Eating disorders “mental health literacy”: an introduction

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 eating-disordered 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 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 non-specialist 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 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 ED-MHL 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 help-seeking 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.

Conclusion

There is no shortage of work to be done in the field of ED-MHL. Elucidating which aspects of ED-MHL most warrant attention in which sections of the community will be key. Research of this kind has the potential to inform the conduct of health promotion, prevention and early intervention programs and to improve clinical practice. What constitutes “good ED-MHL” is necessarily subjective to some extent. I hope that readers will be encouraged to make up their own minds on these issues and contribute research of their own.

Declaration of interest

The author reports no conflicts of interest. The author alone is responsible for the content and writing of this article.