Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. We're all probably familiar with physical first aid, but there is also something called mental health first aid and a new Cochrane review was published in August 2023, looking at the evidence on its effects' In this podcast, Roses Parker, Cochrane's Commissioning Editor, talks with two co-authors, Rachel Richardson who leads the Methods Support Unit in Cochrane and George Wellby who works as a psychiatric registrar in London, UK, about the review'

Roses: Rachel, first of all, can you tell me about mental health first aid training - what is it and why did you do this review?

Rachel: Mental health first aid training, or MHFA for short, originated in Australia in the year 2000' It's a brief training programme aimed at improving mental health literacy and teaching mental health first aid strategies, so that people can provide immediate help to people in distress and signpost them to services'
It's very popular, with MHFA Australia estimating that over six million people worldwide have been trained and it's promoted as an evidence-based programme' We wanted to examine this evidence to find out whether it improves mental health in organisations that have adopted the training, and whether it might be associated with any adverse effects'

Roses: So, what did you find?

Rachel: There were 21 studies including over 22,500 people relevant to our broad set of questions' But, disappointingly, only five studies had actually measured whether MHFA training improved mental health in organisations where it had been implemented' It was also disappointing to find that there were multiple problems in how the research had been done, which meant that the evidence was subject to bias and there were too few people in the studies to allow us to reach definitive conclusions'

Roses: So, that throws up a lot of questions from me! Firstly, what did the studies measure if not the impact on mental health?

Rachel: Most commonly, they measured outcomes such as whether the training improved knowledge about mental health difficulties, and whether it decreased stigma around issues such as depression and schizophrenia' We did examine the impact of the training on these outcomes but felt that they were less important for decision-makers than the actual impact of the training on mental health in the organisations that implemented it'

Roses: Okay, yes, that's fair' Going back to some of the other problems, can you expand a little on the biases and the size of the studies?

Rachel: Sure! In many of the studies, there was a considerable amount of ‘drop-out', with people who had been recruited leaving before the study ended, meaning that the triallists could not ascertain their outcomes' In regard to size, the small number of people in the studies meant that there wasn't enough data to be able to work out the precise effect of the intervention'
Therefore, although our overall finding was that MHFA may be associated with a small improvement, there is also a chance that it may also result in no difference in the mental health of people in organisations that adopt this training'  This gives us very little confidence in the result and we can't conclude that the intervention works or that it doesn't' We also found that there were no systematically collected data on any adverse effects'

Roses: Turning to George, I'm interested in what adverse effects there might be' I understand that there may be adverse effects linked with new drugs, but how does this apply to MHFA training?

George: It's perhaps easier to understand this in terms of unintended consequences' MHFA is obviously styling itself as equivalent to conventional physical first aid but it's actually quite different' A tourniquet or CPR works because of basic physiology and the efficacy is well proven, but mental health problems are much more complex' This leaves much more room for ineffective and unhelpful interventions - a little bit of knowledge can be a dangerous thing' For instance, we know from previous experience that some mental health interventions can have unexpected negative consequences, such as psychological debriefing after traumatic events'
With MHFA, people who have been trained in it may find it stressful if they feel obliged to give support to people with potentially serious mental health problems, such as suicidality' There may also be situations where implementing MHFA training allows institutions to avoid actually addressing aspects of toxic culture or work-practices that are causing distress' Lastly, MHFA may encourage people to medicalise ordinary distress and increase demand for mental health care which cannot be provided because of a lack of sufficient resources'

Roses: So, how would you sum up your conclusions after doing the review?

George: We think it's striking that such a popular intervention is not better supported by evidence that it actually improves mental health' There is a notable lack of evidence to show that the training benefits the mental health of the communities the trainees are embedded in, which should be an important outcome for any public health intervention'
We're also concerned about the lack of evidence on unintended consequences' MHFA training may seem to be a good idea in theory, but, as researchers, we know that just because something seems like it should work, doesn't necessarily mean that it does work when it's properly evaluated' There's a great book that goes into these concepts in much more detail – it's called Testing Treatments and it's freely available online'

Roses: Thanks, I agree that's a really helpful book, which people can get from the website testingtreatments dot org' Going back to the review, what advice would you give organisations considering adopting MHFA training?

George: Of course, every organisation is different, but they should decide what they are aiming to achieve and then decide what to do based on the evidence' As well as the economic cost of MHFA training, there is also an opportunity cost in that it might get in the way of doing something else, and organisations should consider what other steps they might take to improve the mental health of their members'

Roses: And, next, what advice would you give to people conducting research into MHFA?

George: Firstly, future research should systematically measure and report any adverse events associated with MHFA and try to objectively measure outcomes that are relevant to individuals in the wider community, such as the use of mental health services' The studies should also recruit enough participants to be able to demonstrate the effects of MHFA in a precise way'

Roses: Finally, if someone would like to read your review, how can they get hold of it?

George: It's online in the Cochrane Library, so if listeners go to Cochrane Library dot com and search ‘mental health first aid', they'll find it'