From the Editor
Bell Let’s Talk generates incredible attention. The annual effort raised almost $7 million this January, with tens of millions of social media interactions. It was praised by many, including the Prime Minister.
But do awareness campaigns like Bell’s actually result in people seeking care? And are awareness campaigns ultimately helpful? In this week’s Reading, we have two selections that consider these questions.
In the first selection, the study authors look at the Bell campaign, as well as outpatient visits for mental health, tapping Ontario databases. “The 2012 Bell Let’s Talk was temporarily associated with increases in the trends of outpatient mental health visits, especially within the adolescent female cohort.”
The second selection is an interview with Dr. Simon Wessely, one of the most prominent psychiatrists in the U.K., and the president of the Royal Society of Medicine. In a BMJ interview, he weighs in on integrating mental health and physical health services, his choice of psychiatry as a profession, and – yes – the role of awareness campaigns. “Every time we have a mental health awareness week my spirits sink. We don’t need people to be more aware. We can’t deal with the ones who already are aware.”
Big campaign, big impact?
So are awareness campaigns worthwhile? You can read these selections and draw your own conclusions.
Awareness and Impact
“Youth Mental Health Services Utilization Rates After a Large-Scale Social Media Campaign: Population-Based Interrupted Time-Series Analysis”
Richard G Booth, Britney N Allen, Krista M Bray Jenkyn, Lihua Li, Salimah Z Shariff
JMIR Mental Health, April-June 2018
Over the last decade, the growing use of social media technology has become an important method for many forms of societal communication. Given the broad reach of social media, it has been leveraged as a communication mechanism for a range of different health interventions, including smoking cessation, alcohol awareness, HIV prevention, childhood obesity, sexual health practices, and mental health awareness. However, it is not certain whether these types of social media campaigns actually influence the behaviors of intended audiences or the health care system in measurable ways. Research completed to date provides an incomplete picture regarding the impact of social media used in health campaigns. Currently, we know that traditional mass media health campaigns conveyed by television, radio, print advertisements, and outdoor media can generate reasonably effective results at the population level, especially when multiple media interventions are used to target an episodic situation (eg, vaccination). What remains unclear is whether large-scale health awareness campaigns underpinned primarily by social media messaging can also generate measureable behavior change at the population level, especially around sensitive topics such as mental illness and its related stigma.
In Canada, one mental health awareness campaign that has gained significant attention since 2011 is Bell Let’s Talk. First initiated in February 2011 and led by the Canadian telecommunications company Bell Canada, the Bell Let’s Talk campaign has become a yearly event that draws significant volumes of social media traffic related to mental health and stigma awareness. The campaign is hosted by Clara Hughes, a prominent Canadian female athlete who medaled for Canada in both the summer and winter Olympics from 1996 to 2010. By recounting her struggles with depression, the campaign encourages the public to start a dialogue to break the silence around mental illness and to support mental health awareness across Canada. To achieve this, the campaign encourages the public to interact with the campaign’s various digital markers via social media on a predetermined day each year…
Despite the success of Bell Let’s Talk and other similar mental health or antistigma campaigns, limited research has focused on evaluating the impact on behavior change. Instead, previous research has focused on evaluating campaign awareness by the public and resulting attitude changes and knowledge uptake. Recent evaluation of Bell Let’s Talk by Harris/Decima has suggested that the campaign was successful at decreasing stigma and increasing personal awareness in a random telephone survey of Canadian adults (N=1007) over a 5-year period (2011-2015); however, no examination of the campaign’s influence on behavior change at population level has been undertaken. To our knowledge, population-level behavior change of people in response to a mass media mental health campaign has only been addressed in one study, and no known studies exist where social media was used as a primary mechanism of intervention dissemination.
Richard G. Booth
So begins a paper by Western University’s Richard Booth and his co-authors.
Here’s what they did:
- They “conducted a cross-sectional time series analysis of all youth aged 10 to 24 years who accessed outpatient mental health services from January 1, 2006 to December 31, 2015 in the province of Ontario, Canada.”
- To do this, they drew from several provincial databases, including the physician billing database (allowing them to analyze both primary care and psychiatrist visits).
- Demographic information, including gender and age, were used.
- Statistical analyses were done, including an “interrupted time series, autoregressive integrated moving average modeling was implemented to evaluate the impact of the campaign on rates of monthly outpatient mental health visits.”
Here’s what they found:
- “In Ontario, the estimated number of youth aged 10 to 24 years during the study time period ranged from 2,576,630 (2006) to 2,564,097 (2015).”
- Adolescents and primary care: “The monthly mental health visit rate to primary health care for females increased from 10.2/1000 in April 2006 to 14.1/1000 in April 2015, whereas male adolescents exhibited a moderate change from 9.7/1000 to 9.8/1000.”
- Adolescents and psychiatric services: “The monthly mental health visit rate to psychiatric services for female and male youth over the same two time points increased from 1.5/1000 to 3.1/1000 and 2.5/1000 to 3.4/1000, respectively.” New visits also increased.
- After adjustments. “The campaign was associated with a statistically significant increase in the slope (visit rate) for all four outcomes among both sexes.”
- Young adults and primary care: “Among females, the mental visit rate to primary health care increased from 26.5/1000 to 29.2/1000 over the 10-year period. Males also experienced increases from 16.6/1000 to 20.3/1000 over study.”
- Young adults and psychiatric services: “The monthly mental health visit rate to psychiatric services for males and females over the same two times points also increased from 2.1/1000 to 2.3/1000 and 1.95/1000 to 2.5/1000 for females and males, respectively.” New visits increased as well.
- “In young adults, a statistically significant increase in the slope of the primary health care visit rates in females (0.17, P<.001), but not males, was observed…” (See figures below for a summary of primary health care data.)
From 2006 to 2015, the rates of outpatient mental health use by youth aged 10 to 24 years in the province of Ontario increased for both males and females. The 2012 Bell Let’s Talk was temporarily associated with increases in the trends of outpatient mental health visits, especially within the adolescent female cohort. Although no discernable difference in the immediate change in the rate of mental health visits was observed among the adolescent groups, young adults exhibited a slight drop in most outpatient mental health visits, followed by a moderate increase or plateauing of rates.
A few thoughts:
- This is an interesting study.
- Of course, the authors make a big assumption: that visits are directly related to tweets (and other social media interactions).
- It’s a big assumption – is it a reasonable assumption? The authors themselves concede that other factors may be at play. They note: “Given the growing public literacy related to mental illness and the increasing use of social media for all forms of communication (including discussion related mental health), a range of extraneous variables not specifically measured in this study may offer explanatory insights related to the observed increasing mental health utilization slopes. One such promising extraneous factor was the increasing diversity of social media technology that emerged during the latter years of the study.”
- Regardless of the exact impact of Bell Let’s Talk, the data suggests that some impact is likely.
Awareness and Mental Health
Simon Wessely: “Every time we have a mental health awareness week my spirits sink”
BMJ, 21 September 2017
One of the UK’s most prominent psychiatrists has called for an end to public awareness campaigning about mental health. It ‘massively expands demand’ on already stretched NHS services and may be convincing people they are ill when they are not, warns Simon Wessely, who was until June president of the Royal College of Psychiatrists.
‘Every time we have a mental health awareness week my spirits sink,’ says Wessely, who in July became the first psychiatrist to be president of the Royal Society of Medicine. ‘We don’t need people to be more aware. We can’t deal with the ones who already are aware.’
Fresh from his move to the royal society, Wessely remains concerned about the over-reporting and under-resourcing of mental illness, and the lack of integration between mental and physical health services—despite NHS England head Simon Stevens’ affirmation last month that mental health is now ‘front and centre’ of the health service agenda.
The interview is short, and doesn’t require much of summary here.
Dr. Wessely weighs in on various matters:
“We should stop the awareness now. In fact, if anything we might be getting too aware. One wonders what’s happening when you have 78% of students telling their union they have mental health problems—you have to think, ‘Well, this seems unlikely.’”
“I’d give up parity between mental and physical health any day if I could have integration.”
“I vividly remember neurologists at Queen Square [the National Hospital for Neurology and Neurosurgery in London] would always say, ‘You seem a decent enough chap. I can’t understand why you want to do psychiatry.’”
A few thoughts:
- Dr. Simon Wessely has a reputation for giving a lively interview – and he doesn’t disappoint.
- Are public awareness campaigns problematic? He puts forward a good argument.
- Do such campaigns really “expand demand” – or do they reduce stigma making it possible for people with mental illness to feel more able to get care?
- On a personal note, years ago, I remember a patient who was inspired by Olympian Clara Hughes to finally acknowledge her bipolar disorder, going so far as discussing her illness experience on Facebook. She was amazed by the outpouring of support; it helped transform her life.
- Regardless of whether or not we find Dr. Wessely’s argument persuasive, those of us in mental health care must recognize the risks of public awareness campaigns. In Canada, Bell Let’s Talk and other efforts have helped change the national dialogue, giving many with mental illness hope. But if people continue to struggle with access to care and if standards of care remain uneven, the moment may pass, and the hope will dissipate.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.