children Review Effectiveness of Mental Health Literacy Programs in Primary and Secondary Schools: A Systematic Review with Meta-Analysis Isaac Daniel Amado-Rodríguez 1, * , Rocio Casañas 2 , Laia Mas-Expósito 2 , Pere Castellví 3 , Juan Francisco Roldan-Merino 4 , Irma Casas 5 , Lluís Lalucat-Jo 2 and Mª Isabel Fernández-San Martín 6 1 PhD Program in Biomedical Research Methodology and Public Health, Autonomous University of Barcelona, 08193 Barcelona, Spain 2 Associació Centre d’Higiene Mental Les Corts, Research Department, 08029 Barcelona, Spain; rocio.casanas@chmcorts.com (R.C.); laia.mas@chmcorts.com (L.M.-E.); lluis.lalucat@chmcorts.com (L.L.-J.) 3 Department of Medicine, Universitat Internacional de Catalunya (UIC), Sant Cugat del Vallès, 08195 Barcelona, Spain; pere.castellvi.obiols@gmail.com 4 Campus Docent, Sant Joan de Déu-Fundació Privada, Escuela de Enfermería, 08034 Barcelona, Spain; jroldan@santjoandedeu.edu.es 5 Program in Biomedical Research Methodology and Public Health, Autonomous University of Barcelona, 08193 Barcelona, Spain; irma.casas@uab.cat 6 Unitat Docent Multiprofessional Gerència Territorial Barcelona, Institut Català de la Salut, 08025 Barcelona, Spain; mifsanmartin.bcn.ics@gencat.cat * Correspondence: isaac.dar92@gmail.com   Abstract: In recent years, there has been an increase in studies evaluating the effectiveness of mental Citation: Amado-Rodríguez, I.D.; health literacy programs within the context of education as a universal, preventive intervention. A Casañas, R.; Mas-Expósito, L.; systematic review and meta-analysis regarding the effectiveness of mental health literacy interven- Castellví, P.; Roldan-Merino, J.F.; tions in schools, from 2013 to the present, on mental health knowledge, stigma, and help-seeking Casas, I.; Lalucat-Jo, L.; is conducted. Of the 795 identified references, 15 studies met the inclusion criteria. Mental health Fernández-San Martín, M.I. knowledge increased after the interventions (standardized mean difference: SMD = 0.61; 95% CI Effectiveness of Mental Health (0.05, 0.74)), at two months (SMD = 0.60; 95% CI (0.4, 1.07)) and six months (SMD = 0.39; 95% CI Literacy Programs in Primary and Secondary Schools: A Systematic (0.27, 0.51)). No significant differences were observed between stigma and improving help-seeking. Review with Meta-Analysis. Children Mental health literacy interventions are effective in augmenting mental health knowledge, but not in 2022, 9, 480. https://doi.org/ reducing stigma or improving help-seeking behavior. 10.3390/children9040480 Keywords: mental health literacy; stigma; help-seeking; adolescent; intervention; meta-analysis; Academic Editor: Benedetto Vitiello systematic review Received: 14 March 2022 Accepted: 30 March 2022 Published: 31 March 2022 Publisher’s Note: MDPI stays neutral 1. Introduction with regard to jurisdictional claims in Most mental health problems in individuals commence between 12 and 25 years of published maps and institutional affil- age, with 20% of adolescents being affected [1,2]. Moreover, it is calculated that 50% of such iations. issues appear before the age of 14 [3]. In spite of this elevated incidence, 70–80% of young people and adults do not receive adequate mental healthcare [4]. Due to the importance of mental health during adolescence, international bodies such as the European Union (EU) and the World Health Organization (WHO) are promoting policies and interventions to pre- Copyright: © 2022 by the authors. vent mental health disorders and raise awareness. They are highlighting the need to analyze Licensee MDPI, Basel, Switzerland. and diffuse good practice, for instance, with the EU-Compass for action on Mental health This article is an open access article and Well-being [5], and encourage multi-sectorial strategies to provide integral support for distributed under the terms and mental health [6]. The WHO is currently carrying out its Comprehensive Mental Health conditions of the Creative Commons Action Plan 2013–2020 and its subsequent update until 2030. This plan aims to ensure that Attribution (CC BY) license (https:// 80% of countries will have at least three functioning national, multisectoral mental health creativecommons.org/licenses/by/ 4.0/). promotion and prevention programs by 2030. These plans have to be targeted at vulnerable Children 2022, 9, 480. https://doi.org/10.3390/children9040480 https://www.mdpi.com/journal/children Children 2022, 9, 480 2 of 19 groups using, as an example, programs like mental health awareness/anti-stigmatization or school-based mental health prevention and promotion [7,8]. Within this framework lies the concept of mental health literacy (MHL), which has been described by Jorm [9] as “the knowledge and beliefs about mental health problems that help in their recognition, man- agement, and prevention”. This definition includes the capacity to recognize and inform oneself about mental disorders and their risk factors and how to seek treatment and profes- sional support [9]. In recent years, the notion of MHL has been undergoing changes and has become an integral, multifactorial concept that recognizes the need to reduce mental health stigma and foster first aid [10–12]. Its programs are focused on the capacity of individuals to understand and make correct use of healthcare information so as to better understand mental health disorders, improve treatment compliance, and be aware of how and when to look for assistance. The effectiveness of MHL interventions has been demonstrated in systematic revisions such as those by Wei [2] and Seedaket [13]. The former included 27 studies carried out up to 2012 in the field of education with 17,643 individuals aged 12 to 25 years. It reported an increase in knowledge concerning mental health and a decrease in stigma both in the short-term and during follow-up. The latter was made up of seven randomized clinical trials (RCTs) performed up to 2020 in a population aged 10 to 19 years and had results that were similar to Wei’s review. All the interventions improved mental health knowledge: 71% and 25% for stigma and help-seeking, respectively. As neither of the two systematic reviews included a meta-analysis, the effect size of this kind of intervention could not be established. The objective of this systematic review with meta-analysis is to evaluate the effectiveness of MHL interventions on mental health knowledge, stigma, and help-seeking in young, school-enrolled populations from the beginning of the international Comprehensive Mental Health Action Plan 2013–2030 to the present. 2. Materials and Methods This review was carried out according to the protocol Preferred Reporting Items for Sys- tematic reviews and Meta-Analyses (PRISMA) [14]. The review protocol was pre-registered on the International Prospective Register of Systematic Reviews (PROSPERO) [15] prior to data extraction (CRD42021281178, access date on 10 October 2021 in https://www.crd. york.ac.uk/prospero/display_record.php?RecordID=281178). 2.1. Inclusion Criteria Inclusion criteria for studies regarding the efficacy/effectiveness of MHL interventions were the following: (1) population aged between 10–19 years; (2) research carried out in primary and/or secondary schools; (3) interventions with presence-based modality (school setting); (4) RCT and quasi-experimental (QE) design; (5) outcomes: mental health knowl- edge, stigma, and/or help-seeking; (6) studies performed from commencement of the WHO 2013–2030 Action Plan on Mental Health [7,8] and the set-up of programs of mental health prevention and promotion such as MHL; and (7) no language limits. Exclusion criteria were: (1) qualitative studies; (2) determined populations, for instance, university students and students with specific mental health or drug abuse issues; (3) studies concerning mental health first aid; (4) MHL interventions focused on a specific disorder (depression, schizophrenia...); and (5) MHL interventions that only assess the concept of stigma. 2.2. Study Search and Selection Strategy The search was performed with the databases Pubmed, Psycinfo, Web of Science, and Cinahl from January 2013 to July 2020. The bibliographic search in the three databases included the following terms in the widest sense possible: (“mental health literacy” AND (“program*” OR “intervention*”) AND “young”) OR (“mental health literacy” AND school AND adolesc*). The secondary strategy involved examining the references of the included studies and relevant reviews. Duplicates and studies that did not fulfill the inclusion criteria were eliminated, and only article-type publications were selected. After revising the study abstracts, those that were related to the theme of the present research were accepted. Finally, Children 2022, 9, 480 3 of 19 a hand search was conducted. The studies were included according to peer review, and the following information extracted: author, year, country, design, educational stage, age, number of subjects, follow-up, type of intervention, duration of intervention, professional who delivers intervention, measurement tools, and level of evidence. The Scottish Intercollegiate Guidelines Network (SIGN) [16] was employed to establish the identified studies’ level of scientific evidence. We completed a cross-tabulation of each article selected by I.A.R. response categories to obtain frequencies and percentages of each variable of interest in the study. Inter-rater agreement was performed among two team members (blinded to peer review) to assess acceptance by determining the grade of evidence and practice guideline levels. The two members extracted the data from the included investigations and coded the studies considering the variables of our research questions. Concordance was considered adequate if it met at least 80% [17]. Seven studies (46, 6%) were randomly selected, and the investigators independently extracted the information and entered it into a codebook. The consistency of these data among the two evaluators was evaluated by calculating the proportion of agreements and disagreements in the different codes. Interrater agreement was 97.4%. Cohen’s Kappa was not calculated due to the low variability of agreement between the evaluators [18]. The SIGN model is based on three sections (internal validity, general evaluation, and study description) and classifies the research into 8 levels of evidence. These range from 1++ the maximum available evidence (high-quality meta-analyses, systematic reviews of clinical trials, and clinical trials with a reduced risk of bias) to 4 (expert opinions) [16] (Appendix A, Table A1). 2.3. Analysis A meta-analysis of the main variables (mental health knowledge, stigma, and help- seeking) was performed employing standard mean differences (SMDs) due to the different quantitative scales employed. The pooled estimates were evaluated post-intervention and at 2- and 6-months follow-up. A meta-analysis of random effects was carried out in order to obtain pooled estimates as differences were observed among the studies. These included: (a) content and methodology; (b) intervention duration; (c) outcome measures and definition criteria; (d) follow-up evaluation; and (e) clinical and sociodemographic characteristics. Opposite direction scale values were recodified. Heterogeneity was measured by the statistical test I2 . A value of 0–40% indicated low heterogeneity; 40–75% moderate; 75–100% considerable [19]. Publication bias was assessed with a funnel plot (scatter plot with treatment effectiveness against study sample size) [20]. Review Manager (RevMan) software was employed for the meta-analysis, and the program Stata was employed for the meta-regression. 3. Results 3.1. Study Description Out of 795 identified studies, 15 fulfilled the inclusion criteria (Figure 1), 6 were RCT, and 9 QE. With respect to the country of origin, three were performed in Japan, three in Canada, two in the United Kingdom, two in the United States, and only one each for Spain, Portugal, Nigeria, Norway, and Australia. Of the 15 studies, 5 (33%) assessed the intervention’s effectiveness pre- and post-intervention and 10 (66.7%) provided follow-up evaluations ranging from 1 to 12 months (Table 1) [21–35]. Approximately half of the selected study interventions were carried out by teaching professionals in the educational centers (n = 8; 53.3%). Some disparity was observed regarding the length of the interventions, which varied from 45 min to 12 h. One of them did not specify its duration [27]. 3.2. Study Quality Table 1 depicts the level of scientific evidence of the identified studies. It ranged from 1++ (maximum level of evidence) to 2+ which were studies with a moderate probability of establishing causal relationships (1++: 20%, 1+: 13.33%, 1−: 6.67%, 2++: 33.33% and 2+: Children 2022, 9, 480 4 of 19 26.67%). All the RCTs had a level of evidence between 1++ and 1−, whilst the QEs were classified between 2++ and 2+. 3.3. Evaluation of Mental Health Knowledge Of the 15 selected studies, 1 of them pending publication [26], 6 presented statistically significant improvements at the moment of post-intervention and 10 at follow-up (between 1 and 12 months). In only one study was a statistically significant improvement observed at follow-up, but not at the moment of post-intervention [27]. With respect to the analysis of change in knowledge, we included eight studies (six RCTs and two QEs) at the moment of post-intervention and obtained, broadly speaking, a significant increase (SMD = 0.61; 95% CI (0.17, 1.04)) with marked heterogeneity I2 = 97% (Figure 2). If we analyze it according to the type of study, a significant increase was observed in both QEs (SMD = 1.26; 95% CI (0.59, 1.93)) and in RCTs (SMD = 0.40; 95% CI (0.05, 0.74)). At the two-month follow-up, we included three studies (one RCT and two QEs) and observed a significant rise in knowledge (SMD = 0.60; 95% CI (0.14, 1.07); I2 = 89%) (Figure 3). If we analyzed it according to the type of study, a significant increase was observed in the QEs (SMD = 0.85; 95% CI (0.72, 0.99)) but not in the RCTs (SMD = 0.08; 95% CI (−0.24, 0.41) p = 0.61). At the six-month follow-up, three RTCs were incorporated, which also showed a significant increase in knowledge (SMD = 0.39; 95% CI (0.27, 0.51)) without heterogeneity I2 = 0% (Figure 4). The QEs studies presented a greater SMD than Children 2022, 9, x FOR PEER REVIEW that observed for the RCTs at both post-intervention and the two-month follow-up. After 4 of 19 performing the meta-regression, we did not observe a significant relationship between the hours of intervention and the effect on knowledge (p = 0.450) (Table 2). Figure Figure 1. PRISMA2020 1. PRISMA 2020flow flowdiagram diagram forfor newnew systematic systematic reviews, reviews, which which included included searches searches of of data- databases bases andand registers. registers. Children 2022, 9, 480 5 of 19 Table 1. Description of the studies included in the systematic review. Education Author (Year) Country Design Age N Follow-Up Intervention Evaluation Tools Sign Stage • Depression Literacy Scale (D-Lit) IG: Headstrong (10 h): Given • Depression Stigma Scale (DSS) Perry (2014) [21] IG (n = 207) Pre, post, and at by teachers at the educational • Inventory of Attitudes towards RCT Secondary 13–16 years 1++ Australia CG (n = 173) 6 months center Seeking Mental Health Services CG: Usual intervention (IASMHS) • Questionnaire about mental health IG: The Guide (6 h): Given by knowledge: 15 multiple-choice Milin (2016) [22] IG (n = 362) Pre and post (between 1 teachers at the educational questions (OC) RCT Secondary 16–18 years 1+ Canada CG (n = 172) and 2 months) center • Stigma: Likert scale with 8 CG: Usual intervention questions (OC) IG: School Space (4 h and 45 mins): Given by researchers • Mental Health Knowledge and teachers at the Schedule (MAKS) Chisholm (2016) [23] IG (n = 354) • The Reported and Intended RCT Secondary 12–13 years Pre and post at 2 weeks educational center in contact 1++ United Kingdom CG (n = 303) Behaviour Scale (RIBS) with a patient; CG: Change contact for mental health • Seeking Help (OC) record IG: Finding Space (3 h): • Mental Health Literacy Campos questionnaire: 18 items about Given by expert psychologist (2018) [24] IG (n =259) Pre, post at 1 week, and knowledge/stereotypes, 10 items RCT Secondary 12–14 years and student of Psychology 1+ Portugal CG (n =284) 6 months about seeking help, and 5 items Master’s Degree; CG: Usual intervention about self-help strategies IG: In Our Own Voice (1 h): • In Our Own Voice Knowledge Given by individuals with Measure Pinto-Foltz (2019) [25] IG (n = 95) Pre, post, at 1 and RCT Secondary 13–17 years mental health problems • The Revised Attribution 1− United States CG (n = 61) 2 months (older than 18 years); CG: No Questionnaire intervention Children 2022, 9, 480 6 of 19 Table 1. Cont. Education Author (Year) Country Design Age N Follow-Up Intervention Evaluation Tools Sign Stage • Questionnaire about knowledge EspaiJove.net: 35 multiple-choice IG: EspaiJove.net Program (7 items Casañas IG (n = 295) Pre, post, at 6 and h): Given by mental health • The Reported and Intended (2021) [26] RCT Secondary 13–15 years 1++ CG (n = 251) 12 months nurses Behaviour Scale (RIBS) Spain CG: No intervention • General Help-Seeking behaviors modified • Knowledge about mental IG: Mental health for disorders scale everyone (3 days): Given by • Prejudice and stigma: Likert scale Skre (2013) [27] IG (n = 520) QE Secondary 13–16 years Pre and post at 2 months teachers at the educational of 4 items (OC) 2++ Norway CG (n = 550) center; CG: Usual • Seeking help: free response intervention questions (OC) Dogra 2005 Adaptation Bella-Awusah (2014) [28] IG (n = 78) Pre, post, and at Program (3 h): Given by • UK Pinfold questionnaire QE Secondary 10–18 years modified (OC) 2+ Nigeria CG (n = 76) 6 months researchers CG: Usual intervention • Questionnaire about knowledge: The Guide (10–12 h): Given 28 items (OC) Mcluckie (2014) [29] QE Pre, post, and at Secondary 14–15 years n = 265 by teachers at the educational • Attitudes/stigma: Likert scale 2++ Canada without CG 2 months center 8 questions (OC) • Questionnaire about knowledge: Kutcher The Guide (10–12 h): Given 28 items (OC) QE Pre, post, and at (2015) [30] Secondary 14–15 years n = 175 by teachers at the educational • Attitudes/stigma: Likert scale 2+ without CG 2 months Canada center 8 questions (OC) The Short MHL Program for • Questionnaire about knowledge: Ojio(2015) [31] QE Pre, post, and at Teens (1 h and 40 min): 12 questions and 2 comic strips Secondary 14–15 years n = 118 with 3 questions about seeking 2++ Japan without CG 3 months Given by teachers at the educational center help (OC) Children 2022, 9, 480 7 of 19 Table 1. Cont. Education Author (Year) Country Design Age N Follow-Up Intervention Evaluation Tools Sign Stage • Questionnaire about knowledge: Patalay (2017) [32] Open Minds (1 h and 40 min): 4 questions (OC) QE without CG Secondary 13–15 years n = 234 Pre and post • Non-stigmatized attitudes: 2++ United Kingdom Given by medical students 5 items (OC) • Questionnaire about knowledge: The Short MHL Program for 7 questions (OC) Pre, post, and at 3 Pre-Teens (45 min): Given by • A comic strip asking what they Ojio (2019) [33] Japan QE without CG Primary 10–12 years n = 662 2+ months teachers at the educational would do if it happened to them center (OC) Youth Aware of Mental • General help-seeking behaviors Lindow Health (4 h and 10 min: questionnaire (GHSQ) QE • Stigma: 4 and 7 items (OC) (2020) [34] Secondary 12–18 years n = 436 Pre and post at 3 months Given by personnel trained 2+ without CG • Mental health resources: 2 scales United States by researchers at the educational center (OC) IG: Short MHL Program • Questionnaire about knowledge: (SMHLP) (50 min): Given by 10 questions (OC) Yamaguchi (2020) [35] IG (n = 364) Pre, post, and at • Recognition and intention to seek QE Secondary 15–16 years teachers at the educational 2++ Japan CG (n = 611) 2 months help: 2 comic strips ad 2 questions center CG: Usual intervention with 4 levels (OC) Abbreviations: RCT, randomized clinical trial; QE, quasi-experimental; CG, control group; IG, intervention group; n, number of participants; OC, own creation. observed in the QEs (SMD = 0.85; 95% CI (0.72, 0.99)) but not in the RCTs (SMD = 0.08; 95% CI (−0.24, 0.41) p = 0.61). At the six-month follow-up, three RTCs were incorporated, which also showed a significant increase in knowledge (SMD = 0.39; 95% CI (0.27, 0.51)) without heterogeneity I2 = 0% (Figure 4). The QEs studies presented a greater SMD than that observed for the RCTs at both post-intervention and the two-month follow-up. After Children 2022, 9, 480 8 ofthe performing the meta-regression, we did not observe a significant relationship between 19 hours of intervention and the effect on knowledge (p = 0.450) (Table 2). Children Children 2022, 2022,9, 9,xxFOR FORPEER PEERREVIEW REVIEW 88 of of19 19 Figure 2. Meta-analysis Figure 2. Meta-analysis of of change change in in level of knowledge level of knowledge post-intervention. post-intervention. Figure Figure3.3. Figure Meta-analysis 3.Meta-analysis of Meta-analysisof change in ofchange in level level of of knowledge of knowledgeat at 222months. months. months. Figure 4.Meta-analysis Figure4.4. Figure Meta-analysisof Meta-analysis ofchange of change in in level of level of knowledgeat of knowledge at666months. months. months. Table Table 2. 2. Meta-regression Meta-regression between between hours hours of of intervention intervention and and knowledge. knowledge. StMeanDiff StMeanDiff Coef. Coef. Std. Std. Err. Err. tt P>|t| P>|t| [95% [95% Conf. Conf. Interval] Interval] Length Length -0.031 -0.031 0.040 0.040 −0.78 −0.78 0.450 0.450 −0.118; −0.118; 0.056 0.056 Cons Cons 0.691 0.691 0.213 0.213 3.24 3.24 0.007 0.007 0.226; 0.226; 1.155 1.155 REML REML estimate estimate of of between-study between-study variance variance Number Number of of obs obs == 14 14 % % residual residual variation variation due due to to heterogeneity heterogeneity Tau2 Tau2 == 0.2005 0.2005 Children 2022, 9, 480 9 of 19 Table 2. Meta-regression between hours of intervention and knowledge. StMeanDiff Coef. Std. Err. t P > |t| [95% Conf. Interval] Length −0.031 0.040 −0.78 0.450 −0.118; 0.056 Cons 0.691 0.213 3.24 0.007 0.226; 1.155 REML estimate of between-study variance Number of obs = 14 % residual variation due to heterogeneity Tau2 = 0.2005 Proportion of between-study variance explained I-squared res = 95.15% With Knapp-Hartung modification Adj R-squared = −2.42% 3.4. Evaluation of Mental Health Stigma/Attitudes Of the selected studies, 12 evaluated changes in mental health stigma/attitudes, 9 of which reported statistically significant results [21–24,27,29,30,32,34]. With respect to the analysis of stigma, at both the moment of post-intervention (SMD = 0.06; 95% CI (−0.28, 0.41); I2 = 95%) and at 6 months (SMD = 0.012; 95% CI (−0.44, 0.68); I2 = 95%), no statistically significant differences were observed after the interventions (Figures 5 and 6). We did Children 2022, Children 2022, 9, 9, xx FOR FOR PEER PEER REVIEW REVIEW 99 of of 19 19 not observe a significant relationship between the hours of intervention and the effect on stigma (p = 0.890) at the meta-regression (Table 3). Figure 5. Figure 5. Figure Meta-analysis of Meta-analysis of 5. Meta-analysis change of change in change in level in level of level of stigma of stigma post-intervention. stigma post-intervention. post-intervention. Figure Figure 6. Figure 6. Meta-analysis 6. Meta-analysis of Meta-analysis of change of change in change in level in level of level of stigma of stigma at at 666 months. stigma at months. months. Table 3. Table 3. Meta-regression Meta-regression between between hours hours of of intervention intervention and and stigma. stigma. StMeanDiff Coef. Std. Err. t P>|t| [95% Conf. Interval] Length −0.007 0.048 −0.14 0.890 −0.118; 0.104 Cons 0.118 0.298 0.39 0.704 −0.571; 0.806 REML estimate of between-study variance Number of obs = 10 Children 2022, 9, 480 10 of 19 Table 3. Meta-regression between hours of intervention and stigma. StMeanDiff Coef. Std. Err. t P > |t| [95% Conf. Interval] Length −0.007 0.048 −0.14 0.890 −0.118; 0.104 Cons 0.118 0.298 0.39 0.704 −0.571; 0.806 REML estimate of between-study variance Number of obs = 10 % residual variation due to heterogeneity Tau2 = 0.1778 Proportion of between-study variance explained I-squared res = 94.43% With Knapp-Hartung modification Adj R-squared = −12.22% 3.5. Evaluation of Help-Seeking Assessment of help-seeking for mental health was present in nine studies, five of which reported a significant improvement at the moment of post-intervention [24,27,31,33,35]. With respect to the analysis of change in help-seeking, we included three studies (three Children 2022, 9, x FOR PEER REVIEW 10 of 19 Children 2022, 9, x FOR PEER REVIEWRCTs) at the moment of post-intervention and did not obtained a significant increase (p10 = of 0.24; 19 2 SMD = 0.20; 95% CI (−0.13, 0.52)) with heterogeneity I = 90% (Figure 7). At the six-month follow-up we included two studies (two RCTs) and not statistically significant differences =were 0%) observed (Figure 8). After after theperforming the(SMD interventions meta-regression, we(−did = 0.02; 95% CI not 0.14, I2 = 0%) observe 0.19) a significant (Figure 8). = 0%) (Figure 8). After performing the meta-regression, we did not observe a significant relationship between After performing the hours of intervention the meta-regression, we did notand the effect observe on help-seeking a significant (p between relationship = 0.392) relationship between the hours of intervention and the effect on help-seeking (p = 0.392) (Table 4). of intervention and the effect on help-seeking (p = 0.392) (Table 4). the hours (Table 4). Figure 7. Meta-analysis of change in help-seeking post-intervention. Figure 7. Figure Meta-analysis of 7. Meta-analysis of change change in in help-seeking help-seeking post-intervention. post-intervention. Figure 8. Meta-analysis of change in help-seeking at 6 months. Figure Figure 8. 8. Meta-analysis Meta-analysis of of change change in in help-seeking help-seeking at at 66 months. months. Table 4. Meta-regression between hours of intervention and help-seeking. Table 4. Meta-regression between hours of intervention and help-seeking. Table 4. Meta-regression between hours of intervention and help-seeking. StMeanDiff Coef. Std. Err. t P>|t| [95% Conf. Interval] StMeanDiff Coef. Std. Err. t P>|t| [95% Conf. Interval] StMeanDiff Coef. Std. Err. t P > |t| [95% Conf. Interval] Length -0.033 0.033 -1.00 0.392 -0.138; 0.072 Length Length -0.033 −0.033 0.033 0.033 -1.00−1.00 0.392 0.392 -0.138; 0.0720.072 −0.138; Cons 0.325 0.221 1.46 0.239 -0.381; 1.03 Cons Cons 0.325 0.325 0.221 0.221 1.46 1.46 0.239 0.239 −0.381; -0.381; 1.03 1.03 REML REMLestimate estimateofofbetween-study variance between-study variance Number Numberofofobs obs=5=5 REML estimate of between-study variance % residual variation due to heterogeneity Number of obs =5 Tau2 = 0.0426 % residual variation due to heterogeneity Tau2 = 0.0426 % residualofvariation Proportion due tovariance between-study heterogeneity explained Tau2 = 0.0426 I-squared res =82.93% Proportion of between-study With variance explained Knapp-Hartung modification I-squared res =82.93% Adj R-squared = 0.61% Proportion of between-study variance explained I-squared res =82.93% With Knapp-Hartung modification Adj R-squared =0.61% With Knapp-Hartung modification Adj R-squared =0.61% The funnel plots were calculated to assess publication bias (Appendix B, Figures A1–A7), The funnel although plots statistical were tests calculated were not appliedto assess due topublication having less bias than(Appendix 10 studies. B, Figures A1– The funnel plots were calculated to assess publication bias (Appendix B, Figures A1– A7), although statistical tests were not applied due to having less than 10 studies. A7), although statistical tests were not applied due to having less than 10 studies. 4. Discussion 4. Discussion This review examines the effectiveness of mental health literacy interventions for This review examines the effectiveness of mental health literacy interventions for young people in educational centers from the beginning of the international Comprehen- young people in educational centers from the beginning of the international Comprehen- Children 2022, 9, 480 11 of 19 4. Discussion This review examines the effectiveness of mental health literacy interventions for young people in educational centers from the beginning of the international Comprehen- sive Mental Health Action Plan 2013–2030 to the present. It assesses how such programs influence knowledge regarding mental health, the stigma surrounding it, and help-seeking. Most of them displayed positive effects, although only the variable of knowledge showed significant improvement in the short- and long-term. With respect to knowledge, we observed that after analysis, the studies with the best post-intervention results were two QEs (Yamaguchi and Bella-Awusah) [28,35], followed by one RCT from Campos [24]. These findings were maintained at two months in Yamaguchi and Bella-Awusah [28,35] and at six months in Campos [24]. As shown in the comparison of results, QE studies tended to overestimate intervention effectiveness (lack of randomization leading to a greater probability of bias). The three interventions lasted less than 3 h and differed with respect to the characteristics of the individual responsible for carrying them out (teacher, researcher, and expert psychologist). In general, we observed a statistically significant improvement in knowledge for the studies analyzed both post-intervention (SMD = 0.61) and at the six-month follow-up (SMD = 0.39) compared to the usual programs. Regarding stigma, the studies by Campos [24] and Perry [21] were the only ones that demonstrated statistically significant improvements post-intervention at the meta-analysis. While both were RCTs, they differed with respect to duration (3 h and 10 h, respectively) and professionals delivering the intervention (expert psychologists and teachers, respectively). Both studies did not present contact with a person who has suffered from mental disorders in comparison with the studies by Casañas [26], Pinto-Foltz [25], and Chisholm [23], who obtained worse results in this variable. Milin´s study [22] did not present direct contact, but it did have video interviews and cases with young people with mental illnesses. The QE study of Bella-Awusah [25] analyzed intervention carried out by a psychologist and without direct contact but did not present post-intervention improvements. Future research should assess whether a first-person experience is an unfavorable factor in reducing stigma or if educational sessions with specialists or teachers are more effective in reducing stigma. We observed that Campos [24] employed the same tool to measure knowledge and stigma in contrast to the other studies, which used different scales, this could be a bias in this study, and we should take these results with caution. After analyzing the studies, we did not find a significant improvement post-intervention (SMD = 0.06; p = 0.72) nor at the six-month follow-up (SMD = 0.12; p = 0.68). In the help-seeking variable, the three studies included in the meta-analysis were RCTs, with a different duration between them (10 h [22], 4 h 45 min [23], and 3 h [24]), as those in charge of carrying out the interventions (teachers [22], a researcher together with teachers [23], and an expert psychologist [24]). We observed that Campos [24] presents a significant improvement in the short term in the meta-analysis but not at 6 months. In general, no significant improvements were found in this variable, neither post-intervention (SMD = 0.2; p = 0.24), nor at 6 months (SMD = 0.02; p = 0.79). Regarding the analysis over time, worse results were observed in the three main variables as time progressed. This may be due to the fact that over time if knowledge is not reinforced, it is progressively forgotten, as Ebbinghaus [36] and other current studies postulate [37]. In addition, no significant time-dependent relationship was observed in the hours of intervention with the three main variables (knowledge, stigma, and help-seeking), as can be seen in the meta-regression in Tables 2–4. These results are similar to the results of the Wei and Seedaket [2,13] reviews both in terms of knowledge, stigma, and help-seeking at a qualitative level. However, because they did not perform their respective meta-analyses, we cannot compare them. There was considerable variability amongst the interventions with respect to format, content, and measurement tools which hindered comparison. Moreover, their duration ranged from 45–50 min, as was the case of the Short MHL program [31,33], up to 12 h for The Guide [29,30]. In addition, MHL domains were not consistent; some studies included Children 2022, 9, 480 12 of 19 them in their broadest sense, for instance, Perry [21], Campos [24], and Pinto-Foltz [23]; whilst others were only concerned with the detection of one or two specific mental health disorders such as Ojio [31,33]. Our findings concur with the systematic review performed by Mansfield [38], in which the lack of homogeneity regarding the concept of MHL was highlighted. There was also a tendency to focus solely on the identification of mental health disorders rather than examining the issue from a broader, more positive perspective. The review of Nobre [39] provided us with plausibility to the search carried out since they present similar results in the selected articles, despite having different objectives and selection criteria. The most recent review, Freitan [40], also assesses knowledge and stigma but not help-seeking. Freitan’s analysis differs from ours by including participants with mental illness, the time stage of the included studies, and the interventions outside the school context. Both studies present after the meta-analysis improvement in knowledge but not in stigma in the follow-up phase. Our review presents some limitations. Firstly, the design of the studies was heteroge- neous, and we observed a greater weighting in the case of the QEs when calculating the intervention effect. Moreover, the three variables (knowledge concerning mental health, stigma, and help-seeking behavior) were assessed with different scales, and one-third of the studies employed their own unvalidated tools to measure help-seeking. Secondly, regarding publication bias, it should be noted that the statistical analysis could not be performed due to having fewer than 10 studies. We have to emphasize that only one study [28] belongs to an economically depressed region. Instead, we found descriptive studies in those locations like Vietnam, Sub-Saharan Africa, and Zambia [41–43], but not the evaluation of interventions. This can cause the results to be irreproducible in these regions. Thirdly, it should be noted as a limitation that studies prior to 2013 were not included. In this study, we were interested in assessing the studies carried out during the period of implementation of the WHO Comprehensive Mental Health Action Plan 2013–2020 [7] and the promotion of this plan in mental health prevention and promotion interventions such as MHL in the adolescent population. We have to add that our data search was mainly in health databases. This could have caused the loss of information from specialized education databases. Our results should be interpreted with caution. In spite of the short- and medium- term clinical benefits regarding the improvement in knowledge, we lack sufficient data to evaluate the efficacy of these interventions long-term (12 months follow-up). Further studies with more robust methodology, for instance, RCTs, with interventions that share the same MHL concept domains and employ the same measurement tools (particularly with respect to help-seeking) are warranted. More studies are needed that focus on the conditions in which the study is carried out, such as the content of the intervention, the person responsible for delivering the intervention, or the way of carrying out the intervention (use of videos, contact with first-person experience, talking, etc.). Subsequent studies should assess the following time frame until 2030 to study the evolution of the effectiveness of interventions based on MHL in the classroom after the end of the WHO plan in that year. 5. Conclusions Mental health literacy interventions in a young school-age population improve mental health knowledge. Considering the limited data meta-analyzed, we cannot conclude that MHL interventions are effective on stigma and help-seeking outcomes. Even so, the results of individual studies on such outcomes are encouraging. There is considerable variabil- ity in the concept of mental health literacy and the instruments used to evaluate these interventions. Future research should go further on the effectiveness of MHL intervention considering stigma and help-seeking outcomes and, in addition, analyze other factors associated with the effectiveness of MHL interventions, such as the length of follow-ups and the type of professional in charge of carrying it out. Children 2022, 9, 480 13 of 19 Author Contributions: All authors have contributed to the design and content of the study. I.D.A.-R., L.L.-J. and R.C. were responsible for the project administration and funding acquisition. I.D.A.-R., R.C. and L.M.-E. contributed to the development of the research methodology, writing/original draft preparation, and writing/review and editing. M.I.F.-S.M., P.C. were in charge of the statistical analysis. R.C., L.M.-E. and I.D.A.-R. participated in the data collection. I.D.A.-R., L.L.-J., R.C., L.M.-E., M.I.F.-S.M., J.F.R.-M. and I.C. participated in the writing/review and editing. All authors have read and agreed to the published version of the manuscript. Funding: This study was performed with support from Investigació i Realització del Doctorat a l’Atenció Primària Idiap Jordi Gol reference IDIAP: 7Z20/010- 2020, and assistance for doctoral thesis completion offered by the territorial management of the Catalan Health Institute (ICS) in Barcelona for recently graduated specialists in family and community nursing 2019. The trial received a research grant from the Carlos III Institute of Health, Ministry of Economy and Competitiveness (Spain). This was awarded in the 2015 call for tenders under the Health Strategy Action 2013–2016, within the National Research Program aimed at Societal Challenges, within the Technical, Scientific, and Innovation Research National Plan 2013–2016, with reference PI15/01613, and was co-funded by the European Union ERDF funds (European Regional Development Fund). This research was also funded by the Department of Health, Government of Catalonia (Spain) in the 2017 call for grants under the Strategic Plan for Research and Innovation in Health (PERIS) 2016–2020, with reference SLT002/16/00202. Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. Data Availability Statement: The data presented in this study are available on request from the corresponding author. Acknowledgments: This research has been carried out within the framework of the Biomedical and Public Health Research Methodology doctoral program at the Barcelona Autonomous Univer- sity (UAB). We would like to acknowledge the collaboration of Jorge Piqueras Marques from the Universitat Internacional de Catalunya (UIC). Conflicts of Interest: The authors declare no conflict of interest. Appendix A Table A1. SIGN Grading System. Levels of Evidence High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low 1++ risk of bias 1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias 1− Meta-analyses, systematic reviews, or RCTs with a high risk of bias High-quality systematic reviews of case control or cohort or studies High-quality 2++ case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal Well-conducted case control or cohort studies with a low risk of confounding or bias 2+ and a moderate probability that the relationship is causal Case control or cohort studies with a high risk of confounding or bias and a 2− significant risk that the relationship is not causal 3 Non-analytic studies, e.g., case reports, case series 4 Expert opinion Children 2022, 9, 480 14 of 19 Children Children 2022, 2022,9, 9,xxFOR FORPEER PEERREVIEW REVIEW 14 14 of of19 19 Appendix B. Funnel Plots Appendix Appendix B. B. Funnel Funnel Plots Plots Figure Figure A1.Funnel FigureA1. A1. Funnelplot Funnel plotpos-intervention plot pos-interventionknowledge. pos-intervention knowledge. knowledge. Figure A2. FigureA2. Figure Funnel A2.Funnel plot Funnelplot knowledge plotknowledge at at222months. knowledgeat months. months. Children2022, Children Children 2022,9,9, 2022, 9,480 xx FOR FOR PEER PEER REVIEW REVIEW 15ofof 15 15 of19 19 19 FigureA3. Figure Figure A3.Funnel A3. Funnelplot Funnel plotknowledge plot knowledgeatat knowledge at666months. months. months. Figure Figure A4.Funnel FigureA4. A4. Funnelplot Funnel plotpost-intervention plot post-interventionstigma. post-intervention stigma. stigma. Children 2022, Children 2022, 9, 9, 480 x FOR PEER REVIEW 16 of 16 of 19 19 Children 2022, 9, x FOR PEER REVIEW 16 of 19 Figure A5. Figure A5. Funnel Funnel plot plot stigma stigma at at 66 months. months. Figure A5. Funnel plot stigma at 6 months. Figure A6. Funnel Figure A6. Funnel plot plot post-intervention post-intervention help-seeking. help-seeking. Figure A6. Funnel plot post-intervention help-seeking. Children 2022, 9, Children 2022, 9, 480 x FOR PEER REVIEW 17 17 of of 19 19 Figure A7. Funnel Figure A7. Funnel plot plot help-seeking help-seeking at at 66 months. months. References References 1. Kessler, R.C.; Berglund, P.; Demler, O.; Jin, R.; Merikangas, K.R.; Walters, E.E. Lifetime Prevalence and Age-of-Onset Distributions 1. Kessler, R.C.; Berglund, P.; Demler, O.; Jin, R.; Merikangas, K.R.; Walters, E.E. Lifetime Prevalence and Age-of-Onset of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch. Gen. Psychiatry 2005, 62, 593–602. [CrossRef] Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch. Gen. Psychiatry 2005, 62, 593–602. [PubMed] https://doi.org/10.1001/ARCHPSYC.62.6.593. 2. Wei, Y.; Hayden, J.A.; Kutcher, S.; Zygmunt, A.; McGrath, P. 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