human psychopharmacology Hum. Psychopharmacol Clin Exp 2014; 29: 211–215. Published online 27 March 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/hup.2397
REVIEW ARTICLE
Health literacy and the pharmacological treatment of anxiety disorders: a systematic review M. Carlotta Palazzo1*, Bernardo Dell’Osso1, A Carlo Altamura1, Dan J Stein2 and David S Baldwin2,3 1
University of Milan, Department of Psychiatry, Fondazione IRCSS Ca’ Granda, Ospedale Maggiore Policlinico, Milano, Italy Department of Psychiatry, University of Cape Town, Cape Town, South Africa 3 Clinical and Experimental Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton SO14 3DT, UK 2
Objective Anxiety disorders are treatable conditions, but many affected individuals neither seek professional help nor adhere to recommended pharmacological treatments. Increasing the health literacy of people with (or at risk of) anxiety disorders may encourage treatment-seeking and adherence to recommended interventions. Aims of this study were to review the literature relating to health literacy in the treatment of anxiety disorders, focusing on results on public opinion on psychotropic medications and its effectiveness in improving access to psychiatric health care and the actual use of medications. Methods A computerized literature search of the published literature on mental health literacy was undertaken, focusing on the question of whether increased mental health literacy led to increased treatment-seeking and pharmacotherapy adherence in individuals with anxiety disorders. Results Twelve relevant articles were identified. All reported that improving mental health literacy leads to raised awareness, and in 10 out of 12 studies, increased help-seeking. However, there is currently no unequivocal evidence to show that increasing health literacy leads to increased use of medication in any psychiatric disorder, including anxiety disorders. Two studies show that knowledge of presumed biological mechanisms can predict use of psychotropic medication, including antidepressants, in psychiatric disorders, however, not specifically in anxiety disorders. Conclusion There have been few investigations of health literacy focused on psychotropic medications. Given the prevalence, burden and sub-optimal recognition, and treatment of anxiety disorders, further work is needed to determine whether increased mental health literacy is associated with treatment-seeking and medication adherence in patients with these disorders. Copyright © 2014 John Wiley & Sons, Ltd. key words—health literacy; anxiety disorders; pharmacological treatment
BACKGROUND Anxiety disorders are common, distressing, and impairing conditions, associated with significant social costs (Wittchen et al., 2011). When compared with individuals with other psychiatric conditions, those with anxiety disorders are high utilizers of health services (Lépine, 2002). Furthermore, anxiety symptoms and disorders often precede the development of other mental and physical disorders, including major depressive disorder and substance use disorders (Roy-Byrne et al., 2008). Anxiety disorders are treatable conditions, but many affected individuals do not seek professional help or do not adhere to recommended interventions (Oliver et al., 2005; Nutt et al., 2007; Baldwin et al., 2010; *Correspondence to: M. Carlotta Palazzo, University of Milan, Department of Psychiatry, Fondazione IRCSS Ca’ Granda, Ospedale Maggiore Policlinico, Milano, Italy. E-mail: [email protected]
Copyright © 2014 John Wiley & Sons, Ltd.
2013). Deficits in the ability to recognize symptoms may contribute to low levels of help seeking (Coles and Coleman, 2010). A recent mental health survey on drop-out from treatment showed how drop-out was unrelated to the mental disorder experienced (odds ratio (OR) = 1.1 for mood disorders, anxiety disorders, and drug abuse). Considering only anxiety disorders, there was an OR difference between patients coming from a high income countries (OR = 1.3; 1.1–1.6) versus low income ones (OR = 1.8; 0.9–3.5). This difference appears more striking when considering that treatment was more common in high-income (12.0%, s.e. = 0.2) than in higher-middle income (8.7%, s.e. = 0.3) or in low/lower-middle-income (3.4%, s.e. = 0.2) countries (Wells et al., 2013). Attitudinal and structural barriers to appropriate care include the stigma associated with mental disorder and its treatment and the limited numbers of suitably trained health care professionals (Angermeyer and Matschinger, 1996; Corrigan et al., Received 9 May 2013 Accepted 21 January 2014
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2003; Hugo et al., 2003; Sorsdahl and Stein, 2010). Both sets of barriers contribute to under-diagnosis and under-treatment of anxiety disorders (Weiller et al., 1998; Young et al., 2001). ‘Health literacy’ has been defined as ‘the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions’ (Jorm et al., 1997; Nielsen-Bohlman et al., 2004). Increasing health literacy of individuals with or at risk of anxiety disorders may encourage appropriate treatmentseeking through increasing knowledge of the disorder and its treatments (Jorm, 2012). We aimed to appraise the current literature on the role of health literacy in increasing treatment-seeking and medication adherence, focusing on anxiety disorders and their treatment. METHOD A computerized search of the published literature on health literacy about psychotropic medications in individuals with anxiety disorders, with a specific focus on whether randomized controlled trials has been undertaken in this area. Key terms included ‘health literacy’, ‘anxiety disorder’, ‘neuropsychopharmacology’, ‘mood disorder’, ‘antidepressants’, and ‘psychotropic medication’; the research was performed mainly on Pubmed; the period covered was between January 1996 and September 2013. The search was furtherly extended on Science Direct and Google scholar. RESULTS Fifty-four studies were identified online while performing a search for ‘health literacy’ on ‘anxiety disorders’ in adult population. Most of the identified studies were not specifically focused on anxiety disorders but referred to a range of psychiatric conditions. We identified a total of 12 articles, which focused on health literacy and mentioned at least an anxiety disorder and a standardized pharmacological treatment for anxiety. These could be grouped in two areas of interest: (i) the influence of mental health literacy on attitudes toward use of psychiatric care system and/or reducing the disparity between public opinion and clinician consensus and (ii) health literacy about psychotropic medication. MENTAL HEALTH LITERACY AND ATTITUDES TOWARD USE OF PSYCHIATRIC CARE SYSTEM Six publications focused on the effect of mental health literacy on improving access to standardized treatments for mental disorder. Gulliver and colleagues Copyright © 2014 John Wiley & Sons, Ltd.
AL.
(2012), in a recent review, showed that improving mental health literacy is effective in fostering a helpseeking attitude; but it is not certain whether this leads to increased uptake of pharmacological therapies (Gulliver et al., 2012). This review included six randomized control trials, not specifically targeting anxiety disorders but including affective disorders. Two publications (Jorm et al., 2000; Reavley & Jorm 2011) were based on investigations of the perceived usefulness, among the general population, of differing treatments for psychiatric disorders, the findings being quite different to the suggestions of standardized guidelines: Jorm and colleagues undertook a postal survey on a large sample of adults (n = 3109). Within these subjects, 422 persons with high level of depressive/anxious symptoms were followed up 6 months later and asked which interventions they actually used. Beliefs about the perceived helpfulness of an intervention did not always predict the actual use of that intervention leading to a discrepancy between a better opinion on mental health care services and their use by general population. However, beliefs about the perceived benefits of antidepressant drugs were associated with their actual use (Jorm et al., 2000). Broadly, this gap can be explained by differences in insight, more than a lack of efficacy of the intervention itself. Again, it is uncertain whether this ‘ranking’ affects the relative frequency with which these interventions are actually used (Jorm et al., 2000; Reavley and Jorm, 2011). An Australian study that examined the impact of public education campaigns over 15 years, designed to enhance mental health literacy found that public and professional beliefs on treatment efficacy differ (Reavley & Jorm, 2012). However, in 15 years, the ability to properly label psychiatric condition has improved, and general population seem to have more positive ratings for a range of interventions, including help from mental health professionals and antidepressants. This study was a replication of data collected in 1995 that used case vignettes, in order to describe how the general population was able to recognize different psychiatric conditions and the helpfulness of care services and standardized treatments. The study was replicated in 2003 and extended in 2011, including social phobia. Depression was correctly labeled only by 39% of survey responders in 1995, whereas in 2011, this rate increased to nearly 74%. Relating to possible helpfulness of medication, antidepressants were considered ‘useful’ by 28.7% of 1995 responders, but in 2011, this increased to 59%. Findings by the same group specifically relating to health literacy about depression and an anxiety disorder (social phobia) in young patients and in Hum. Psychopharmacol Clin Exp 2014; 29: 211–215. DOI: 10.1002/hup
health literacy in anxiety disorders: a review
clinicians (including GP, psychologists, psychiatrists, and nurses) showed that there are still differences between public beliefs and clinicians’ opinions (Jorm et al., 2008). Specifically, a postal survey was carried out on the beliefs of Australian clinicians about helpful interventions/medication use. The clinicians showed consensus about the helpfulness of most of mental health professional caregivers, and antidepressants were generally recommended in adults. However, patients and their caregivers showed much lower endorsement of standardized treatment (antidepressants and cognitive-behavior therapy), whereas clinicians had much lower endorsement than the public of informal supports (family, friends, and support groups). HEALTH LITERACY ABOUT PSYCHOTROPIC MEDICATION Although public understanding of the benefits and risks of psychotropic drug treatment appears to have increased, marked suspiciousness about safety and efficacy is still common (Angermeyer and Matschinger, 2004). A study performed in Germany comparing attitude to psychotropic drugs in the early 1990 was repeated in 2001 (Angermeyer et al., 1993; Angermeyer and Matschinger, 1996; Angermeyer and Matschinger, 2004). Using vignettes, responders to this survey were asked to label common mental disorders and the perceived helpfulness of treatment, including medications. The results were comparable with those showed in the Australian groups but, focusing more on the role of drugs, they described how psychopharmacotherapy was rejected by the vast majority of respondents in 1996. In 2001, following an enlargement of health literacy campaign, respondents were more ready to acknowledge beneficial effects of drug treatment, however, far from ideal. We find it interesting that a gap between responders from East Germany and West Germany still existed in 2001; this could be explained by the need for using different strategies within different social contexts. The same methods were used to compare attitudes toward mental disorders (depression and schizophrenia) and pharmacological treatment, performed in cohorts of patients from Russia and Slovakia compared with the previously described German cohort. This study design that evaluated the effects of a program on mental health literacy after important reforms of the psychiatric system found that patients after the reform were theoretically more likely to seek help from a psychiatrist: but it is uncertain whether this would lead to greater uptake of the treatment. The endorsement of the presence of ‘brain disease’ as a cause of mental disorder was associated Copyright © 2014 John Wiley & Sons, Ltd.
213
with a greater willingness to undergo psychotropic drug treatment (Angermeyer et al., 2005). A similar study, which compared Australian and Japanese samples, found that in Japan, where the mental health ‘system’ is more oriented to hospital care, belief in the benefits of treatment was higher: regardless of the patients’ ability to properly label the pathological condition. By contrast, in Australia, where there is a more community-oriented approach, there was a positive correlation between better knowledge about disease and better access to treatment but negative correlation with actual use of psychotropic medication (Jorm et al., 2005). In both countries, household interviews were carried out concerning beliefs in relation to case vignettes, followed by a series of questions asking the respondent to rate the likely helpfulness of various interventions, including medications. Another interesting study found that better understanding of the presumed biological correlates of mental disorders was associated with improved attitude toward psychotropic medications but was not associated with better attitudes toward mental illness among the general public (Schomerus et al., 2012). This author conducted a meta-analysis to investigate if the increase knowledge about the biological correlates of mental disorders has translated into improved public understanding of mental illness. The meta-analysis included six papers published before 2011, selected as performing time-trend analyses or including at least an enquire repeated in a minimum of two occasions with the same methodology. Apparently, although the approach to emphasize biological correlates seems useful to enhance the acceptance of professional medical treatment for mental disorders, it is not suitable to improve social tolerance toward those suffering from mental illness. This failure in lowering stigma could imply the need for different strategies to improve public opinion on psychiatric conditions. DISCUSSION Efforts to enhance mental health literacy about psychotropic drug treatment can contribute to encourage patient-centered medicine, to make the path to mental health services easier to follow, and to reduce the overall burden of mental disorders. In many countries, major efforts have been made in recent decades to reduce perceived barriers between the general public and mental health services (Angermeyer and Matschinger, 2005). Research in the areas of mood disorders and substance abuse demonstrates the positive impact of improved health literacy in changing behaviors through school interventions, mass messages, and public campaigns (Wright et al., 2007). Hum. Psychopharmacol Clin Exp 2014; 29: 211–215. DOI: 10.1002/hup
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However, relatively little is known about how to enhance knowledge about psychotropic medication, especially in the relatively neglected area of anxiety disorders: most surveys and campaigns have been focused on mood disorders and psychosis. When compared with other forms of mental illness, anxiety disorders remain characterized by significantly greater delays in obtaining any kind of treatment and effective treatment, regardless of age, gender, and ethnicity (Johnson and Coles, 2013). A major limitation to the use of psychotropic drugs in anxiety disorders is the concern about potential side effects, but informing the patient about prescribed medications can be associated with increased involvement of patients in treatment, enhanced follow-up, and greater adherence to treatment (Baldwin et al., 2013). Increased health literacy about disease and its treatment can contribute to a non-judgmental environment, with positive attitudes toward mental disorder and psychotropic drug treatment. However, the relative ‘endorsement’ of particular treatment approaches by the general public does not always corresponds to the ranking of possible interventions in terms of effectiveness and acceptability by health professionals. A more easily accessible health system, with a low perception of stigma, may be insufficient to optimize opinions and behavior about mental disorders and psychotropic drugs. It remains largely uncertain whether better understanding of presumed molecular mechanisms underpinning psychiatric disorder and the response to treatment leads to greater willingness to seek and undergo psychotropic drug treatment. Further studies of health literacy about anxiety disorders and their treatments are needed.
AL.
FUTURE DIRECTIONS The availability of information about mental care services seems to be the first line intervention to improve access to treatment otherwise frequently neglected. Patients suffering from an anxiety disorder should be included in epidemiological studies of mental health literacy. A possible suggestion for a campaign to improve the access to psychiatric services and the use of psychotropic medication could include two levels of intervention. The first step would be improved knowledge in the first line caregivers, such as general practitioner, nurses, and social workers; the second step is being a campaign for the general population, with media support, to lower the stigma on psychiatric disorders, even supporting patient advocacy groups. As health literacy seems to work in increasing awareness, a similar effort should be taken in increasing literacy about psychotropic medications. CONFLICT OF INTEREST The authors make no declaration of potential conflicts of interest connected to this paper. ACKNOWLEDGEMENT M. Carlotta Palazzo participated in the Joint European South African Research Network in Anxiety Disorders program (Baldwin and Stein, 2012), which is supported by the European Union through the EU-FP7 Marie Curie Actions International Research Staff Exchange Scheme (PIRSESGA-2010- 269213).
REFERENCES LIMITATIONS The limited number of studies focusing on anxiety disorders was the major limitation to this paper. Literature on health literacy is mainly related to psychosis and affective disorders, despite the high prevalence of these conditions. Therefore, this review was conducted on studies mentioning at least an anxiety disorder or a standardized treatment for anxiety disorders. However, the perceived use of antidepressants in anxiety may differ from its perceived use in affective disorders. Cultural values and perception of mental health add a bias in interpreting studies on health literacy. Finally, time-trend analyses of mental illness-related public attitudes have been conducted mainly in industrialized, first-world countries, and developments in other parts of the world are poorly understood. Copyright © 2014 John Wiley & Sons, Ltd.
Angermeyer MC, Matschinger H. 1996. Public attitude towards psychiatric treatment. Acta Psychiatr Scand 94(5): 326–336. Angermeyer MC, Matschinger H. 2004. Public attitudes towards psychotropic drugs: have there been any changes in recent years? Pharmacopsychiatry 37(4): 152–156. Angermeyer MC, Matschinger H. 2005. Have there been any changes in the public’s attitudes towards psychiatric treatment? Results from representative population surveys in Germany in the years 1990 and 2001. Acta Psychiatr Scand 111: 68–72. Angermeyer MC, Däumer R, Matschinger H. 1993. Benefits and risks of psychotropic medication in the eyes of the general public: results of a survey in the Federal Republic of Germany. Pharmacopsychiatry 26(4): 114–120. Angermeyer MC, Breier P, Dietrich S, Kenzine D, Matschinger H. 2005. Public attitudes toward psychiatric treatment. An international comparison.Soc Psychiatry Psychiatr Epidemiol 40(11): 855–864. Baldwin DS, Stein DJ. 2012. A joint European and South African research network in anxiety disorders.Hum Psychopharmacol 27(1): 4–5. Baldwin DS, Allgulander C, Altamura AC, et al. 2010. Manifesto for a European anxiety disorders research network. Eur Neuropsychopharmacol 20(6): 426–432. Baldwin DS, Rafiq R, Talal B. 2013. Overcoming barriers in the pharmacological treatment of anxiety disorders Neuropsychiatry 3(1): 33–43.
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health literacy in anxiety disorders: a review Coles ME, Coleman SL. 2010. Barriers to treatment seeking for anxiety disorders: initial data on the role of mental health literacy. Depress Anxiety 27(1): 63–71. Corrigan P, Thompson V, Lambert D, Sangster Y, Noel JG, Campbell J. 2003. Perceptions of discrimination among persons with serious mental illness. Psychiatr Serv 54: 1105–1110. Gulliver A, Griffiths KM, Christensen H, Brewer JL. 2012. A systematic review of help-seeking interventions for depression, anxiety and general psychological distress. BMC Psychiatry 12: 81. Hugo CJ, Boshoff DE, Traut A, Zungu-Dirwayi N, Stein DJ. 2003. Community attitudes toward and knowledge of mental illness in South Africa. Soc Psychiatry Psychiatr Epidemiol 38(12): 715–719. Johnson EM, Coles ME. 2013. Failure and Delay in TreatmentSeeking Across Anxiety Disorders. Community Ment Health J 49(6): 668–674. Jorm AF. 2012. Mental health literacy: empowering the community to take action for better mental health. Am Psychol 67(3): 231–243. Jorm AF, Korten AE, Jacomb PA, Christensen H, Rodgers B, Pollitt P. 1997. ‘Mental health literacy’: a survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Med J Aust 166: 182–186. Jorm AF, Medway J, Christensen H, Korten AE, Jacomb PA, Rodgers B. 2000. Public beliefs about the helpfulness of interventions for depression: effects on actions taken when experiencing anxiety and depression symptoms. Aust N Z J Psychiatry 34(4): 619–626. Jorm AF, Nakane Y, Christensen H, Yoshioka K, Griffiths KM, Wata Y. 2005. Public beliefs about treatment and outcome of mental disorders: a comparison of Australia and Japan.BMC Med 9(3): 12. Jorm AF, Morgan AJ, Wright A. 2008. Interventions that are helpful for depression and anxiety in young people: a comparison of clinicians’ beliefs with those of youth and their parents. J Affect Disord 111(2-3): 227–234. Lépine JP. 2002. The epidemiology of anxiety disorders: prevalence and societal costs. J Clin Psychiatry 63(Suppl 14): 4–8. Nielsen-Bohlman L, Panzer AM, Kindig DA. 2004. Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. The National Academies Press: Washington, DC. Nutt DJ, Kessler RC, Alonso J, et al. 2007. Consensus statement on the benefit to the community of ESEMeD (European Study of the
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Epidemiology of Mental Disorders) survey data on depression and anxiety. J Clin Psychiatry 68(Suppl 2): 42–48. Oliver MI, Pearson N, Coe N, Gunnell D. 2005. Help-seeking behaviour in men and women with common mental health problems: cross-sectional study.Br J Psychiatry 186: 297–301. Reavley NJ, Jorm AF. 2011. Recognition of mental disorders and beliefs about treatment and outcome: findings from an Australian national survey of mental health literacy and stigma. Aust N Z J Psychiatry 45(11): 947–56. Reavley NJ, Jorm AF. 2012. Public recognition of mental disorders and beliefs about treatment: changes in Australia over 16 years. Br J Psychiatry 200(5): 419–425. Roy-Byrne PP, Davidson KW, Kessler RC, et al. 2008. Anxiety disorders and comorbid medical illness. Gen Hosp Psychiatry 30(3): 208–225. Schomerus G, Schwahn C, Holzinger A, et al. 2012. Evolution of public attitudes about mental illness: a systematic review and meta-analysis. Acta Psychiatrica Scandinavia. 440–450. Sorsdahl KR, Stein DJ. 2010. Knowledge of and stigma associated with mental disorders in a South African community sample. J Nerv Ment Dis 198(10): 742–747. Weiller E, Bisserbe JC, Maier W, Lecrubier Y. 1998. Prevalence and recognition of anxiety syndromes in five European primary care settings. A report from the WHO study on Psychological Problems in General Health Care. Br J Psychiatry 34: 18–23. Wells JE, Browne MO, Aguilar-Gaxiola S, et al. 2013. Drop out from outpatient mental healthcare in the World Health Organization’s World Mental Health Survey initiative. Br J Psychiatry 202(1): 42–49. Wittchen HU, Jacobi F, Rehm J, et al. 2011. The size and burden of mental disorders and other disorders of the brain in Europe in 2010. Neuropsychopharmacol 21: 655–679. Wright A, McGorry PD, Harris MG, Jorm AF, Pennell K. 2006. Development and evaluation of a youth mental health community awareness campaign - The compass strategy. BMC Public Health 6: 215. Wright A, Jorm A, Harris M, McGorry P. 2007. What’s in a name? Is accurate recognition and labeling of mental disorders by young people associated with better help-seeking and treatment preferences? Soc Psychiatry Psychiatr Epidemiol 42: 244–250. Young AS, Klap R, Sherbourne CD, Wells KB. 2001. The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psychiatry 58(1): 55–61.
Hum. Psychopharmacol Clin Exp 2014; 29: 211–215. DOI: 10.1002/hup
REVIEW ARTICLE
Health literacy and the pharmacological treatment of anxiety disorders: a systematic review M. Carlotta Palazzo1*, Bernardo Dell’Osso1, A Carlo Altamura1, Dan J Stein2 and David S Baldwin2,3 1
University of Milan, Department of Psychiatry, Fondazione IRCSS Ca’ Granda, Ospedale Maggiore Policlinico, Milano, Italy Department of Psychiatry, University of Cape Town, Cape Town, South Africa 3 Clinical and Experimental Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton SO14 3DT, UK 2
Objective Anxiety disorders are treatable conditions, but many affected individuals neither seek professional help nor adhere to recommended pharmacological treatments. Increasing the health literacy of people with (or at risk of) anxiety disorders may encourage treatment-seeking and adherence to recommended interventions. Aims of this study were to review the literature relating to health literacy in the treatment of anxiety disorders, focusing on results on public opinion on psychotropic medications and its effectiveness in improving access to psychiatric health care and the actual use of medications. Methods A computerized literature search of the published literature on mental health literacy was undertaken, focusing on the question of whether increased mental health literacy led to increased treatment-seeking and pharmacotherapy adherence in individuals with anxiety disorders. Results Twelve relevant articles were identified. All reported that improving mental health literacy leads to raised awareness, and in 10 out of 12 studies, increased help-seeking. However, there is currently no unequivocal evidence to show that increasing health literacy leads to increased use of medication in any psychiatric disorder, including anxiety disorders. Two studies show that knowledge of presumed biological mechanisms can predict use of psychotropic medication, including antidepressants, in psychiatric disorders, however, not specifically in anxiety disorders. Conclusion There have been few investigations of health literacy focused on psychotropic medications. Given the prevalence, burden and sub-optimal recognition, and treatment of anxiety disorders, further work is needed to determine whether increased mental health literacy is associated with treatment-seeking and medication adherence in patients with these disorders. Copyright © 2014 John Wiley & Sons, Ltd. key words—health literacy; anxiety disorders; pharmacological treatment
BACKGROUND Anxiety disorders are common, distressing, and impairing conditions, associated with significant social costs (Wittchen et al., 2011). When compared with individuals with other psychiatric conditions, those with anxiety disorders are high utilizers of health services (Lépine, 2002). Furthermore, anxiety symptoms and disorders often precede the development of other mental and physical disorders, including major depressive disorder and substance use disorders (Roy-Byrne et al., 2008). Anxiety disorders are treatable conditions, but many affected individuals do not seek professional help or do not adhere to recommended interventions (Oliver et al., 2005; Nutt et al., 2007; Baldwin et al., 2010; *Correspondence to: M. Carlotta Palazzo, University of Milan, Department of Psychiatry, Fondazione IRCSS Ca’ Granda, Ospedale Maggiore Policlinico, Milano, Italy. E-mail: [email protected]
Copyright © 2014 John Wiley & Sons, Ltd.
2013). Deficits in the ability to recognize symptoms may contribute to low levels of help seeking (Coles and Coleman, 2010). A recent mental health survey on drop-out from treatment showed how drop-out was unrelated to the mental disorder experienced (odds ratio (OR) = 1.1 for mood disorders, anxiety disorders, and drug abuse). Considering only anxiety disorders, there was an OR difference between patients coming from a high income countries (OR = 1.3; 1.1–1.6) versus low income ones (OR = 1.8; 0.9–3.5). This difference appears more striking when considering that treatment was more common in high-income (12.0%, s.e. = 0.2) than in higher-middle income (8.7%, s.e. = 0.3) or in low/lower-middle-income (3.4%, s.e. = 0.2) countries (Wells et al., 2013). Attitudinal and structural barriers to appropriate care include the stigma associated with mental disorder and its treatment and the limited numbers of suitably trained health care professionals (Angermeyer and Matschinger, 1996; Corrigan et al., Received 9 May 2013 Accepted 21 January 2014
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2003; Hugo et al., 2003; Sorsdahl and Stein, 2010). Both sets of barriers contribute to under-diagnosis and under-treatment of anxiety disorders (Weiller et al., 1998; Young et al., 2001). ‘Health literacy’ has been defined as ‘the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions’ (Jorm et al., 1997; Nielsen-Bohlman et al., 2004). Increasing health literacy of individuals with or at risk of anxiety disorders may encourage appropriate treatmentseeking through increasing knowledge of the disorder and its treatments (Jorm, 2012). We aimed to appraise the current literature on the role of health literacy in increasing treatment-seeking and medication adherence, focusing on anxiety disorders and their treatment. METHOD A computerized search of the published literature on health literacy about psychotropic medications in individuals with anxiety disorders, with a specific focus on whether randomized controlled trials has been undertaken in this area. Key terms included ‘health literacy’, ‘anxiety disorder’, ‘neuropsychopharmacology’, ‘mood disorder’, ‘antidepressants’, and ‘psychotropic medication’; the research was performed mainly on Pubmed; the period covered was between January 1996 and September 2013. The search was furtherly extended on Science Direct and Google scholar. RESULTS Fifty-four studies were identified online while performing a search for ‘health literacy’ on ‘anxiety disorders’ in adult population. Most of the identified studies were not specifically focused on anxiety disorders but referred to a range of psychiatric conditions. We identified a total of 12 articles, which focused on health literacy and mentioned at least an anxiety disorder and a standardized pharmacological treatment for anxiety. These could be grouped in two areas of interest: (i) the influence of mental health literacy on attitudes toward use of psychiatric care system and/or reducing the disparity between public opinion and clinician consensus and (ii) health literacy about psychotropic medication. MENTAL HEALTH LITERACY AND ATTITUDES TOWARD USE OF PSYCHIATRIC CARE SYSTEM Six publications focused on the effect of mental health literacy on improving access to standardized treatments for mental disorder. Gulliver and colleagues Copyright © 2014 John Wiley & Sons, Ltd.
AL.
(2012), in a recent review, showed that improving mental health literacy is effective in fostering a helpseeking attitude; but it is not certain whether this leads to increased uptake of pharmacological therapies (Gulliver et al., 2012). This review included six randomized control trials, not specifically targeting anxiety disorders but including affective disorders. Two publications (Jorm et al., 2000; Reavley & Jorm 2011) were based on investigations of the perceived usefulness, among the general population, of differing treatments for psychiatric disorders, the findings being quite different to the suggestions of standardized guidelines: Jorm and colleagues undertook a postal survey on a large sample of adults (n = 3109). Within these subjects, 422 persons with high level of depressive/anxious symptoms were followed up 6 months later and asked which interventions they actually used. Beliefs about the perceived helpfulness of an intervention did not always predict the actual use of that intervention leading to a discrepancy between a better opinion on mental health care services and their use by general population. However, beliefs about the perceived benefits of antidepressant drugs were associated with their actual use (Jorm et al., 2000). Broadly, this gap can be explained by differences in insight, more than a lack of efficacy of the intervention itself. Again, it is uncertain whether this ‘ranking’ affects the relative frequency with which these interventions are actually used (Jorm et al., 2000; Reavley and Jorm, 2011). An Australian study that examined the impact of public education campaigns over 15 years, designed to enhance mental health literacy found that public and professional beliefs on treatment efficacy differ (Reavley & Jorm, 2012). However, in 15 years, the ability to properly label psychiatric condition has improved, and general population seem to have more positive ratings for a range of interventions, including help from mental health professionals and antidepressants. This study was a replication of data collected in 1995 that used case vignettes, in order to describe how the general population was able to recognize different psychiatric conditions and the helpfulness of care services and standardized treatments. The study was replicated in 2003 and extended in 2011, including social phobia. Depression was correctly labeled only by 39% of survey responders in 1995, whereas in 2011, this rate increased to nearly 74%. Relating to possible helpfulness of medication, antidepressants were considered ‘useful’ by 28.7% of 1995 responders, but in 2011, this increased to 59%. Findings by the same group specifically relating to health literacy about depression and an anxiety disorder (social phobia) in young patients and in Hum. Psychopharmacol Clin Exp 2014; 29: 211–215. DOI: 10.1002/hup
health literacy in anxiety disorders: a review
clinicians (including GP, psychologists, psychiatrists, and nurses) showed that there are still differences between public beliefs and clinicians’ opinions (Jorm et al., 2008). Specifically, a postal survey was carried out on the beliefs of Australian clinicians about helpful interventions/medication use. The clinicians showed consensus about the helpfulness of most of mental health professional caregivers, and antidepressants were generally recommended in adults. However, patients and their caregivers showed much lower endorsement of standardized treatment (antidepressants and cognitive-behavior therapy), whereas clinicians had much lower endorsement than the public of informal supports (family, friends, and support groups). HEALTH LITERACY ABOUT PSYCHOTROPIC MEDICATION Although public understanding of the benefits and risks of psychotropic drug treatment appears to have increased, marked suspiciousness about safety and efficacy is still common (Angermeyer and Matschinger, 2004). A study performed in Germany comparing attitude to psychotropic drugs in the early 1990 was repeated in 2001 (Angermeyer et al., 1993; Angermeyer and Matschinger, 1996; Angermeyer and Matschinger, 2004). Using vignettes, responders to this survey were asked to label common mental disorders and the perceived helpfulness of treatment, including medications. The results were comparable with those showed in the Australian groups but, focusing more on the role of drugs, they described how psychopharmacotherapy was rejected by the vast majority of respondents in 1996. In 2001, following an enlargement of health literacy campaign, respondents were more ready to acknowledge beneficial effects of drug treatment, however, far from ideal. We find it interesting that a gap between responders from East Germany and West Germany still existed in 2001; this could be explained by the need for using different strategies within different social contexts. The same methods were used to compare attitudes toward mental disorders (depression and schizophrenia) and pharmacological treatment, performed in cohorts of patients from Russia and Slovakia compared with the previously described German cohort. This study design that evaluated the effects of a program on mental health literacy after important reforms of the psychiatric system found that patients after the reform were theoretically more likely to seek help from a psychiatrist: but it is uncertain whether this would lead to greater uptake of the treatment. The endorsement of the presence of ‘brain disease’ as a cause of mental disorder was associated Copyright © 2014 John Wiley & Sons, Ltd.
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with a greater willingness to undergo psychotropic drug treatment (Angermeyer et al., 2005). A similar study, which compared Australian and Japanese samples, found that in Japan, where the mental health ‘system’ is more oriented to hospital care, belief in the benefits of treatment was higher: regardless of the patients’ ability to properly label the pathological condition. By contrast, in Australia, where there is a more community-oriented approach, there was a positive correlation between better knowledge about disease and better access to treatment but negative correlation with actual use of psychotropic medication (Jorm et al., 2005). In both countries, household interviews were carried out concerning beliefs in relation to case vignettes, followed by a series of questions asking the respondent to rate the likely helpfulness of various interventions, including medications. Another interesting study found that better understanding of the presumed biological correlates of mental disorders was associated with improved attitude toward psychotropic medications but was not associated with better attitudes toward mental illness among the general public (Schomerus et al., 2012). This author conducted a meta-analysis to investigate if the increase knowledge about the biological correlates of mental disorders has translated into improved public understanding of mental illness. The meta-analysis included six papers published before 2011, selected as performing time-trend analyses or including at least an enquire repeated in a minimum of two occasions with the same methodology. Apparently, although the approach to emphasize biological correlates seems useful to enhance the acceptance of professional medical treatment for mental disorders, it is not suitable to improve social tolerance toward those suffering from mental illness. This failure in lowering stigma could imply the need for different strategies to improve public opinion on psychiatric conditions. DISCUSSION Efforts to enhance mental health literacy about psychotropic drug treatment can contribute to encourage patient-centered medicine, to make the path to mental health services easier to follow, and to reduce the overall burden of mental disorders. In many countries, major efforts have been made in recent decades to reduce perceived barriers between the general public and mental health services (Angermeyer and Matschinger, 2005). Research in the areas of mood disorders and substance abuse demonstrates the positive impact of improved health literacy in changing behaviors through school interventions, mass messages, and public campaigns (Wright et al., 2007). Hum. Psychopharmacol Clin Exp 2014; 29: 211–215. DOI: 10.1002/hup
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However, relatively little is known about how to enhance knowledge about psychotropic medication, especially in the relatively neglected area of anxiety disorders: most surveys and campaigns have been focused on mood disorders and psychosis. When compared with other forms of mental illness, anxiety disorders remain characterized by significantly greater delays in obtaining any kind of treatment and effective treatment, regardless of age, gender, and ethnicity (Johnson and Coles, 2013). A major limitation to the use of psychotropic drugs in anxiety disorders is the concern about potential side effects, but informing the patient about prescribed medications can be associated with increased involvement of patients in treatment, enhanced follow-up, and greater adherence to treatment (Baldwin et al., 2013). Increased health literacy about disease and its treatment can contribute to a non-judgmental environment, with positive attitudes toward mental disorder and psychotropic drug treatment. However, the relative ‘endorsement’ of particular treatment approaches by the general public does not always corresponds to the ranking of possible interventions in terms of effectiveness and acceptability by health professionals. A more easily accessible health system, with a low perception of stigma, may be insufficient to optimize opinions and behavior about mental disorders and psychotropic drugs. It remains largely uncertain whether better understanding of presumed molecular mechanisms underpinning psychiatric disorder and the response to treatment leads to greater willingness to seek and undergo psychotropic drug treatment. Further studies of health literacy about anxiety disorders and their treatments are needed.
AL.
FUTURE DIRECTIONS The availability of information about mental care services seems to be the first line intervention to improve access to treatment otherwise frequently neglected. Patients suffering from an anxiety disorder should be included in epidemiological studies of mental health literacy. A possible suggestion for a campaign to improve the access to psychiatric services and the use of psychotropic medication could include two levels of intervention. The first step would be improved knowledge in the first line caregivers, such as general practitioner, nurses, and social workers; the second step is being a campaign for the general population, with media support, to lower the stigma on psychiatric disorders, even supporting patient advocacy groups. As health literacy seems to work in increasing awareness, a similar effort should be taken in increasing literacy about psychotropic medications. CONFLICT OF INTEREST The authors make no declaration of potential conflicts of interest connected to this paper. ACKNOWLEDGEMENT M. Carlotta Palazzo participated in the Joint European South African Research Network in Anxiety Disorders program (Baldwin and Stein, 2012), which is supported by the European Union through the EU-FP7 Marie Curie Actions International Research Staff Exchange Scheme (PIRSESGA-2010- 269213).
REFERENCES LIMITATIONS The limited number of studies focusing on anxiety disorders was the major limitation to this paper. Literature on health literacy is mainly related to psychosis and affective disorders, despite the high prevalence of these conditions. Therefore, this review was conducted on studies mentioning at least an anxiety disorder or a standardized treatment for anxiety disorders. However, the perceived use of antidepressants in anxiety may differ from its perceived use in affective disorders. Cultural values and perception of mental health add a bias in interpreting studies on health literacy. Finally, time-trend analyses of mental illness-related public attitudes have been conducted mainly in industrialized, first-world countries, and developments in other parts of the world are poorly understood. Copyright © 2014 John Wiley & Sons, Ltd.
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