Patrick McGorry: Why we may be overdoing mental health ‘awareness’ in schools

Some research has shown mental health awareness programs are not only ineffective, but they may even cause harm to a subset of young people exposed to them, writes psychiatrist Patrick McGorry.

A quarter of a century ago, mental illness began to emerge from the shadows and we were able to start talking more openly about it.

Thanks to former Victorian premier Jeff Kennett, who had discovered at the World Economic Forum in 1999 that depression was becoming the leading contributor to health burden around the world, Beyondblue came into being to raise awareness and understanding. This sparked a sea change, which gained momentum in other countries too, and now an army of individuals and groups mount a constant stream of “awareness campaigns” involving bike rides, long walks, kayak journeys, push up challenges and other feats of sacrifice and endurance, all in a good cause.

Mostly however these have been limited to common mental disorders. Other forms of mental illness remain poorly understood.

Schools across Australia are inundated with an array of mental health literacy programs, resilience training and mindfulness training, many or most without an evidence base to support their value or safety.

TikTok and other social media platforms are dripping with often quite random and unregulated mental health content. The basic proposition was that greater awareness is the first step to recognising a threat to health and to seeking help and therefore to recovery.

This was a reasonable assumption and especially so given the youth mental health crisis that has been building over the past two decades and is weakening our whole society. So how has it all been going and are we seeing the benefits?

Patrick McGorry whether too much focus on ‘awareness’ is causing problems.

Lucy Foulkes is a senior research fellow in the Department of Experimental Psychology at the University of Oxford. She has been looking carefully at whether efforts intended to reduce mental health problems, such as awareness-raising campaigns and a range of school initiatives, may inadvertently increase these problems in some individuals, how such a perverse outcome might happen and who might be at greatest risk.

There is emerging evidence to justify her concerns and efforts to understand what is happening.

It is important though to state at the outset that mental ill health remains a major and the most neglected and misunderstood public health problem we face, and there is no doubt that there has been a genuine and substantial increase in mental illness in teenagers and young adults since the early 2000s.

It may also be true to say that all that glitters is not gold. Some of what is labelled as illness is in fact within the spectrum of normal human experience and does not necessarily need professional help. This appears to be increasing too.

Nevertheless, the major problem is still that most young people with a genuine need for professional and expert care cannot access it in a timely way.

And one of the effects for many years of putting too many of a limited number of eggs into the awareness basket and into whole of school programs has been to create the impression that something, and perhaps enough, is being done to tackle mental illness.

The Albanese government fortunately has seen beyond this and has made the reimagining and expansion of youth mental health care system the top priority for this term of government.

In fact a series of research studies, particularly from the UK, has shown that not only are so called “universal” or whole of school awareness or mental health literacy programs not effective, they may even cause harm to at least a subset of those young people exposed to them. The AWARE trial in the UK was conducted with 12,166 pupils across 153 schools. The trial explored the impact of two interventions within schools – Youth Aware of Mental Health (YAM) and The Mental Health and High School Curriculum Guide (The Guide) in the short and longer term on young people’s self-reported emotional difficulties and intentions to seek help. While there were short term benefits on distress and help-seeking, after 9-12 months, both interventions were associated with increased emotional difficulties. The conclusions were that these interventions were not cost effective and while beneficial for a number of students, at least at first, they were also potentially harmful for others, especially for those students who did not have current mental health problems. More research is needed before they can be recommended for widespread use.

Patrick McGorry AO, the executive director of Orygen, writes about unanticipated and perverse effect of awareness programs. Picture: Orygen

Another landmark study, the MYRIAD trial (My Resilience in Adolescence) was a rigorously conducted study in the UK, testing whether school-based mindfulness training (SBMT) improved the mental health and wellbeing of young adolescents aged 11–16. The trial was the largest study of its kind involving over 28,000 students, 650 teachers, and 100 secondary schools. MYRIAD found that universal mindfulness programs in schools are not effective for improving adolescent mental health and wellbeing, and highlighted a need for more targeted, individualised support for students most in need. These findings inform future school mental health strategies and policy decisions.

Another unanticipated and perverse effect of awareness programs reminds me of what we used to call “medical student syndrome”. As we learned the symptoms of new diseases as medical students, we often began to notice similar changes in ourselves and started to worry that we might be developing such an illness. This could be a pathway to hypochondriasis. Nowadays with large scale unsophisticated mental health literacy programs and misinformation on social media platforms like TikTok, there is an increasing level of self-diagnosis of anxiety, depression and to a growing and extraordinary extent ADHD and ASD. Lucy Foulkes even suggests that social media has romanticised self diagnosis in a contagious way, which creates new risks. This trend is made possible because mental ill health exists on a spectrum, and the definitions of many but not all mental disorders overlap with normal human experience. And as the architect of the DSM 4 classification Dr Allen Frances has admitted in recent years, some of these definitions have broadened and diluted. This makes it so easy, especially if one is struggling with life in other way to see securing a diagnosis and recognition as a lifeline.

This is very understandable and helps to explain some of the social contagion that we are witnessing in this space.

Too much mental health awareness in schools can actually be harmful according to research. Picture: Aflo Images via Canva

As Dr Suzanne O’Sullivan in her book “The Age of Diagnosis” notes, all this does not mean that many of these people need some form of help and understanding but misdiagnosis and the wrong treatment is a significant risk. This is what many critics have been on about in terms of “over-medicalisation”. So, in the real world, we see a mixture of mainly under-diagnosis and under-investment in mental health, but with a growing layer of over- or misdiagnosis at the shallow end of the mental health pool, which needs a rather different approach.

25 years on from the rise of awareness campaigns and universal strategies in mental health, the bottom line is that public education is a complex challenge and the interplay between the development of clear and appropriate pathways to care especially for those who are developing potentially serious, disabling or life threatening forms of mental illness and the delivery of the right kind of information must be better understood. We must focus on early detection and treatment of the substantial and growing number of people with emerging mental illness which will involve a more sophisticated public education dimension which should be more targeted and specific based on what we have learned so far.

Professor Patrick McGorry AO is a psychiatrist, professor of youth mental health at the University of Melbourne and founding editor of the journal Early Intervention in Psychiatry.

He is also the Executive Director of Orygen, a not-for-profit youth mental health research institute and charity.

Originally published as Patrick McGorry: Why we may be overdoing mental health ‘awareness’ in schools