“We’re not educated on that enough, and we really should be”: adolescents’ views of mental health service education

ABSTRACT

Purpose

Despite the susceptibility to the experience of mental distress during adolescence, this population often demonstrate poor help-seeking behaviours. Efforts have been made by schools to address adolescents’ knowledge around mental health; less focus has been given to addressing their knowledge of mental health services and avenues for help-seeking. This study aimed to explore adolescents’ views of mental health services education.

Methods

An interpretive descriptive design was adopted. Thirty adolescents from Ireland participated in individual interviews. Data were analysed using content analysis.

Two themes were identified

Recognizing Gaps in Knowledge about Mental Health Service Education, and Enhancing Mental Health Service Education for Young People. Participants reported gaps in their knowledge about mental health services and were uncertain how to access help. Current strategies (e.g., print media) were considered tokenistic and ineffective; instead, multimedia (film/TV) approaches were recommended.

Results

Two themes were identified: Recognizing Gaps in Knowledge about Mental HealthService Education, and Enhancing Mental Health Service Education for YoungPeople. Participants reported gaps in their knowledge about mental healthservices and were uncertain how to access help. Current strategies (e.g., print media) were considered tokenistic and ineffective; instead, multimedia (film/TV) approaches were recommended.

Conclusions

Current mental health education programmes need to expand their focus beyond social/emotional well-being, providing adolescents with the knowledge they need to access appropriate supports. Considering traditional print media was viewed as ineffective, while film/TV had an influence on perceptions of mental health services, a multimedia approach to education may be an effective way of engaging this population.

KEYWORDS:

• Adolescents
• education
• help-seeking
• interpretive description
• mental health
• mental health education
• mental health services
• qualitative
• school mental health
• young people

Background

Adolescence is a stage of transition between the dependence associated with childhood, and the independence of becoming an adult (Horgan, 2017; Steinberg, 2019; Wang et al., 2021). Change involves more than physical development: interactions with other individuals in complex and dynamic environments also influence development (Steinberg, 2019). In this sense, adolescence can be viewed as a time of psychosocial development, with the adolescent learning to think in abstract terms about their position in the social environment (Briggs, 2008; Steinberg, 2019).

While such self-discovery can result in positive and meaningful engagement with the social world, the period of transition between childhood and adulthood is not without its challenges, and this stage of development is often a peak period for the onset of mental distress (Kaasbøll et al., 2021), defined as a unique discomforting emotional or psychological state often marked by low mood and anxiety (Arvidsdotter et al., 2016; Ridner, 2004). Indeed, the World Health Organisation (World Health Organisation, 2021) report half of all mental illnesses in adulthood start by age 14. Several factors have been identified which potentially contribute to adolescent mental distress, including the complex interplay between a developing sexuality and self-awareness (Horgan, 2017); a shift in personal identity and how the “self” is perceived in a changing social environment (Steinberg, 2019); interpersonal problems such as complex peer relationships (Adedeji et al., 2022), loneliness (Hards et al., 2022), and violence (Bentivegna & Patalay, 2022; Marcal, 2022); and the relationship between increased use of social media and its associated isolation from others, and pressure from peer groups to experiment with substances (Rogers & Pilgrim, 2014).

Although research highlights the connection between first experiences of mental distress and the adolescent period, until relatively recently, there has been little focus on rates of mental distress experienced by adolescents. This is a concern, given that, in their My World Survey 2, Dooley et al. (2019) identified increased levels of depression and anxiety, and decreased levels of protective factors among adolescents since the publication of the original survey (Dooley & Fitzgerald, 2012). These findings correlate with what other authors have reported (Li et al., 2022; Wilson & Dumornay, 2022). For example Daly (2021) reported that, among US adolescents, rates of depression had almost doubled between 2009 and 2019 (from 8.1% to 15.8%). Similar trends can be observed in the UK (Deighton et al., 2019) indicating a growing vulnerability among this population.

Despite the susceptibility to the experience of mental distress in adolescence, globally, this population often demonstrates poor help-seeking behaviours (Lawrence et al., 2015), with mixed findings in terms of males and females (Breslin et al., 2022; De Luca et al., 2019). While adolescents demonstrate a preference for informal sources, such as friends and family (Dooley et al., 2019; Sears, 2020; Yoshioka et al., 2015), many express reluctance to seek help from anyone, including mental health services (Sears, 2020). Mental health services refer to government, professional, or ay organizations who provide assessment, diagnosis, and treatment in a variety of settings (including inpatient, outpatient, primary care and student health centres), to enhance mental health (American Psychological Association, 2023; Citizens Information, 2020; Health Service Executive, 2022; Hill et al., 2020) Once a person accesses these services, they receive interdisciplinary care that from staff such as psychiatrists, nurses, counsellors, psychologists, social workers, vocational support trainers, or occupational therapists. A range of care environments constitute the mental health services, including day hospitals, day centres, sheltered workshops, out-patient clinics, and inpatient services. In these environments, service users are offered a diverse range of treatments such as cognitive behavioural therapy, dialectical behavioural therapy, and medication (Citizens Information, 2020; Health Service Executive, 2022). As a consequence of not accessing appropriate services, the benefits of early intervention, such as increased rate of recovery and reduced hospitalization rates (Allouche et al., 2021; Becker et al., 2019; Peiper et al., 2017), are often rendered impossible to adolescents.

In recent years, there has been a global, concentrated effort by school systems to address mental health promotion (Allen et al., 2022; Arora & Agios, 2019; Connors et al., 2021; Mental Health Ireland, 2022; Sapthiang et al., 2019; Teng et al., 2017; Watson et al., 2019). Given the number of complex psychosocial factors that can lead to the experience of mental distress during adolescence (Horgan, 2017; Rogers & Pilgrim, 2014; Steinberg, 2019), the provision of relevant mental health education to this population is paramount. Teng et al. (2017) commented that adolescents are becoming more aware about mental health and have a greater understanding of “illnesses such as depression, anxiety, and eating disorders” (p. 172), leading to more open discussions. Indeed, much of the previous research around adolescent mental health is concerned with knowledge of and attitudes towards mental illnesses (Sakellari et al., 2014); less is known about their views on mental health services and how the education system has influenced these views.

Although it is important that school curricula address social and emotional wellbeing, education on mental health services is also required. In the absence of such education, adolescents may be unfamiliar with the process of accessing these services in a timely fashion, and the benefits of early intervention—including the reduction of the burden of mental distress—may not be available to this population (Clarke et al., 2021). Moreover, beliefs formed in adolescence are likely to persist into adulthood (Bos et al., 2021; Rawal et al., 2022; Starr & Simpkins, 2021), including beliefs about mental health (Dunkley-Smith et al., 2021). Consequently, negative perceptions of and misinformation about services not challenged during people’s formative years are likely to influence help-seeking attitudes and behaviours across the lifespan. Therefore, the aim of this study is to explore adolescents’ views of being educated on mental health services.

Methods

Design

This study was guided by an interpretive descriptive methodological approach. Interpretive description can be described as a logic model (rather than a traditional “prescriptive” methodology), used as an inductive approach to understand human phenomena. It allows researchers the flexibility and creativity to address a research question without compromising methodological integrity and rigour (Thorne, 2016; Thorne et al., 1997).

The research was underpinned by a relativistic ontological position (i.e., there are multiple realities which are mind dependent) and an interpretivist epistemological position (i.e., knowledge is subjective, and the researcher’s interpretations are a fundamental aspect of the research) (Scotland, 2012; Thorne, 2016; Walker & Dewar, 2000).

Ethics

Ethical approval was gained from the University’s Social Research Ethics Committee. Informed consent was obtained from parents/guardians, and informed written and verbal assent was obtained from each participant. Participants were informed that their participation was voluntary, and that use of pseudonyms would ensure anonymity. They were also informed that they could withdraw from the study, up to two weeks post-interview (when data analysis began), without repercussions.

Participants

Although there are no “rules” on sample sizes in interpretive description (Thorne, 2016), studies guided by this approach typically employ sample sizes of between 12–23 (Charlebois & Law, 2022; Timmins et al., 2023; Ziebart et al., 2022). However, we were also aware that adolescents can sometimes be reticent when engaging in qualitative research (Upadhyay & Lipkovich, 2020), particularly when discussing topics often considered “taboo”, such as mental health (Tharaldsen et al., 2016). Based on samples in previous qualitative studies with adolescents, where depth of interviews was achieved (Bryan & Chor, 2019; Steiner et al., 2019), we aimed to recruit a purposive sample of 30 students in the Transition Year (4^th year) of secondary school. Transition year (4^th year) is an optional (non-exam) year taken by adolescents aged 15–17 in Ireland, introduced in 1974, where less focus is placed on typical academic structure, and instead, young people are encouraged to take more responsibility for their own learning and independent decision making (McGuire, 2019). While each school tailors its transition year programme based on the needs of its students, in addition to personal development and work experience, it is common for the curriculum to place an emphasis on mental health and wellbeing (Mental Health Ireland, 2022).

We sought to recruit an equal number of participants from rural and urban schools. Letters were sent to schools informing them of the study; six schools were initially chosen at random, selected from a freely accessible online database. Once contact was made, a gatekeeper (teacher) was established at each site. Three schools (one urban, two rural) agreed to participate; from these schools, the sample size of thirty was achieved, and so no other schools were contacted. Fewer males (n = 8) than females (n = 22) agreed to take part in the study. Owing to the low male response rate, we included all males who met the inclusion criteria in the study, while female participants were selected on a “first-come-first-serve” basis. Fifteen students from one urban school participated: four males and eleven females. Ten students from rural school A comprised one male and nine females. Five students from rural school B comprised three males and two females. Most students were white Irish; the mean age of participants was 15.5 (see Table 1).

Table 1. Demographics.

		Number (n)
Gender	Male	8
	Female	22
Geographical area	Urban	15
	Rural	15
Age	15	8
	16	22
Race/ethnicity	White Irish	28
	Any other white background	2

Procedure

Interviews were conducted within school grounds, in a private room, by one male and one female researcher, in 2019. A semi-structured interview guide was used based on topics gleaned from the literature. We asked participants questions about where they got their information about mental health services from, where they felt a good place to give information about services to young people would be, if this would be different to people of other ages, and what kind of things their school had done to educate them about services. Interviews were audio-recorded and transcribed verbatim. While interviewing, we were conscious that adolescent participants can be uncomfortable in the presence of adult researchers. In order to minimize discomfort and enhance rapport, we began the interview with some casual conversation about the school routine, joking that our interview was a welcome break/distraction from their usual class activities, utilizing humour in a manner recommended by Au (2019). This led to laughter and acted as an appropriate ice-breaker. Interviews lasted approx. 40 minutes.

Data were analysed using qualitative content analysis. In line with Green et al. (2007), four phases to the analysis were undertaken. Immersion in the data was achieved through reading and re-reading of transcripts, and listening to recordings (Green et al., 2007). Data were then coded (condensed and labelled) by one researcher; these were then reviewed by a senior researcher and refined. Two rounds of coding cycles were completed, and consensus was reached about the final codes. Next, the relationship between codes were examined. Codes were grouped together, first into sub-categories, and then into categories. Again, this was reviewed by a senior researcher. Finally, the underlying meaning throughout categories was explored; this involved the whole research team meeting to debate and refine themes (Graneheim & Lundman, 2004; Green et al., 2007) (see Appendix).

The rigour of analysis was enhanced through the constant re-working of codes, categories, and themes by three researchers (Goodwin et al., 2019). Quotations from participants support all interpretation, enhancing transferability and credibility (Graneheim & Lundman, 2004).

Findings

Two themes were identified. The first theme, Recognizing Gaps in Knowledge about Mental Health Service Education, comprised the categories, “Experiences with Mental Health Education and Mental Health Service Education”, “Influences Outside of the School Environment”, and “Recognising the Importance of Mental Health Service Education”. The second theme, Enhancing Mental Health Service Education for Young People comprised the categories “How to Engage Students” and “When to Engage Students” (see Figure 1).

Figure 1. Overview of themes.

Theme 1. Recognizing gaps in knowledge about mental health service education

Under this theme, participants spoke about their previous experiences with mental health services education/information. This included information provided within the school environment, but they also addressed external influences, such as multimedia. Participants also recognized deficits in their knowledge, and acknowledged that they needed to become better informed.

Category 1.1. Experiences with mental health education and mental health service education

Participants spoke about education they had received in relation to mental health and mental health services, with the school positioned as the primary place in which such education was delivered. While participants commented that they had spoken about these topics during classes on Social, Personal, and Health Education (SPHE), it was suggested that the teachers/schools took a superficial approach to mental health education—referring to this area, but not discussing it in depth.

We have obviously talked a bit about it in SPHE as well, so we don’t talk much about it but we would … we would address it, but um … we wouldn’t have full-blown conversations (Colette)

One way in which schools were noted to promote mental health-related activities was by engaging with Mental Health Week or Mental Health Day. Participants commented that during these times, schools put up mental health service-related posters and distributed leaflets. Although this was perceived by students as the school engaging in mental health promotion, text-based educational resources—such as posters—did not have a lasting impact on perceptions of services. Furthermore, while participants viewed the promotion of Mental Health Week/Day positively, such promotion was always stated as being short-lived, with no evidence of an ongoing mental health-related education strategy in place.

We’d have a day or two when there’s, like, Mental Health Day and then they’d have leaflets and posters around the school about who you can contact and stuff (Hannah)

In addition to distribution/posting of print media, it was also noted that, during Mental Health Week/Day, the school encouraged attendance at talks given by people associated with mental health services. Some schools were reported to invite speakers in, while others organized trips to events in their nearest city. Either way, it was clear that schools valued the input of speakers with insights into mental health.

We haven’t done much apart from that trip […] to [city name] to see all the speakers but there we got a lot of … a lot of education from there because there was a good few speakers that had gone through um … hard times (Colette)

Although it was clear that the talks had left some impression on participants, they were not able to recall who had given talks, or they were unable to recount any of the content that had been delivered by speakers. Indeed, some participants only had a vague sense that they had attended a mental health talk in the past but were not always able to confirm this with conviction.

It was back a few years ago now. We got one … I guess it was a … I think it was some sort of a doctor. I’m not sure though. […] They came in from outside the school, all right … to give us a talk. But I’m not sure. I’m not sure, to be honest (Connor)

Other participants voiced concerns about the lack of in-depth mental health talks, even during periods when a mental health strategy was being promoted within the school environment. There was the suggestion of “tokenism” here, with schools pronouncing certain periods as being dedicated to mental health promotion; however, this engagement was perceived as superficial, given that specific talks in this area were not organized. This sense of tokenism was evident in accounts from every participant.

But this is three years later and we haven’t gotten a massive talk with mental health yet. Even Mental Health Day, they didn’t really talk about it at all in the school (Millie)

The concept of “tokenism” was also suggested in relation to mental health-related talks which had been facilitated within the school. One participant spoke about being involved in a charity run for Pieta House which involved a brief conversation related to mental health. She voiced concerns about how her school had an opportunity to signpost students to relevant mental health services but failed to do so.

It was just, kind of, a general talk [about Pieta House] for a couple minutes but that was kind of it. […] There was no, kind of, giving out places, like, for people to go or where to go for mental health (Barbara)

Another participant also addressed this tokenism, noting that mental health-related discussions would only take place following someone dying by suicide in the school. Overall, a “reactive” or “ad-hoc” approach to mental health education was reported. Participants recognized that this approach indicated schools were not as committed to advancing mental health promotion as they presented themselves.

If something happened in school, like, the teacher would probably say like “Oh, these services are there to help anyone.” […] I think they only, like, talk about, like, something … like, a suicide would happen or something like that happened (Hilda)

Category 1.2. Influences outside of the school environment

Participants also spoke about sources of information on mental health and mental health services external to the school environment. Their views of mental health care environments (MHCEs) were clearly influenced by TV programmes, with programmes set in hospitals, for example. Owing to exposure to these programmes, participants were able to recall the names of specific staff members, such as psychiatrists.

Just watching TV […] like, Home and Away. If they have problems, they go to, like, the hospital and they go speak to someone, like a psychiatrist (Darragh)

Film was also cited as an influence on their views. In particular, the horror genre emerged as a significant influence on how participants viewed places such as “asylums”. These places—considered more “intense” than usual mental health services—housed dangerous or “mad” service users. In this regards, MHCEs were considered frightening, dangerous places, with links made between mental ill-health and criminal behaviour.

Well, there was one particular horror movie that I watched called “Wrong Turn 4” where um … a group of three […] criminals […] escape from an asylum (Adam)

Oh, this is a, like, mad, like, place—asylums where they keep mental people (Denise)

Participants voiced some insights into the fictitious depictions of mental health services in multimedia. It was suggested that what was presented in film and TV programmes was an exaggerated version of reality, with certain portrayals existing purely to satisfy certain genre staples or tropes, such as what one would observe in the horror genre.

I don’t really know how that’ll be in real life, but it seems very exaggerated in a horror movie (Colm)

However, despite the assertion that multimedia depictions of mental health services are exaggerated and not entirely realistic, one participant noted that these depictions must be, to a certain extent, grounded in reality. It was stated that “inaccurate” multimedia presentations of services were influenced by real-life services and did not solely stem from the imaginations of filmmakers/TV producers. In this regard, participants communicated an awareness that, while portrayals of services in TV programmes and film should be taken with “a pinch of salt”, not all portrayals were to be dismissed as “inaccurate”.

This could be completely inaccurate […], but if it’s portrayed like that in movies, then surely someone must’ve got it from somewhere (Adam)

Several participants spoke about social media as an influence. Platforms such as Twitter and Facebook were mentioned, but there was a lack of certainty reported as to how social media actually influenced perceptions, or, indeed, if mental health-related content had even appeared on these platforms. It was noted that social media can guide people to specific websites that may be able to provide help for those experiencing mental health issues and will also offer positive phrases related to mental health. However, participants were unable to link the generic quotes cited to any particular mental health organization or website, indicating that such platforms may not actually influence perceptions of services.

I’ve seen more of it around social media on Facebook and stuff. […] Just seeing, like, “If you need help, contact this website,” and, you know, um … “Help isn’t always that far away” and all those kind of things, but yeah. Not much of it, but sometimes, yeah (Emma)

Participants spoke about posters and leaflets with information about mental health services. These were considered by participants to have influenced their views of services, in the sense that they demonstrated some awareness about the existence of suicide helplines. However, participants were unable to recall the names of any specific suicide prevention services advertised via the medium of posters and leaflets. This indicates that traditional text-based resources may only have a superficial influence on adolescent mental health education.

Like, there is, like, a big thing of leaflets up in our doctor’s, but, I don’t know … I haven’t read them. But I’m guessing there probably would be something about mental health on there (Denise)

Category 1.3. Recognising the importance of mental health service education

Participants acknowledged the importance of mental health service-related education and recognized that they were lacking in knowledge around this area. One participant made specific reference to the number of times she had replied “I don’t know” throughout the interview. The frequency of this response alerted her to the fact that education around this important area was required.

Like, a lot of my questions, I’m answering, “I don’t know”, because I just simply don’t […] But definitely, like, we’re not educated on that enough, and we really should be (Ingrid)

Participants communicated insights into why this education was important. They acknowledged that, at some time, they may experience mental health issues, or that they may need to support someone else experiencing an issue. However, owing to the gaps communicated in relation to mental health services, they realized that they would be at a disadvantage here. It was suggested that education around this area should be delivered to adolescents to equip them with the information they may need in the future.

We just need more information in case something actually happens that we can get help or help others (Gertrude)

Furthermore, it was acknowledged that educating people about services and learning about the roles of staff would enhance trust. It is important to address the implicit sentiment here: in the absence of education about mental health, people may not place their trust in services.

If you’re actually told about it and you know about the work they’re doing, you’ll kinda trust it a bit more (Barbara)

Theme 2. Enhancing mental health service education for young people

Under the second theme, participants provided some insights into developing their mental health service education. This included suggestions on how their knowledge could be developed, but also the most appropriate ages to whom this information should be directed.

Category 2.1. How to engage students

Participants demonstrated insight into the importance of fundraising, acknowledging that such charitable endeavours benefited people in need of mental health care. However, they also noted that, in addition to such altruistic efforts, fundraising would also contribute towards the development of service awareness among adolescent volunteers.

Maybe us doing, like, I don’t know, fundraising for, like, units—mental health units—to make sure that everyone gets the care that they need and … d’you know, places like that. I don’t know—just make more—like, highlight it a bit more (Beatrice)

Participants spoke about the popularity of the internet and social media among their generation, commenting that online platforms would be advantageous in reaching large numbers of adolescents. In particular, the use of advertisements for mental health services was recommended as an innovative way in which to engage people, and to draw their attention to services.

Instagram would be … If you put ads on that, like, there’s already ads on it, and just, like, promote it and just get it out there (Leanne)

However, there were also participants who did not see the value in the use of online platforms as a tool to enhance awareness about mental health services. Participants commented that advertisements tend to be tailored around what people had already been searching for online, meaning only those individuals who had sought information on mental health would be exposed to such advertisements/educational material. It was stated that the general public would not take note of such advertisements, as they would not be relevant to them.

Facebook and Instagram and stuff like that that would just pop up whenever you’re going through it, and then people would see it. I don’t know if they take much notice of it, though (Fiona)

Participants noted that print media would not be an effective way of delivering education, commenting that people may not even pay attention to these resources. One participant stated that even people who needed help for their mental health issues would not be encouraged to access services through print media. As noted earlier, print media did not have an influence on how mental health services were perceived, and this appears to be connected with a lack of confidence in such media.

There are posters saying, “Talk to a friend,” “Get help,” and all that … but I don’t think a poster is much good in kind of convincing someone to get help (Edward)

It was suggested that both videos about mental health services and TV advertising these services could be effective educational resources. However, advertising via social media was rejected by some participants, this method of education was perceived more favourably in the context of TV. It is clear from their accounts that there was a connection between influence and valued educational strategies, with non-influential sources (print media) rejected as an educational strategy by some participants, and more influential sources (visual media) embraced.

D’you know the homeless ads that are on for Christmas? […] Instead of homeless, put in mental health services, like, advertising, for people who need to go to services, that they’re open, they’re available, and people are always welcoming them if they need help (Joan)

Although it was noted that they had not had much exposure to mental health talks, a consensus was evident that this approach to education would be embraced. In particular, participants stated that they would value contributions from people who worked for mental health services, and they would be interested in their experiential knowledge.

Like, they could, like, have more speakers […] more explanations of what it is, like, if you need to contact them, how you can contact them. More speakers I think is major (Joan)

Interestingly, participants suggested that a mandatory/scheduled approach to education would be effective. As noted earlier, mental health-related education sometimes emerged from talks about other contexts. A talk on cyberbullying—which participants related to mental health—was reported to fool students into believing that their social media posts would be displayed for others to see. This was then revealed as a ruse, but considering several participants made reference to this event, it is obvious that this was an effective way of promoting retention of education.

We did have a talk on cyberbullying,[…] at the very end of the interview, the woman said, “I have a picture of one of your conversations about you bullying someone,” but then it turned out that it was just a picture saying, “Have you seen all your reactions to when I told you?” and I think after that everyone just went, “Oh wow, this is really important” (Millie)

Category 2.2. When to engage adolescents

It was suggested that a passive approach to education would not be effective, and that people would be unlikely to independently educate themselves on the topic of mental health services. Instead, the classroom environment was suggested as an effective place in which to engage in such education, owing to the fact that students would not have a choice but to take notice of the educational content being delivered. In essence, an approach to education where students had no choice but to engage with mental health service content was recommended.

If we were in a class […] you’ll take in the information there instead of just being at home like on your own required read something or listen to it (Barbara)

The subject of advertisements was once again brought up in the context of this approach to education. While participants had previously spoken about not paying attention to advertisements on social media, it was noted that, when given no option to skip such advertisements, they could be used as a potential effective education strategy. Education about mental health services emerged as an important topic for participants, but it was apparent that a passive or voluntary position would not result with engagement; instead the delivery of such education was perceived as needing to be compulsory.

If you had it on YouTube as well. D’you know, before some videos there’s ads, and you have to watch them. You would probably pay attention if you had to watch it if you can’t skip it (Denise)

Participants also commented on when mental health service-related education should be delivered to students. It was noted that it would not always be appropriate to involve younger students in discussions related to mental health, and that more in-depth conversations in this area should be targeted at older groups. Nevertheless, there was a suggestion that mental health service-related content should be introduced in early years, with an incremental, year-by-year approach to education adopted. In this manner, first year students would be aware of mental health service-related concepts, which would build up to more in-depth discussions by the time students were in their senior cycle of education.

Up to third year we were too young to, kind of, talk about that kind of thing. We’re starting to talk about it more now because we’re in Transition Year (Colette)

I would like for First Years who come in, […] like a small bit here and there so at least people know, and then maybe as they go up along to Third Year or TY or Fourth Year, that then, they look into more and more and more (Ingrid)

Additionally, it was recommended that a mental health focus within the school should be considered on a regular, ongoing basis. This relates back to the dissatisfaction participants voiced in relation to the ad-hoc approach they felt was generally being adopted. The perception that such education needs to be more embedded in the school ethos indicates an awareness within participants about the importance of mental health-related education.

I think, actually, we had a mental health week last year, but I don’t think a week is enough. I think it should just be all-round activities, like, once a week that can promote positive mental health (Janet)

Discussion

The findings of this study draw attention to the need to educate adolescents about mental health services. Adolescents acknowledged the importance of being more mental health aware, and many lamented the perceived failure of the education system in satisfying their mental health service knowledge needs. This voiced concern is significant as research shows us that schools are well positioned to reach large numbers of adolescents simultaneously to provide early intervention and prevent mental health problems from developing (Clarke et al., 2021; Sifat et al., 2022). Additionally, it is important that mental health education is embedded through a whole-school approach and within school curricula to ensure both positive mental health is promoted alongside pathways to therapeutic interventions for those who are at risk (Hoare et al., 2017; Sheinman et al., 2018). Under the current Wellbeing Policy Statement and Framework for Practice (Government of Ireland, 2019), the focus is on fostering wellbeing in young people. While this is important, findings from the current study highlight a need for schools to transcend the boundaries of wellbeing and equip adolescents with the skills and knowledge to navigate mental health services if needed.

Some adolescents in this study acknowledged their school’s efforts to promote mental health and to educate adolescents about this area, although it was felt that such efforts were often superficial. It was noted that, while there are certain days and weeks dedicated to mental health promotion, this was insufficient in educating students about mental health and mental health services, and adolescents recommended a more sustained approach. Bonell et al. (2014) commented that the mental health of adolescents is often not appropriately addressed until they reach third-level education. In Ireland, mental health education is often limited to the SPHE curriculum in the junior certificate cycle (Beirne et al., 2013), a curriculum studied by Irish adolescents from the ages of 12/13 to 15/16 (Citizens Information, 2021). However, despite the publication of new Junior Cycle Wellbeing Guidelines (National Council for Curriculum and Assessment, 2017), the quality of delivery of mental health and wellbeing promotion often is undermined by some teachers’ value of wellbeing and mental health promotion, training and requisite knowledge (Byrne & Carthy, 2021). Therefore, there is a need for a more prolonged dynamic approach to mental health education in schools to support adolescents’ knowledge needs around mental health services (Government of Ireland, 2020). At a national level, wellbeing and mental health education policy needs to be updated to ensure longevity and relatability for students, alongside clear and sustainable to methods as to how schools can embed mental health education within their curricula (Byrne & Carthy, 2021). Such recommendations will ensure that all schools are supported in enhancing adolescents’ knowledge of mental health and mental health services.

Adolescents spoke about education strategies with which they were familiar, or that had been employed by their school. Text-based forms of information (e.g., posters and information leaflets/pamphlets) were cited as an ineffective way of communicating information to adolescents, and it was noted that they were unlikely to pay attention to such resources. Indeed, participants were unable to recall what information was communicated through print media; consequently, the actual potential for print media to influence perceptions is questionable. Several researchers (e.g., Gaiha et al., 2014; Ni et al., 2014; Paul et al., 2008; Randhawa & Stein, 2007) have found that print media does not have a strong effect on perceptions of mental health services. Furthermore, research on adolescents’ consumption of media reports significant decreases in use of print media (Twenge et al., 2019; Wagoner et al., 2019). For example, Twenge et al. (2019) found that 60% of adolescents read books or magazines in the 1970s, whereas as only 16% of adolescents today engage with these media. This indicates that traditional forms of education may be insufficient when trying to provide adolescents with information about mental health services and that other, more age-appropriate forms of dissemination warrant exploration.

Unlike a text-based approach, the influence of film and TV was less ambiguous. Most adolescents referred to film or TV as having had an impact on their perceptions of mental health services. It is known that adolescents demonstrate a preference for interactive or multi-modal approaches to education over traditional didactic processes (Jiang et al., 2019; Laholt et al., 2019; Mman et al., 2017; Sagalowsky et al., 2020; Smith et al., 2020). Furthermore, several studies have found that visual education methods resulted in statistically significant improved attitudes towards mental distress and help-seeking (Chisholm et al., 2016; Goodwin et al., 2021; Ojio et al., 2018; Saporito et al., 2011) Chisholm et al. (2016) found their educational intervention, which comprised videos, interactive elements, and presentations, resulted in statistically significant improvements in knowledge about mental health, emotional wellbeing, and attitudes towards help-seeking among 12–13-year-olds. The video elements of this intervention were positively evaluated, with one participant stating, “I liked the videos because they were effective and they actually showed you what people can do” (p. 9). Given that adolescents enjoy visual education media, and the fact that such media can elicit significant changes in knowledge about mental health, in addition to the suggestions of adolescents in the current study, a film-based intervention could be developed to educate adolescents about mental health services. Such an approach would utilize the visual methods embraced by adolescents in other research and build on the work in other areas related to mental health education.

One specific visual method of education suggested by adolescents was the use of TV advertisements. In recent years, there have been several media campaigns that aimed to encourage people to talk more about mental health, and combat stigma in this area (e.g., the “Ask” campaign [Reck, 2017] and “Little Things” [Connecting for Life, 2015]). However, research around the effectiveness of such campaigns is limited to one study (Rubio-Valera et al., 2016), which found that individuals who had been exposed to a national mass media mental health campaign had more positive attitudes towards help-seeking than those who had not been exposed. Although research around the effectiveness of advertisements in educating adolescents about mental health services is unavailable, advertisements in general have been found to significantly enhance their knowledge about other topics (e.g., Kim et al., 2019 [perceptions of cigarettes]). Given this evidence, and recommendations from adolescents in the current study, using advertisements may be an effective way of enhancing adolescents’ knowledge of mental health services. It is important that such advertisements highlight the gravity of mental distress and the importance of seeking help from mental health services, given the potential that some campaigns have demonstrated in trivializing this area (O’Malley, 2019).

Although adolescents highlighted the importance of becoming more informed about mental health services, it was suggested that there would be little engagement with such education unless it comprised a compulsory or required element. Compulsory education around recognizing signs of mental distress and the process of seeking help from mental health services has been introduced in US schools in states such as Florida for students in six to twelfth grades in all public schools (Mental Health Weekly, 2019) and New York for students in elementary, middle, and high schools (DiGulio, 2018). A similar approach was adopted in the UK under its 2020 plan, with compulsory mental health education focusing on symptom recognition and signposting to mental health services (Department of Education, 2019). In Ireland, the Mindout Programme was launched in 2019 for adolescents aged 15–18 (Mental Health Ireland, 2022). However, the emphasis of Mindout is on social and emotional wellbeing rather than signposting to mental health services (National Youth Council of Ireland, 2020). Although longitudinal findings on the effects of adolescent compulsory mental health education are not available, there are comparable findings in other areas of adolescent education. For example, in the UK, the rates of pregnancies in under-18s have declined by 50% since the introduction of the compulsory Sex and Relationships Education Strategy, with increases in the numbers of people aged between 16 and 24 stating that school is their main source of education in this area (Ingham, 2016). With more schools globally introducing mental health education initiatives (Joint Action on Mental Health and Well-Being, 2017; Wood & McDaniel, 2020), there will be further opportunities for longitudinal research on adolescents’ views of mental health services.

While the Irish education system should be commended for the introduction of content around mental and emotional health and wellbeing through the most recent Wellbeing Policy Statement and Framework for Practice (2019) (Government of Ireland, 2019), this content needs to be advanced to incorporate information around mental health services, especially given that the formal education system has been cited by several authors as the ideal place to address mental health (AUTHORS [in press]; Hampson et al., 2018; McMahon et al., 2017; O’Connor et al., 2018). Globally, teachers are frequently tasked with delivering mental wellbeing promotion and prevention education (AUTHORS [in press]; Joint Action on Mental Health and Well-Being, 2017); however, they often reported receiving very limited training regarding mental health (Goodwin et al., 2023; Punukollu et al., 2019; Willis et al., 2019). To this end, mental health education needs to be more of a priority at a pre-service later so that teachers can be better prepared to offer appropriate supports to students. Moreover, given that, globally, time is often a barrier to addressing this content in the classroom, the delivery of mental health education needs to be protected so that students receive adequate information (Goodwin et al., 2023). Teachers need to be supported by those with expertise in mental health, such as external mental health professionals. A more robust, collaborative relationship between school and mental health systems would enrich the help-seeking process, foster more supportive structures, thus facilitating early intervention and the prevention of mental distress among adolescents (Goodwin et al., 2023; Clarke et al., 2021).

This study has limitations. It has been suggested that general public perspectives are unreliable and inconsistent, owing to the fact that two contradictory views can be held at one time. It is also acknowledged that members of the general public may acquiesce with what they perceive to be the demands of the researcher (Furnham, 1988; Furnham et al., 2009); of note, this has been found to be the case with adolescent participants (Simonds et al., 2014). Another limitation relates to the sample which was largely female, thus limiting transferability. However, in studies focusing on adolescents, it is common for males to be underrepresented in comparison to females (Kazlauskaite & Fife, 2021), particularly in relation to mental health research (Gagnon et al., 2017; Goodwin et al., 2016). Future research in this area should endeavour to recruit a more representative gender sample.

Conclusion

The current study highlights deficits in adolescents’ knowledge around mental health services. Furthermore, adolescents acknowledged these deficits, and expressed interest in becoming more informed about mental health services. Education around mental health services needs to be firmly embedded in the school system, with the aim of bolstering help-seeking decisions. Programmes currently in place need to expand their focus beyond social and emotional wellbeing so that adolescents are adequately informed about pathways to accessing help. Considering adolescents’ preference for visual forms of education, it is recommended that, in addition to didactic content, feasible and relatable multimedia, such as film, should be incorporated to enhance engagement. Moreover, people working within mental health services should be encouraged to increase their visibility within education, attending career days, or delivering talks within schools. These speakers should be very clear about their role and the role of services, in an effort to enhance retention of information, given we found that participants’ recollections of talks about mental health were vague. Enhancing information about mental health services for young people in this manner may lead to appropriate, timely referral to services.

It should be ensured that teachers are sufficiently supported in delivering health service education to adolescents. Continuing Professional Development (CPD) courses or “in service days” for teachers should be developed and delivered by those with expertise in mental health, thus strengthening links between health and education systems.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research received no specific grant from any , commercial or not-for-profit sectors. Open Access funding provided by the IReL Consortium.

Notes on contributors

John Goodwin

John Goodwin is a lecturer in mental health nursing and programme lead for the undergraduate mental health nursing programme, School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, T12 AK54, Ireland; email: [email protected]. His research interests include mental health helpseeking, media depictions of mental illness, public perceptions of mental health care environments, the use of the arts and creativity in mental health, young people’s mental health, and mental health stigma. ORCID ID: 0000-0002-2044-1861

Eileen Savage

Eileen Savage is an Emeritus Professor, School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, T12 AK54, Ireland; email: [email protected]. Her research interests include self-management, symptom experiences and management experiences (including mental health symptoms), and integrated care. ORCID ID: 0000-0002-2403-557X

Niamh O’Brien

Niamh O’Brien is an assistant professor education, Froebel Department of Primary and Early Childhood Education, Maynooth University, School Of Education, North Campus Maynooth University, Maynooth, Co. Kildare, W23 F2H6, Ireland; email: [email protected]. Her research aims to investigate wellbeing and positive mental health intervention cross all levels of education, from primary level to higher-level education. Niamh’s work seeks to understand mental health intervention design and impactful wellbeing practices among students, teachers, and student-teachers. ORCID ID: 0000-0002-2087-814X

Áine O’Donovan

Aine O’Donovan is a Senior Lecturer in mental health, School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, T12 AK54, Ireland; email: [email protected]. Aine’s research interests focus on young people’s mental health, with a specific interest in positive mental health, depression, self-harm, and e-health. ORCID ID: 0000-0001-6377-4140

Appendix.

Table

Theme	Recognizing Gaps in Knowledge about Mental Health Service Education
Category	Experiences with mental health education and mental health service education	Influences outside of the school environment	Recognising the importance of mental health service education
Codes	.Fundraising in school. Dismissive towards SPHE mental health content. Posters to promote mental health. Leaflets to promote mental health. School promotes Mental Health Week. Mental health weeks/months enhance awareness. Speakers to promote mental health. Unable to recall speakers.	Multimedia influences perceptions. TV is an influence on perceptions of services. Soap operas as an influence (hospital environment). Horror movies as an influence. Movies are an influence on perceptions about services. Insight into fictitious portrayals of services. Multimedia depictions are not entirely inaccurate. Social media as an influence. Influence of social media called into question. Posters as an influence. Influence of posters called into question. Leaflets as an influence. Influence of leaflets called into question.	Gaps in knowledge addressed. Awareness about mental health is key. Eager for mental health service education. School does not do enough to educate students. Ad Hoc Talk. Tokenism acknowledged. Mental health content present in other contexts. Talks have only been provided in the context of bullying.

Table

Theme	Enhancing Mental Health Service Education for Young People
Category	How to engage students	When to engage students
Codes	Darkness into Light enhances awareness. Charity enhances awareness. Using online sources as education. Social Media to enhance awareness. Social media not recommended as an education tool. Print media is ineffective as an education tool. Visual media can educate people. Recommend more talks. Suggestion of compulsory education.	Young people lack capacity for mental health education. Education should be incremental from 1^st year up. Education important in transition year. Regular/ongoing education required.