability of clinical placements in mental health settings varies considerably among education providers, with some students completing their training without undertaking such structured clinical experiences. Students have generally reported that their placements in mental health settings have been positive and valuable experiences, but have raised concerns about the amount of support they received from education providers and healthcare staff. Several strategies have been shown to enhance clinical placement experiences (e.g. providing students with adequate preparation in the classroom, implementing learning contracts and providing clinical supervision). Educators and healthcare staff need to work together for the betterment of student learning and the healthcare professions.

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Mental Health Research in Ghana: A Literature Review

1 Department of Anthropology, University College London, 14 Taviton St, London, UK, WC1H 0BW

2 P O Box 060, Institute of Psychiatry, King's College London, Denmark Hill, London, SE5 8AF

Context/Background

Mental health is a neglected area in health care in Ghana. With few clinicians and trained researchers in the field, research has been limited both in quantity and quality.

A search of the available literature revealed 98 articles published between 1955 and 2009. Sixty-six are reviewed in this paper.

Topics covered included hospital and community-based prevalence studies, psychosis, depression, substance misuse, self-harm, and help-seeking. Much of the research was small in scale and thus largely speculative in its conclusions. Epidemiological data is scarce and unreliable and no large-scale studies have been published. There are very few studies of clinical practice in mental health.

Conclusions

The existing literature suggests several important areas for future research to inform the development of targeted and effective interventions in mental health care in Ghana.

Introduction

Psychiatry in Ghana is neglected in health care and research. In 1972 Adomakoh proclaimed in this journal ‘There is a dearth of detailed knowledge of psychiatric illness in this country’. 1 Nearly 40 years later the research record has expanded, but accurate data on epidemiology, treatment and outcomes is still sorely needed. In the absence of reliable evidence, the gaps are filled by data extrapolated from international research, “guesstimates”, and anecdotal evidence.

The first study of mental illness in the then Gold Coast was commissioned by the Colonial Office to study ‘the forms of neurosis and psychosis among West Africans’. Four hundred cases of mental disorder were identified with the help of census enumerators and chiefs. 2 This was followed in the 1950s by ethnographic research of people with mental disorder attending rural shrines. 3 Following independence and the training of Ghanaian psychiatrists, local psychiatrists began to publish clinically-based research. However with limited resources and research expertise, the studies were small and output was limited. This situation has persisted until recently. The majority of research in mental health has been undertaken by the country's few psychiatrists, occasionally assisted by expatriate researchers or clinicians and has remained small in scale.

Recently a new impetus for mental health in Ghana has seen the establishment of mental health NGOs, the drafting of a new mental health bill, increased training for psychiatrists and psychiatric nurses, proposals for training new cadres of primary health care specialists in mental health, and increased media attention. There has also been an increase in the number of research projects and publications on mental health from a diversity of disciplines including psychology, sociology and anthropology.

The Kintampo Health Research Centre has supported studies of risk factors for psychosis, mental disorders among older people, an ethnography of psychosis, 4 , 5 and an epidemiology of postnatal depression. The Mental Health and Poverty Project , which conducted research on mental health policy in four African countries including Ghana, 6 has produced several publications in indexed journals. 7 , 8 , 9 , 10 , 11

The PubMed indexing of the African Journal of Psychiatry and the online publication of the Ghana Medical Journal (GMJ) present new opportunities for mental health research in Ghana to provide a much-needed contribution to regional and international research on African mental health. This paper aims to provide an overview of the current state of research on mental health in Ghana, and a critical review of published research papers. The findings of these papers are synthesised to highlight priority areas for mental health research in Ghana which should be of value to both clinicians and researchers in the field.

A literature search was conducted of social science and medical journals in Ghana and the UK. The authors conducted an on-line search of Pubmed using MeSH terms ‘ psychiatry AND Ghana ’, ‘ mental disorders AND Ghana ’ ‘ mental health services AND Ghana ’, ‘ mental health AND Ghana’, ‘self-injurious behaviour AND Ghana’ , in addition to a manual search of the libraries of Korle-Bu Teaching Hospital (KBTH), the Institute of Psychiatry, UK, and the London School of Hygiene and Tropical Medicine (LSHTM).

Ninety-nine articles published between 1955 and 2009 were identified. Thirty-three articles were excluded (see Table 1 ). Sixty-six were included in this review. Articles were grouped under the most relevant topics however there was overlap in some papers (see Table 2 ).

Papers excluded from the review

Reviewed papers by topic

Epidemiology

Early researchers and clinicians predicted an increase in mental disorders in Ghana as a result of the presumed stresses of industrialisation and ‘acculturation’. 12 , 13 Yet to date the true prevalence of mental illness in Ghana remains uncertain. Epidemiological studies are based on small numbers and rely on clinical case-finding methods. Prevalence rates drawn from such data are below expected rates from international comparative studies and in the absence of data from population-based epidemiological studies are likely to be an underestimation.

Since psychiatric hospitals are the most easily accessible research sites, particularly for hard-pressed clinicians, a number of studies have been undertaken drawing on records at Accra Psychiatric Hospital (APH). In a study of first admissions to APH between 1951 and 1971 Forster observed a sharp increase in admissions from 265 in 1951 to 2284 in 1967 followed by a decline to 736 in 1971. 15 This change was attributed this to the political crisis between 1961–1966, however since then admissions approximate to the 1960s figure despite political stability and economic development in recent years. Hospital admissions are unreliable indicators of psychiatric morbidity since they are confounded by population growth and increased awareness and exclude many cases who do not attend psychiatric services. 14

The few community-based prevalence studies do not employ standardised research diagnoses or methods. 12 , 16 , 17 , 18 epidemiological In Kumasi 194 participants were interviewed using the mental state examination (MSE) and the Self-Reporting Questionnaire (SRQ). Thirty-eight were diagnosed with depressive illness, of which 33 were women. Five women were diagnosed with schizophrenia and five men with somatisation disorder. Despite the limitations of the methodology, the author calculated an overall prevalence of psychiatric illness of 27.51%. 18 Noting the popularity of prayer camps and shrines in the treatment of mental disorders, Turkson suggests that epidemiological studies of mental illness in Ghana should include these. 19

chizophrenia/psychosis

In 1968 Field stated there had been an explosive increase in schizophrenia within the last 20 years (p.31). 20 However she had no data with which to substantiate such a claim. Her longitudinal study of hundreds of cases attending rural shrines in Ashanti and Brong Ahafo 12 , 20 , 21 provided a wealth of clinical and contextual detail however she did not quantify most of her work. In one exception she approached chiefs and elders of rural towns and villages and identified 41 cases of chronic schizophrenia in 12 villages with a combined population of 4,283. In the 1960s Fortes and Mayer, conducted a study of psychosis among the Tallensi in Northern Ghana. Mayer diagnosed 17 cases of psychosis, eight men and nine women. 17

In the 1980s a study of the prevalence of schizophrenia in Labadi, Greater Accra using clinical interviews and a review of medical records identified 28 cases of schizophrenia including 19 males in a population of 45,195. Thirty-one vagrants were also found to be psychotic. 16 Methods were restricted to tracing cases from APH and Pantang Hospital, screening patients at the polyclinic, visiting a shrine and assessing 175 vagrants. No house-to-house case-finding was conducted.

Studies at APH consistently record schizophrenia and psychosis as the most commonly recorded diagnosis for about 70-75% of inpatients. 1 , 22 In the only identified study of mentally disordered offenders at APH, most had been diagnosed with psychotic illness including 31% with schizophrenia, 20.2% with drug-induced psychoses, and 13.3% with non-specified psychosis. Most of those charged with murder or attempted murder had been diagnosed with psychotic illness, nearly half (48.6%) with schizophrenia. 23

The preponderance of schizophrenia as a diagnosis among inpatients continues to the present day. This is probably since only the most severe cases are admitted. The symptoms of acute psychosis also present grave difficulties for family members to manage at home, and are likely to prompt help-seeking. A Delphi consensus study of resource utilisation for neuropsychiatric disorders in developing countries, including Ghana, suggested that acute psychosis, manic episodes, and severe depression were the most common disorders treated within inpatient psychiatric care. 14

Colonial psychiatrists asserted the virtual absence of depression among Africans, which was later challenged by Field among others. Field surmised that the self-accusations of women who confessed to witchcraft were akin to the self-reproach expressed by women with depression in Britain. 3 , 21 and that ‘Depression is the commonest mental illness of Akan rural women’ (p. 149). 3 Two studies of psychiatric morbidity in general hospitals and clinics suggest that more neurotic and affective disorders may be seen in these facilities than in the psychiatric hospitals although numbers are small. 24 , 25 In a survey of psychiatric morbidity at 6 polyclinics in Accra, of 172 patients, 27 were found to have psychiatric illness, with a further seven having physical illness with concomitant psychiatric illness. Of these 23 (72%) were diagnosed with ‘neurosis’. 24 Lamptey recorded no cases of depression, however it is possible these may have been missed due to the prominence of somatic symptoms such as palpitations, burning sensations and insomnia. In another study of 94 patients referred to a psychiatric out-patient clinic at KBTH the majority were diagnosed with affective (23) and neurotic/stress related disorders (11). 25

To address the lack of cross-cultural data on depression in the early 1980s the World Health Organization sponsored a study utilising the Standardized Assessment for Depressive Disorders (SADD). Fifty patients were assessed using SADD, Thirty-three were female. Anxiety and tension were the core symptoms expressed, with 35% reporting feelings of guilt and self-reproach. Feelings of sadness and loss of interest and enjoyment were commonly reported. Forty reported somatic symptoms including headaches, bodily heat, and generalised body pain. 26

The authors argue that there has been a change in the presentation of depression in Africa compared to earlier data. However, whilst the population of Ghana is more widely educated than in the 1950s, the study recruited a highly selective English-speaking sample who had already interpreted their symptoms in such as way as to approach psychiatric hospital. Indeed Turkson and Dua's study with a larger, less well-educated sample produced contrasting results. They studied 131 female outpatients with a diagnosis of depression using the Montgomery-Asberg Depressive Rating Scale (MADRS). They noted a high degree of somatic symptoms, in particular headaches (77.86%) and sleeplessness (68.7%). In contrast to the SADD study, there were fewer reported psychological symptoms such as pessimistic thoughts (20.61%) and sadness (12.97%). Only 10 (7.3%) reported suicidal thoughts. 27 However the MADRS has fewer psychological items than the SADD and therefore elicits different symptoms, highlighting one of the limitations of standardised instruments, particularly where they have not been validated with the local population.

Osei explored the incidence of depression among 17 self-confessed ‘witches’ at three shrines in the Ashanti region of Ghana. All were diagnosed with depression according to ICD-10. Three also had serious physical health problems. As in the previous studies, many described physical complaints such as a burning sensation or persistent headaches. The women also expressed ideas of guilt relating to having harmed someone in the family through the use of witchcraft. 28 Like Field, Osei suggests that guilt feelings arising from depression might prompt women to confess to witchcraft.

Such research raises interesting issues for the study of mental illness within the context of widespread belief in witchcraft and other supernatural phenomena in Ghana.

Turkson and Dua hypothesise on a link between socioeconomic status and depression, however without a control group and with inadequate numbers they could provide little substantive evidence. A qualitative study of 75 women in the Volta region is highly suggestive of a link between social factors and psychological distress. 29 – 31 Whilst this study did not set out specifically to research mental disorders, almost three quarters of the women interviewed described ‘thinking too much’ or ‘worrying too much’. Importantly, such symptoms were more prominent in women's accounts of their health than physical health problems.

Most participants complained of stresses arising from multiple responsibilities in the arenas of family and work, as well as financial hardship. 30 Headaches, bodily aches and pains, and sleep disturbance were commonly reported. A similar link between such experiences of poverty and possible symptoms of mental illness such as excessive thinking, worry and anxiety, as well as persistent physical symptoms such as headaches, has been made in a study of migrant squatters in Accra. 32 It is probable that some of these women may have met the criteria for a psychiatric diagnosis of depression.

The prominence of somatic symptoms among Ghanaian women diagnosed with depression is notable. Turkson notes that in 1988 32% of all new patients at APH presented with primarily somatic symptoms such as headaches, burning sensations, tiredness and bodily weakness with the majority diagnosed with anxiety, depression and somatisation disorders. 25 This highlights the importance of screening measures which have been locally validated and can identify somatic and non-somatic symptoms. A study of depression and life satisfaction among Nigerian, Australian, Northern Irish, Swazi and Ghanaian college students utilising the Beck Depression Inventory (BDI) for example, found that Ghanaians had significantly lower depression scores than other groups. 33

Aside from sleeplessness and loss of appetite, the BDI items are mostly concerned with psychological aspects of depression such as worthlessness and guilt. In a study of the comparative validity of screening scales for post-natal common mental disorders Weobong provides evidence for the cross-cultural validity and reliability of a Twi version of the Patient Health Questionnaire (PHQ-9). 34

Significantly the study showed that a mixture of somatic and cognitive symptoms best discriminated between cases and non-cases for all scales evaluated.

Given the high birth rate in Ghana, Weobong's study of post-natal depression will provide much-needed data on a condition which has been little researched. The only previous study identified described four cases of psychiatric disorders associated with childbirth treated at APH, including post-partum psychosis and manic-depressive psychosis. The author observed that few cases were referred to the psychiatric hospital and queried whether post-partum mental disorders were being recognised within antenatal wards. He also noted the influence of social factors such as marital problems and financial difficulties. 35

The literature reveals that women are generally underrepresented in psychiatric hospitals in Ghana. In Forster's study of APH inpatient admissions between 1951–1971 males consistently outnumbered females by about 3:1. 15 It has been suggested that when men become acutely mentally unwell they may be more difficult to manage at home, and so are more likely to be brought to the psychiatric hospitals for treatment. 16 18 36 37 Women in Ghana appear to be underserved by mental health services and the majority of women suffering from mental disorders, particularly depression, remain untreated or under the care of churches and shrines. Research at facilities such as polyclinics, shrines and churches may provide a more accurate picture of the numbers of women with mental disorders and their clinical presentation.

Suicide and self-harm

There is very little research on self-harm in Ghana. Roberts and Nkum examined the case notes of 53 patients admitted to Komfo Anokye Teaching Hospital (KATH) over a 5 year period. 38 The most common means of self-harm was ingestion of pesticides (22), and other harmful substances. 10 used ‘physical methods’ including self-stabbing (4). 6 cases were diagnosed with psychosis and 28 with acute reactions to social stresses such as marital and financial problems. The authors found an increase in deliberate self-harm during the five year period compared to an earlier study 39 from 0.3 cases per 1,000 admissions between 1965–1971 to 1.32 cases per 1,000 admissions in 1987. Based on their findings the authors estimated a crude annual incidence of 2.93 per 100,000. However this figure is likely to be an underestimate given that some cases may not reach medical services.

A number of studies comparing suicidal ideation among Ghanaian and Caucasian students in the USA showed significantly lower rates of self-reported suicidal ideation among the Ghanaian sample, as well as more negative attitudes towards suicide. 40 41 A larger survey compared 570 Ghanaian students with students from Uganda and Norway utilising the Attitudes Toward Suicide Questionnaire. Thirty (5.4%) of the Ghanaian sample reported making suicide attempts, significantly lower than either Uganda or Norway. Nine of the respondents reported a completed suicide in the family, and 91 among non-family members, again markedly lower than those reported by the Ugandan and Norwegian respondents. 42

Though these studies seem to suggest a low rate of suicidal ideation in Ghana, generalisation is cautioned since all the studies were conducted with young, urbanised, highly-educated participants. There is also no published research on completed suicides in Ghana. It is possible that the lower reported rates of suicidal ideation or suicide attempts may in part reflect likelihood that Ghanaian students would be less likely to report suicidal ideation due to negative attitudes towards suicide. This is supported by the finding of Hjelmeland et al that 31% of their sample felt that suicide should not be talked about. 42

However these studies also point to possible factors in Ghanaian society which could be employed in suicide prevention including family support, religious belief, and an emphasis on the value of the group. Qualitative studies related to beliefs and attitudes towards suicide, as well as risk factors, would greatly enhance the quantitative data and enable an exploration of some of the correlations observed. 41 There is one recent study on anorexia nervosa among female secondary school students in North East Ghana, a condition which has been considered rare in non-Western cultures.

The researchers completed a clinical examination of physical and mental health, two standard measures of eating behaviour and attitudes, and a depression screen. Of 666 students, 29 were pathologically underweight of which 10 were diagnosed with morbid self-starvation based on clinically significant indicators such as denial of hunger, self-punishment and perfectionist traits. The majority of the participants, both Christian and Muslim, reported regularly engaging in religious fasting. For the 10 engaged in morbid self-starvation, this fasting was particularly frequent, at least once a week, and associated with feelings of self-control and self-punishment. Since self-starvation was not associated with a desire to be thin or a morbid fear of fatness, a diagnosis of anorexia nervosa according to DSM-IV or ICD-10 criteria could not be made.

However the authors suggest that in Ghana fasting rather than dieting may provide the cultural context within which morbid self-starvation occurs. 43 As suggested by the role of somatic symptoms in the presentation of depression in Ghana, this study has important implications regarding the limitations of standardised psychiatric diagnoses and the need to recognise cultural influences on the presentation of mental illness.

Substance misuse

It is notable that the highest number of published papers in this review concerns substance abuse. 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 This may reflect more on the interests of researchers than the severity of the problem. In his sociological study Affinnih claims there has been an increase in the use of drugs such as cocaine and heroin in Accra and other urban centres. 45 , 46 However data from the psychiatric hospitals suggests that cannabis and alcohol are the most frequently used substances and may be a risk factor for the development of psychosis amongst young men. 23 , 25 , 54 , 53

There is limited research on the mental health implications of substance use in Ghana. A study of substance abusers admitted to a private clinic in Accra excluded those with co-morbid mental illness. 49 Importantly only two papers were identified which were primarily concerned with alcohol misuse, one of which is a social history of alcohol use in Ghana. 44 The only epidemiological study of alcohol misuse was conducted with 350 psychiatric outpatients in Kumasi using the WHO Alcohol Use Disorders Identification Test (AUDIT).

The researchers found a prevalence of only 8.6% for hazardous drinking, significantly lower than comparable studies in the West. 53 The link between substance misuse and mental disorders may be exaggerated in the public imagination and the media and there is a tendency to make speculative assertions based on limited evidence. Affinnih for example quotes a minister of health as saying that ‘drugs are responsible for 70% of the cases in local psychiatric hospitals’ (p.397), 45 a figure which is not substantiated by hospital records. More research is needed in this area from a specifically mental health perspective.

Help-seeking

The popularity of traditional healers in the treatment of mental illness has been noted since the earliest studies of mental illness in Ghana and continues to the present day. 55 A study of 194 people attending three shrines in the Ashanti region stated that 100 (51.55%) of these were suffering from a mental illness, the majority (64 (32.99%)) with depression. Another 14 were diagnosed with somatisation, and 19 with psychotic illness, including 6 with schizophrenia, 4 with acute psychosis and 3 with cannabis-induced psychosis. 28 36

Though data is limited, two papers suggest a change in the pattern of help-seeking over the last thirty years, with a greater role for Christian healers. In 1973 a study of 105 patients at APH diagnosed with psychosis showed that almost all (97(92%)) had sought another form of treatment before attending the psychiatric hospital. 67 (64%) patients had consulted a herbalist, 28 (26%) a healing church, and only 2 a fetish priest. 56

A study in 2004 of the use of traditional healers and pastors by 303 new patients attending state and private psychiatric services in Kumasi found that a smaller proportion of patients had consulted other forms of treatment and a greater number reported consulting a pastor than a traditional healer (43 (14.2%) and 18 (5.9%) respectively). There also appeared to be more use of medical facilities in the treatment of mental illness. 14 patients had seen a family doctor and 6 had visited another psychiatric hospital. Nearly a quarter (24.4%) had previously attended one of the other mental health centres in Kumasi. 57

Limited research has been conducted on beliefs and attitudes towards mental illness in Ghana which may influence help-seeking behaviour, though there is much speculation on the spiritual attribution of mental illness amongst the general population. 7 Two studies conducted in the early 1990s suggest a more varied and complex picture. A quantitative survey of 1000 women in Accra found that most (88%) said they would seek help from the psychiatric hospitals and only a minority (8.2%) said they would consult traditional healers.

The most important socio-demographic factors influencing the orientation towards help-seeking were area of residence, ethnicity, migration status, and prior use of medical services. Women who perceived the cause of psychosis to be natural or stress-related were more likely to seek help from mental hospitals than those who identified supernatural causation. 58 Similarly, a study of the effect of social change on causal beliefs of mental disorders and treatment preferences among teachers in Accra found that rather than emphasising spiritual causation for mental illness in Ghana, respondents attributed multiple causal factors to mental illness drawn from biological, social and spiritual models.

The authors attributed this in part to ‘acculturation’ but cautioned that participants may have wished to present themselves as educated and therefore have been less willing to disclose supernatural beliefs.

They also hypothesised that such beliefs may only come into play as an ‘indirect attribution’. 59 In both studies participants were urban residents and most were educated. Using semi-structured interviews with 80 relatives of people with mental illness, and 10 service providers, Quinn explored beliefs about mental illness in Accra and Kumasi, and two rural areas in the Ashanti and Northern regions and how these influenced family responses to mental illness.

In line with the urban ‘acculturation’ thesis, 2 , 17 Quinn reported that in urban areas most respondents attributed mental illness to ‘natural’ causes such as work stress. In the Northern region however, spiritual attributions were more common. The Northern samples were also significantly less educated with 14 out of 19 respondents having no education. Caution should be exercised in generalising these results as the sample size in each area was small. There were also many ‘don't knows’ - 22 out of 80. 60 This may be a reflection of more complex aetiological beliefs and uncertainty around the cause of mental illness than reflected in a binary spiritual/natural schema, as earlier studies have suggested. 37 , 59

Quinn's study claims that there was greater reliance on traditional healing in the North due to beliefs in a spiritual origin of mental illness; however it does not explore these issues in sufficient depth to support this assertion. The lower education of those in the Northern sample as well as their long distance from the psychiatric hospitals was other factors which may have influenced help-seeking. The study also reports that respondents in the Northern Region described greater acceptance of people with mental illness by families and communities with little evidence of stigma, echoing earlier reports. 2 , 17 Quinn's finding however is based on only 19 respondents, 17 of which were male. Since mothers are likely to provide most of the caring role they might have provided differing opinions on the impact of the illness. 60

None of these studies allow for in-depth exploration of possible influences on help-seeking behaviour for mental illness. However they suggest some interesting hypotheses regarding the reputation of traditional healers in treating mental illness, the stigma attached to mental illness and psychiatric hospitals, and the scarcity of psychiatric services.

In common with other mental health researchers and professionals in Africa, these studies recommend collaboration with traditional and faith healers in the treatment of mental illness, such as training healers in recognising severe mental illness, and referring patients to psychiatric services. However traditional healers and pastors may be unwilling to pass on their customers to biomedical practitioners or admit to failings in their intervention. Claims for the efficacy of traditional healers also tend to be anecdotal and speculative and are seldom based on rigorous longitudinal data. Most authors highlight the role of traditional healers in addressing the psychosocial aspects of mental illness and their resonance with cultural beliefs. 37 , 56 , 61 , 62 , 63

Whilst some present a rather idealised picture, 61 others note the inhumane treatment of people with mental illness by traditional healers. 4 , 36 , 62 One paper points to the role of the family in caring for patients within traditional shrines and churches, and shows how this model was replicated within psychiatric facilities by enabling family members to stay with the patient in hospital. 64 Further research is needed on the practices of traditional and faith healers to inform interventions to address the maltreatment of people with mental illness, and ensure that those with mental illness receive the best quality treatment from both psychiatric facilities and informal services.

This review shows that mental health research in Ghana remains limited in both quantity and quality. In the absence of comprehensive research, much is assumed based on scant evidence, and services are heavily influenced by the results of research conducted elsewhere, most often in high-income settings. Whilst researchers have used their findings to argue for more resources for mental health, such pleas would be more forcefully made were there more accurate epidemiological data. It is difficult to estimate the true prevalence of mental disorder and plan effectively for mental health promotion and treatment without more rigorous, large-scale population-based studies. However the published research on mental disorders such as psychosis, depression, substance misuse and self-harm provides insights for future research on the cultural context of these disorders in Ghana, including risk factors, with important implications for clinical intervention and mental health promotion.

A major omission in the literature regards studies of the practice and efficacy of psychiatric treatment in Ghana. Given the scarcity of psychosocial interventions, psychotropic medication is the mainstay of treatment and has been the topic of four papers. 65 , 66 , 67 One study reports that adherence to medication is poor among many patients 68 suggesting the need for further research into the reasons for this, and methods by which to improve both access and adherence.

Most research in Ghana has been conducted by psychiatrists and there is very little published research by psychologists, psychiatric nurses and social workers. The only published study identified on counselling argued for consideration of notions of self-identity, as well as the influence of the multi-lingual post-colonial environment when importing talking therapies, 69 a topic which would benefit from further research. Multidisciplinary research is also needed on the particular social and psychological factors which play an important part in the aetiology and course of mental disorders within Ghana and how these might be addressed.

Research on beliefs and attitudes towards mental illness suggests that these influence not only help-seeking behaviour but also stigma, care-giving and social inclusion. Research in this area may not only point to the roots of stigma, social exclusion and human rights abuse, but also to potential resources for the support and social integration of those with mental disorders. Most importantly research on mental health in Ghana needs to focus on experiences of the mentally ill and their caregivers. Existing research suggests a high social, financial and psychological burden for patients and carers, 4 , 30 , 31 , 60 and further research in this area could provide a powerful tool to argue for greater attention to mental illness as a neglected public health concern.

The studies reviewed have been small in scale and of limited generalizability. Nonetheless, they provide important insights into the development of mental health care in Ghana, and suggest directions for future research. Based on this review we suggest the following priorities for mental health research in Ghana:

• Population-based epidemiological studies of mental disorders - including attention to shrines and churches.
• Research on mental disorders, in particular psychosis, substance use, depression, somatisation, and self-harm including risk factors, clinical picture, course and outcome.
• Outcome studies of interventions within psychiatric services, primary care and other service providers e.g. NGOs
• Experiences of people with mental illness and their family members, including the psychosocial and financial impact, help-seeking and treatment experiences.
• The practices of traditional and religious healers and potential for collaboration.

Evidently these topics call for both quantitative and qualitative methodologies across disciplines in both medicine and social science. However an important caveat remains as to who will conduct this research given the pressures on clinicians and the limited research expertise. For too long mental health research has been dominated by experts in high-income countries with the consequent risk of cultural bias.

There remains a need for capacity building among clinicians across all disciplines to conduct clinically-based research, and for researchers trained in psychiatric epidemiological methods. Collaboration with mental health researchers in Africa and elsewhere, including the Ghanaian diaspora is one suggestion. 70 Above all high quality large-scale research requires funding. Given the burden of mental illness suggested by existing research in Ghana and elsewhere in the region, there is a strong case for international funding for mental health research to provide an evidence-based foundation for targeted and culturally relevant interventions.

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