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http://informahealthcare.com/jmh

 

ISSN: 0963-8237 (print), 1360-0567 (electronic)

 

J Ment Health, 2014; 23(2): 51–54

 

! 2014 Shadowfax Publishing and Informa UK Limited. DOI: 10.3109/09638237.2014.889286

 

EDITORIAL

 

Eating disorders ‘‘mental health literacy’’: an introduction

 

Jonathan M. Mond1,2

 

1Department of Psychology, Macquarie University, Sydney, Australia and 2Research School of Psychology, The Australian National University,

 

Canberra, Australia

 

Introduction

 

No doubt there are many things that readers of this journal

 

would not agree upon. What constitutes ‘‘evidence-based

 

treatment’’, how best to revise classification schemes, and the

 

priority given to prevention, early intervention and treatment

 

approaches to mental health improvement, are some examples.

 

One thing that I hope all readers can agree upon,

 

however, is that community knowledge and understanding

 

of mental health problems is not as good as it should be.

 

Community knowledge and understanding of eatingdisordered

 

behavior may be particularly poor. Reasons for

 

this likely include the fact that certain eating disorders, such

 

as binge eating disorder, are relatively new to the psychiatric

 

nomenclature and the fact that certain eating disorder

 

behaviors, such as extreme dietary restriction and excessive

 

exercise, have strongly ego-syntonic properties. The goal of

 

this contribution is to introduce readers to a field of research

 

that I believe has promise in redressing this situation, namely,

 

‘‘mental health literacy’’. After outlining the origins of the

 

mental health literacy paradigm, I shall do my best to explain

 

why its application to eating-disordered behavior has merit

 

and how research in this field might be progressed.

 

The mental health literacy paradigm

 

Jorm et al. (1997) introduced the term ‘‘mental health

 

literacy’’ (MHL), in the mid-1990s, to refer to ‘‘knowledge

 

and beliefs about mental disorders which aid their recognition,

 

management or prevention’’(p.182). The rationale was

 

that improving community awareness and understanding of

 

the nature and treatment of mental health problems was not, at

 

this time, a priority for government health agencies. As a

 

consequence, members of the public were unsure of the

 

symptoms of different mental health problems and of how to

 

respond to, or prevent, the occurrence of those symptoms in

 

themselves or others. This situation contrasted with that for

 

physical health problems, where it was accepted that the

 

public would benefit by knowing what actions they could take

 

to prevent disease, how to recognize warning signs and assist

 

others in the event of emergencies, and the likely benefits of

 

available treatments (Jorm, 2012).

 

The research methodology could not be simpler – a vignette

 

of a fictional person suffering from a given mental health

 

problems is presented and questions about that problem are

 

posed to study participants. This is the MHL paradigm.

 

Aspects of MHL examined by Jorm (2012) and others thus far

 

include: beliefs about the nature and causes of, and risk factors

 

for, mental health problems; recognition of the symptoms that

 

constitute a mental disorder; knowledge of and beliefs about

 

treatment options and their availability; attitudes and beliefs

 

that may be conducive to stigma and discrimination; and

 

knowledge and understanding of how to assist others who may

 

be developing or experiencing a mental disorder.

 

The use of large, general population surveys in MHL

 

research has permitted stratification of the data by participants’

 

demographic characteristics and symptom levels (Jorm,

 

2012; Jorm et al., 2000). Demographic differences in MHL

 

are important because they indicate specific targets for health

 

promotion efforts, for example, a need to improve MHL

 

relating to depression among young people in rural and

 

remote communities. MHL differences between individuals

 

with and without symptoms, on the other hand, might inform

 

early intervention efforts. Improving community MHL should

 

also facilitate early intervention efforts on the part of family

 

members, friends and others who share information with

 

and interact with symptomatic individuals (Jorm, 2012;

 

Jorm et al., 2000).

 

As I am sure Jorm and colleagues would acknowledge, the

 

concept of MHL was neither radical nor new. Researchers had

 

recognized the need to study the knowledge and beliefs of the

 

public concerning mental health problems for decades

 

(Hayward & Bright, 1997). The early literature included

 

studies of knowledge and beliefs about eating disorders

 

(Branch & Eurman, 1980). What was novel, however, was the

 

rationale provided for the systematic investigation of knowledge

 

and beliefs concerning mental health problems, particularly

 

the view that poor MHL may be a major factor in

 

low or inappropriate help-seeking among individuals with

 

symptoms (Andrews et al., 2000; Meltzer et al., 2000). It is a

 

testament to the efforts of Jorm and colleagues that governments

 

in many countries now incorporate the assessment of

 

Correspondence: Jonathan M. Mond, PhD, MPH, Department of

 

Psychology, C3A 411, Macquarie University, Sydney, NSW 2109,

 

Australia. E-mail: [email protected]

 

MHL in their mental health plans and use this information to

 

inform their health promotion agendas.

 

What is known about ‘‘eating disorders mental

 

health literacy’’?

 

Whereas much has been learned about MHL relating to the

 

‘‘more common mental disorders’’, and to schizophrenia,

 

‘‘eating disorders mental health literacy’’ (ED-MHL) has not,

 

thus far, been a priority for researchers or policy makers.

 

It has therefore not been systematically investigated in the

 

same way as other mental health problems and the detailed

 

information required to inform health promotion and early

 

intervention programs is lacking. Further, it is difficult to

 

determine what is known because there exists a disparate,

 

but substantial, body of research that has examined

 

ED-MHL-related knowledge and beliefs but which has

 

employed an alternative methodology and/or not used the

 

term ‘‘mental health literacy’’ (Crisp et al., 2000; Davidson &

 

Connery, 2003). A systematic review of all relevant research

 

would be beneficial.

 

Nevertheless, perusal of the recent literature suggests a

 

small number of key ‘‘problem areas’’ (Mond et al., 2006b,

 

2008, 2010a). First, it is apparent that awareness and

 

understanding of the spectrum of disordered eating that

 

occurs at the population level is poor (Mond et al., 2006b). To

 

give just one example, ‘‘eating disorders’’ may be associated,

 

in the public mind, with anorexia nervosa and the purging

 

form of bulimia nervosa, whereas binge eating disorder and

 

the non-purging form of bulimia nervosa may tend to be seen

 

as ‘‘normative’’ (Gratwick-Sarll et al., 2013). Second, there

 

appears to be a pervasive belief that eating disorders are either

 

serious but uncommon or common but trivial when the reality

 

is that they are both serious and common (Mond et al., 2006a;

 

Palmer, 2003). Third, attitudes and beliefs likely to be

 

conducive to stigma, such as the beliefs that individuals with

 

eating disorders only have themselves to blame and that these

 

individuals are vain, self-obsessed or weak, are not uncommon

 

(Crisp et al., 2000; Mond et al., 2006b). In addition,

 

ED-MHL has been found to vary as a function of individuals’

 

demographic characteristics and symptom levels. Thus, young

 

men may consider eating disorders to be less serious than

 

do young women (Mond & Arrighi, 2011) and individuals

 

with eating disorder symptoms may be particularly likely to

 

believe that eating-disordered behavior is acceptable or even

 

desirable (Mond et al., 2010a).

 

In terms of whose ED-MHL might be most worthy of

 

attention, research addressing attitudes and beliefs likely to

 

be conducive to low or inappropriate help-seeking among

 

men with disordered eating would be especially welcome,

 

for several reasons (Mond et al., 2013b). First, men may be

 

particularly unlikely to seek advice or treatment for an

 

eating problem. Second, the prevalence of disordered eating

 

and its impact on quality of life are increasing in men.

 

Third, much of the existing ED-MHL research has been

 

confined to the ‘‘high-risk’’ populations of adolescent and

 

young adult women. Moreover, research addressing the

 

ED-MHL of men is important because their knowledge,

 

beliefs and behaviors influence the knowledge, beliefs and

 

behaviors of the individuals with whom they interact,

 

including adolescent and young adult women (Mond et al.,

 

2010a, 2013b).

 

Efforts will also be needed to identify attitudes and beliefs

 

on the part of primary care practitioners and other nonspecialist

 

treatment providers that may undermine effective

 

care delivery. For example, there is good evidence that

 

primary care practitioners are diffident in their ability to

 

recognize and/or screen for the presence of eating disorder

 

psychopathology (Linville et al., 2012; Mond et al., 2010b).

 

Primary care practitioners may also be unsure as to the

 

comparative benefits of different possible treatment

 

approaches and/or treatment providers and, in turn, appropriate

 

referral of their patients. However, the issue of what

 

constitutes ‘‘evidence-based treatment’’ is relevant for both

 

primary care and specialist treatment providers and is not

 

straightforward (Mond, 2012).

 

Perhaps most importantly, efforts will be needed to change

 

the way that eating disorders are viewed by researchers in

 

other fields of academia and by those who are in a position to

 

influence public knowledge, beliefs and policy more generally.

 

The author’s experience, in Australia and the USA, is

 

that eating-disordered behavior is not taken seriously as a

 

public health problem, or, worse still, viewed with contempt,

 

in public health research and policy circles. Certainly this

 

would help to explain why eating disorders research is so

 

rarely featured in leading public health journals (Austin,

 

2012).

 

If institutionalized stigma towards eating disorders

 

research and clinical practice exists, then there is a need to

 

identify the source of this and do something about it. For

 

example, if there is a lingering perception that eating

 

disorders are associated with affluence and privilege and,

 

therefore, not worthy of public policy attention, then this

 

misconception needs to be dispelled (Striegel-Moore &

 

Franko, 2003). The misconception that eating disorders are

 

either serious but uncommon or common but trivial also

 

seems to be stubbornly resistant to change, perhaps because

 

this perception is reinforced by adherence to a dichotomous,

 

medical-model approach to classification and treatment

 

(Mond et al., 2009). Recent changes to the DSM diagnostic

 

criteria for eating disorders, including less stringent criteria

 

for anorexia nervosa and bulimia nervosa and the inclusion of

 

binge eating disorder as a formal diagnosis, should go some

 

way to redressing this problem (Mond, 2013).

 

Eating disorders mental health literacy and the

 

‘‘obesity epidemic’’

 

As I have argued elsewhere (Mond et al., 2009, 2013a), the

 

way in which body dissatisfaction and disordered eating are

 

conceptualized in obesity prevention research, namely, as

 

variables that may need to be assessed as secondary outcomes

 

– as opposed to variables worthy of attention in their own

 

right – is particularly unfortunate, given the conspicuous links

 

between body weight, body dissatisfaction, eating-disordered

 

behavior and mental health. Body-weight-centric obesity

 

prevention messages should be of concern to all those with

 

an interest in the reciprocal relations between physical health

 

and mental health and efforts to improve ED-MHL need to be

 

accompanied by efforts to inculcate a more balanced view of

 

52 J. M. Mond J Ment Health, 2014; 23(2): 51–54

 

the ‘‘obesity epidemic’’ (Bacon & Aphramor, 2011;

 

Campos et al., 2006). In the author’s view, the latter would

 

entail information to the effect that adverse physical and

 

psychosocial consequences are far more likely to occur for

 

moderate and severe obesity than for overweight and mild

 

obesity, that the prevalence of moderate and severe obesity is

 

relatively low, and that moderate degrees of overweight may

 

in fact be associated with better physical and mental health

 

outcomes (Mond et al., 2009).

 

Why is improving ED-MHL important?

 

A potential criticism of the MHL paradigm is that changing

 

knowledge and beliefs does not necessarily lead to behavior

 

change (Stice et al., 2000). Thus, findings from the first

 

generation of ED prevention research were seen to be

 

‘‘disappointing’’ because change in knowledge and beliefs

 

about eating disorders was associated with little or no

 

change in eating-disordered behavior (Stice et al., 2000).

 

However, this argument misses the point (Cowen, 1998;

 

Mond et al., 2013b). The focus of efforts to improve EDMHL

 

is on reducing the individual and community health

 

burden of eating-disordered behavior by reducing stigma and

 

otherwise changing public knowledge and beliefs in ways

 

that promote the importance of early, appropriate helpseeking

 

where this is needed (Cowen, 1998; Mond et al.,

 

2010a, 2013b). Improving ED-MHL may also serve to

 

prevent the occurrence of eating-disordered behavior among

 

individuals at risk or potentially at risk. But that is not the

 

primary objective.

 

Of course, the relative merits of different possible

 

approaches to reducing the health burden of eating-disordered

 

behavior and other mental health problems – health promotion/

 

universal prevention, selective prevention and indicated

 

prevention/early intervention – warrant careful consideration

 

(Munoz et al., 1996). But it also needs to be remembered that

 

these different approaches are not mutually exclusive (Mond

 

et al., 2013b). Efforts to improve ED-MHL at the population

 

level would complement the current focus of eating disorders

 

prevention research on selective interventions in high-risk

 

populations (Stice et al., 2013) and would potentially have

 

multiple benefits, including: (i) greater willingness to seek

 

treatment among individuals with symptoms, (ii) improved

 

uptake of empirically supported treatments, (iii) improved

 

willingness and ability to intervene on the part of family and

 

friends, (iv) improved detection and management of eating disordered

 

behavior in primary care and (v) reduced stigma

 

associated with eating-disordered behavior and mental health

problems more generally