Descriptive Manuscripts

Providing First Aid to People Experiencing Mental Health Problems: Development of Evidence-Based Guidance Materials for Laypeople

Authors
  • Stijn Stroobants orcid logo (Belgian Red Cross, Mechelen)
  • Kim Dockx orcid logo (Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen)
  • Hans Scheers orcid logo (Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen; Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven)
  • Vere Borra orcid logo (Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen; Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven; Cochrane First Aid, Mechelen)
  • Niels De Brier orcid logo (Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen; Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven)
  • Sarah Verlinden (Belgian Red Cross, Mechelen)
  • Karen Lauwers (Belgian Red Cross, Mechelen)
  • Philippe Vandekerckhove orcid logo (Belgian Red Cross, Mechelen; Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, BE; Centre for Evidence-Based Health Care, Stellenbosch University, Cape Town)
  • Emmy De Buck orcid logo (Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen; Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven; Cochrane First Aid, Mechelen)

Abstract

Background: Family and friends are particularly well placed to recognize early signs of mental health problems, provide initial support, and refer to professional help if needed. This project aimed to develop evidence-based guidance materials for laypeople on how to provide help to people experiencing mental health problems, adapted to the context of Flanders, Belgium.

Methods: We performed a systematic literature review for 12 different mental health topics, focusing on communicative support interventions feasible to be performed by laypeople. Systematic literature searches were conducted in MEDLINE, Embase, and PsycNET (October 2018). One reviewer per topic conducted data extraction and methodological quality assessment using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) methodology. The evidence was used to develop a draft manual, which was presented to a multidisciplinary expert panel involving both content experts (n = 10) and mental health peer workers in training (all people with lived experience) (n = 6).

Results: Included studies involved 15 experimental and 75 observational studies, leading to 58 evidence conclusions on communicative interventions, risk factors or protective factors, and their relationship to mental health outcomes. The certainty of the evidence was very low for the majority of the evidence conclusions (84.5%), highlighting the need for expert and stakeholder input to inform practical recommendations. Scientific evidence and expert input were used to formulate 33 individual actions on how to provide first aid to people experiencing mental health problems. The recommendations were made available to laypeople via a guidance manual and a mobile application.

Conclusions: Input from the scientific literature and the expert panel were essential to obtain evidence-based guidance materials that were meaningful for practice in a Flemish context.

Keywords: mental health, Evidence-Based Practice, communication, laypeople education

How to Cite:

Stroobants, S., Dockx, K., Scheers, H., Borra, V., De Brier, N., Verlinden, S., Lauwers, K., Vandekerckhove, P. & De Buck, E., (2023) “Providing First Aid to People Experiencing Mental Health Problems: Development of Evidence-Based Guidance Materials for Laypeople”, International Journal of First Aid Education 6(1), 37–60. doi: https://doi.org/10.25894/ijfae.6.1.8

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Published on
14 Apr 2023
Peer Reviewed

Mental health problems generally involve changes in thinking, feeling or behavior, or a combination of these. This leads to distress and/or problems in functioning well in social, work, or family life. Such changes can present themselves within a broad range of severity, from life’s daily hassles to mental disorders inflicting severe discomfort and impairment. In 2019, a systematic analysis for the Global Burden of Disease Study indicated that mental health disorders were among the top ten leading causes of burden worldwide, responsible for 125.3 million Disability Adjusted Life Years (DALYs, 4.9% of global DALYs), and mainly related to depression and anxiety disorders (GBD 2019 Diseases and Injuries Collaborators, 2020; GBD 2019 Mental Disorders Collaborators, 2022).

The social environment is known to have an important impact on both mental and physical health. For instance, social support has been shown to positively influence mental health outcomes (De Brier et al., 2020; Holt-Lunstad et al., 2010; Santini et al., 2015; Tough et al., 2017). As such, family and friends are particularly well placed to recognize signs of mental health problems, provide initial support, and refer to professional help if needed. This links to the three middle domains of the Chain of Survival Behavior being early recognition, first aid, and accessing help. However, laypeople often lack the knowledge and skills to fulfill this potential, highlighting the need for a range of interventions including awareness campaigns and low-threshold training sessions (Jorm, 2012). In this respect, training programs such as Mental Health First Aid training are a widely disseminated strategy to improve the mental health literacy of laypeople (Kitchener & Jorm, 2002; Liang et al., 2021; Reis et al., 2021). A recent systematic review showed that such training improved relevant knowledge and attitudes up to six months after training, whereas results up to 12 months later remained unclear (Morgan et al., 2018). A narrative review identified 31 studies concerning the development of guidelines for the public on how to provide Mental Health First Aid. However, identified guidelines were mainly developed for English-speaking or Asian countries, or specifically targeted refugees or Australian Aboriginals (Jorm & Ross, 2018).

In reply to the existing lack of evidence-based teaching materials for the general population in Flanders, Belgium, the Flemish government provided funding for the development and implementation of guidelines for laypeople on how to support people experiencing mental health problems. The development of an evidence-based guideline, and subsequent educational materials, relies on the principles of Evidence-Based Practice (EBP). EBP requires the integration of three fundamental components: 1) the best available scientific evidence, 2) the preferences of the target group, and 3) the expertise and practical experience of content and field experts. This is accomplished by conducting systematic literature reviews to obtain the best available evidence, and by involving content and field experts, and people representing the target group (De Buck et al., 2014).

Following this method, we developed a contextualized guidance manual and mobile application. We strived for the materials to be in line with state-of-the-art views in the professional mental health landscape and complementary to already available materials. The project was supported and advised by a steering group involving leading Flemish organizations in mental health care, prevention, and promotion, as well as patient representation. Flanders is one of the few Dutch-speaking regions in the world and it is important to embed first aid recommendations in an appropriate language and relevant background information for the general public. No existing materials were identified which could fulfill the determined needs. The current paper describes the process of developing teaching materials on how to support people experiencing mental health problems for laypeople in a Flemish context.

Methods

We performed a systematic literature review to provide a scientific basis for the guidance materials. The review was performed according to the AGREE II criteria for the development of evidence-based practice guidelines and reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statements (Supporting information S1) (Moher et al., 2009). Time constraints did not allow for protocol publication. Below, we describe the methodology for developing the systematic literature review and the subsequent materials.

Selection of Topics and Defining the Research Question

Twelve mental health topics were selected for inclusion in the manual: addiction, aggression, anxiety, burnout, depression, eating disorder, grief following bereavement, non-suicidal self-injury, psychosis, stress complaints, suicidality, and traumatic events (see Table 1 for explanations). This list of topics was informed through online questioning of the general population and focus group discussions with experts from mental health-related settings. The aim was to cover the most prominent needs for helping people with mental distress in Flanders, Belgium.

Table 1

Mental health topics included in the manual.

TOPIC RELEVANT POPULATION
Addiction People at risk for or experiencing addiction-related symptoms or addiction (related to substance use or another habit/activity such as e.g., gambling, gaming, …)
Aggression People who engage in physical and/or psychological violence, i.e., deliberately harming another person physically and/or psychologically
Anxiety People who are at risk for or experiencing anxiety symptoms (e.g., worry, panic)
Burnout People in a work setting who are at risk for or experiencing burnout-related symptoms (e.g., emotional exhaustion) or burnout.
Depression People who are at risk for or experiencing depressive symptoms (e.g., sadness, loss of interest) or depression.
Eating disorder People who are at risk for or experiencing an eating disorder, i.e., anorexia nervosa, bulimia nervosa or binge-eating disorder.
Grief following bereavement People experiencing the psychological consequences of being confronted with a loved one’s death. Studies focusing on end-of-life care, i.e., grieving before actual death, were not included.
Psychosis People who are at risk for or experiencing psychosis or a psychotic disorder.
Stress complaints People who are at risk for or experiencing stress complaints (e.g., feelings of tension, frustration, nervousness) in response to events or situations.
Suicidality People experiencing suicidal thoughts and/or engaging in suicidal behavior, i.e., undertaking actions implying the risk of ending their own life or the expectation it could end their life.
Non-suicidal self-injury People engaging in non-suicidal self-injury, i.e., deliberately and directly harming their body without suicidal intent or expectation.
Traumatic event People experiencing psychological consequences of undergoing/witnessing an event that involved exposure to or threat of death, a serious injury, or sexual abuse.

The project team (i.e., the authors of the current manuscript), consisting of content experts and systematic review methodologists, formulated research question(s) for these different topics, as previously described (De Brier et al., 2021). Currently available programs on first aid for mental health problems generally involve the following themes: approaching the person, providing practical care and assistance, listening, helping people connect to information or further support, and encouraging the person to get appropriate professional help (Brymer et al., 2012; IFRC Reference Centre for Psychosocial Support, 2018; Morgan et al., 2018; World Health Organization & War Trauma Foundation and World Vision International, 2011). The team dissected and evaluated these different actions, and it was judged that ‘communication’ in the broad sense could be considered as an overarching theme (i.e., approaching, providing care, listening, helping, and encouraging all rely on communication). In this context, communication involves any (non-)verbal intervention that is feasible for a layperson, such as engaging in a conversation, talking with the individual, providing comforting nonverbal communication (e.g., an open posture), or any other form of communication that is used as a coping strategy by people experiencing mental health problems themselves. Therefore, the research question of interest focused on which communication strategies could be used or should be avoided by laypeople to support people experiencing mental health problems.

Systematic Literature Search and Study Selection

We performed a systematic literature search in MEDLINE (PubMed interface), Embase (embase.com interface), and PsycNET. A first search strategy was developed for the mental health topics listed in Table 1 (Supporting Information S2). The search was performed from the date of inception of the database to October 3, 2018. Because of the complexity of the topic and the different terminology, we decided to develop a separate search strategy for the topic of traumatic events on March 8, 2019 (separately published) (De Brier et al., 2021). Reference lists and the 20 most similar articles (feature in MEDLINE) were hand-searched for all included studies and systematic reviews extracted from the original search. The reference lists of included articles based on this additional search were also checked, as well as their 20 most similar articles in MEDLINE. Screening of all references based on title and abstract, and in a second phase based on full text, was done by one reviewer per topic. Studies considered for inclusion involved systematic reviews, randomized controlled trials (RCTs), quasi-RCTs, non-RCTs, (un)controlled before and after studies, interrupted time series, cohort studies, and case-control studies. We included cross-sectional studies if the intervention was performed by a layperson (e.g., friend, family member), but excluded if the study involved a (semi-)professional health worker (e.g., nurse, general practitioner, palliative care worker). If the body of evidence for a specific mental health topic was covered by RCTs, we did not include observational studies. Conference abstracts, qualitative studies, PhD theses, narrative reviews, case studies, and case series were excluded. Only studies published in English or Dutch were included.

We included studies if participants were at risk for or experiencing mental health problems, without any restrictions related to gender, age, or severity. At the level of intervention, we included studies that focused on (any of) different types of communication, either as a concrete intervention (in experimental studies) or as exposure or risk factor (in observational studies). In more concrete terms, the communication strategies could include likely supportive (or unsupportive) actions (e.g., comforting or criticizing the person) aimed at the person experiencing mental health problems, as well as coping strategies adopted by the person themselves (e.g., talking to a confidant). Interventions had to be feasible for a layperson (i.e., someone without any (para)medical or psychological background, including family members, friends, colleagues, caregivers, pastoral workers, or the person themselves (coping through communication)). Any study comparing a communication intervention to no intervention or another intervention feasible in lay settings was included. We also included studies examining the pre-to-post effects of communication. The following interventions were excluded: communication related to the disclosure of a diagnosis, communication as a risk/protective factor for developing mental health problems in later life, mass media campaigns, support groups, computer-assisted communication, storytelling, dream telling, or other treatments that are not fit for a lay setting (i.e., psychotherapy or other interventions requiring extended training and/or professional expertise). The outcome of interest was any mental health or psychological well-being outcome.

Data Extraction, Data Synthesis, and Quality Assessment

Data extraction was performed by one reviewer per topic. The following data were extracted from all included studies where available: study design; characteristics of the population (number of participants, age range, gender distribution); characteristics of the specific intervention (content, duration); methods (and timing, if relevant) of outcome measurement; means, mean differences (MDs), and confidence intervals (CIs) for continuous data; risks, risk ratios (RRs), odds ratios (ORs) and CIs for dichotomous data; or correlation coefficients or regression coefficients in case of correlational research or regression analyses, respectively.

When possible, a random-effects meta-analysis was performed. For dichotomous outcomes, the Mantel-Haenszel method was used; for continuous outcomes, the inverse variance method was used. When a meta-analysis was not feasible, (e.g., due to substantial differences between studies or when only one study was identified) a narrative description of the results was provided. ORs or RRs with 95% CIs were calculated for each of the dichotomous outcomes if not available. MDs or standardized mean differences (SMDs) were calculated for each of the continuous outcomes, as appropriate. Heterogeneity was assessed using non-overlapping confidence intervals of effect sizes between studies and the Chi² and I² statistics. Cochrane’s Review Manager 5 software was used for all analyses (Centre, 2014).

The risk of bias in each of the included studies, as well as a rating of the body of evidence, was assessed by one reviewer per topic according to the GRADE methodology (Schünemann et al., 2013). The latter includes limitations in study design (risk of bias), inconsistency, indirectness, imprecision of the results, and publication bias. Certainty of evidence was rated as very low, low, moderate, or high. All data were documented in a final “evidence summary” per topic (Supporting information S3).

Development of Draft Guidance Manual

As the next step, a manual on helping people who experience mental health problems was drafted. The manual contained information on the following three domains of the Chain of Survival Behavior: how to recognize mental health problems, how to accommodate communicative first aid, and how to inform about and encourage (professional) help when needed. It also provides advice on how to ensure appropriate self-care in the context of first aid for mental health problems. The content of the draft was based on the evidence gathered by the systematic literature search and data collection, for those items for which evidence was identified. Draft recommendations were developed based on content analyses of factor and intervention descriptions in the original studies. To fill gaps not covered by scientific evidence, ‘Good Practice Points’ (GPPs) were formulated based on information extracted from relevant journal articles, books, (inter)national training materials, and content discussions within the research team and with representatives from mental health care organizations in Flanders, Belgium (see Acknowledgements). GPPs are short pieces of advice, formulated by a group of experts from the field, but without a scientifically and systemically identified evidence base. These additional draft recommendations were created similar to the other recommendations, by analysis of original wordings and subsequent translation into first aid actions. First aid actions were complemented by examples of how to practically apply them and embedded in a dynamic framework including four key actions: recognizing mental health problems, providing informal support, guiding towards more help, and taking care of themselves while helping others. Guidance is provided in the context of daily life as well as crisis support. In addition, the draft manual included background information on the selected mental health topics and mental health in general (listed in Table 1). It should be stressed that the manual does not promote diagnosis or treatment by laypeople but encourages and guides their natural role of giving informal help and support.

Multidisciplinary Expert Meeting and Finalizing Materials

The draft manual and evidence summaries were distributed among a panel of experts, consisting of 10 content experts and six mental health peer workers in training from Flanders, Belgium. The content experts were psychologists or psychiatrists active in mental health care (policy) and/or academia. The mental health peer workers were in the final stages of a specific trajectory embedded in social work education. This trajectory is aimed at students with patient or client experiences in mental health care, willing to professionalize their volunteering activities or becoming professional peer-workers in mental health services. Throughout the trajectory, they acquire knowledge and skills to broadly apply their lived experience with mental health problems in support of clients and professionals in daily practice. More information regarding the relevant affiliations of content experts and mental health peer workers in training can be found in the acknowledgments.

In the first stage, all members of the expert panel independently provided written feedback, which was jointly implemented in the draft version of the manual. In the second stage, the expert panel participated in five expert meetings, taking place between February and June 2019. During these in-person meetings, all proposed content changes to the draft manual were separately presented to and discussed by the panel. Likewise, members of the expert panel could propose and formulate additional GPPs during the meetings. Proposed content changes were formally discussed and consensus on all included content was eventually obtained. The manual was finalized in September 2019 (Belgian Red Cross-Flanders, 2019a). Furthermore, the content of this manual was used to develop a mobile application. The App contains similar content but is organized as short easy instructions and recommendations. The mobile application was made freely available in November 2020 (Belgian Red Cross-Flanders, 2020). All materials were developed in Dutch.

Results

Study Identification and Study Characteristics

In total, 30099 records were identified through database searching, of which 27729 hits were related to search strategy 1 (further described below), and 2370 hits were related to search strategy 2 for traumatic events described in De Brier et al., (2021). Following the removal of 6707 duplicates, screening of 21938 records based on title and abstract, and screening of 1403 records based on full-text, 51 primary research articles were included. Another 44 studies were identified from checking the reference lists and 20 most similar articles in MEDLINE of all included studies (n = 51) and 12 relevant systematic reviews (Arcelus et al., 2013; Bryan & Arkowitz, 2015; Fazel et al., 2012; Hallett & Dickens, 2017; Harvey et al., 2008; Hoffmann et al., 2018; Holtom-Viesel & Allan, 2014; Leonidas & Dos Santos, 2014; Macdonald et al., 2016; Minen et al., 2019; Parcesepe et al., 2015; Price et al., 2015). This resulted in a total of 95 included primary research articles. As some research articles discussed the same study data, these 95 articles involved a total of 90 individual studies, including 15 experimental and 75 observational studies. The PRISMA flow chart is depicted in Figure 1. An overview of the study designs within each mental health topic can be found in Table 2. Outcomes (i.e., communicative intervention, risk factor, or mental health) were measured using (non-validated) questionnaires, instruments, subscales of existing scales, or self-developed questionnaires. A detailed overview can be found in Supporting Information S3 (Table ‘Characteristics of included studies’, column ‘Remarks’).

Table 2

An overview of the included study designs within each of the mental health topics.

Experimental studies Observational studies Total number of studies
Topic RCT Non-RCT UBA study PC study CC study CS study
Addiction 2 2 4
Aggression 4 1 5
Anxiety 1 11 12
Burnout 1 3 4
Depression 7 1 2 1 1 12
Eating disorders 12 4 16
Grief following bereavement 1 2 10 13
Psychosis 3 2 5
Non-suicidal self-injury 3 2 5
Stress complaints 2 2
Suicidality 3 1 4 8
Traumatic event 1 8 9
  • RCT = Randomized controlled trial; Non-RCT = non-randomized controlled trial; UBA = Uncontrolled before-after; PC = Prospective Cohort; CC = Case-control; CS = Cross-sectional.

Figure 1
Figure 1

PRISMA study flow chart.

PRISMA study flow chart

Best Available Evidence on Communication Strategies and Characteristics Considered for Laypeople

Based on the identified evidence, 58 separate evidence conclusions were formulated. The detailed evidence summary for each mental health topic (characteristics of included studies, study findings, risk of bias assessment, GRADE analysis, and evidence conclusions) is available in Supporting Information S3. The certainty of the evidence, as determined by the GRADE approach, was very low for the majority of evidence conclusions (84.5%). Reasons for downgrading are documented in Supporting Information S3 (“Certainty of the body of evidence” tables). It is crucial to note that the cross-sectional study design was the most abundant study type, implying that exposure and outcome variables were measured at the same time via questionnaires. As a consequence, it is difficult to infer causal relationships from the results. The number of included studies and included participants varied strongly per evidence conclusion (ranging from one to nine studies and 24 to 22703 participants).

The evidence conclusions for each topic are available in Supporting Information S3 (detailed overview), Table 3 (summarized, schematic overview), and Supporting Information S4 (narrative summary).

Table 3

Association between communication strategies and mental health outcomes.

INTERVENTION EXPOSURE FACTOR TYPE OF ASSOCIATIONa OUTCOMES RESULTS CERTAINTY OF THE EVIDENCE (GRADE) NUMBER OF INCLUDED STUDIES NUMBER OF PARTICIPANTS PER STUDY (RANGE)
Addiction
Parent-child communication about substance use Association not shown Substance use r: –0.00, p > 0.05 Very low 1 (Wills et al., 2003) 297
Talking with someone about your problems Protective factor Alcohol use disorder; substance use; alcohol/drug dependence Narrative conclusionb Very low 3 (Borders et al., 2010; Fisher et al., 2008; Wang et al., 2009) 250–10195
Aggression
Reasoning Association not shown Physical violence Narrative conclusionb Very low 2 (Billingham & Sack, 1986; Messinger et al., 2012) 387–1056
Repair attempts (minimizing negative statements, using humor, taking breaks) Protective factor Physical violence; psychological violence r: –0.046, p < 0.01 Very low 1 (Cornelius et al., 2010) 173
Accepting influence (trying to find mutual ground) Protective factor Physical violence; Psychological violence r: –0.29, p < 0.01
r: –0.42, p < 0.01
Very low 1 (Cornelius et al., 2010) 173
Avoidant communication Risk factor Physical violence Narrative conclusionb Very low 1 (Goussinsky et al., 2017) 857
Temporary conflict avoidance Association not shown Physical violence Narrative conclusionb Very low 1 (Messinger et al., 2012) 917–1056
Escalation Risk factor Physical violence; Psychological violence Narrative conclusionb Very low 3 (Cornelius et al., 2010; Goussinsky et al., 2017; Messinger et al., 2012) 173–1056
Communication problems Risk factor Physical violence MD: 2.2, p < 0.001 Very low 1 (Robertson & Murachvor, 2007) 116
Anxiety
Talking with friends/others Protective factor Anxiety (various questionnaires) Narrative conclusionb Very low 2 (Dyregrov et al., 1994; Wallin et al., 2016) 63–174
Communication Protective factor Anxiety (various questionnaires) Narrative conclusionb Very low 4 (Edwards & Clarke, 2004; Fite et al., 2014; Hodgson et al., 1997; Howell et al., 2015) 32–747
Avoidance of communication Risk factor Anxiety (various questionnaires) Narrative conclusionb Very low 4 (Jeong et al., 2016; Shin et al., 2016; Wallin et al., 2016; Yu & Sherman, 2015) 173–990
Lower perceived degree of disclosure Risk factor Anxiety (GAD2) r: 0.31, p < 0.0001 Very low 1 (Haun et al., 2014) 189
End-of-life conference Effective Clinically significant symptoms of anxiety OR: 0.39, 95%CI [0.18;0.86], p = 0.02 Moderate 1 (Lautrette et al., 2007) 108
Positive emotion words Association not shown Anxiety (MASC) β: –0.16, p > 0.05 Very low 1 (Wardecker et al., 2017) 39
Burnout
Supervisory communication Protective factor Time to return to work; Emotional exhaustion; Depersonalization Narrative conclusionb Very low 2 (Kim & Lee, 2009; Nieuwenhuijsen et al., 2004) 85–478
Talking as a coping strategy Protective factor Emotional exhaustion Narrative conclusionb Very low 2 (Gupta et al., 2012; Lemaire & Wallace, 2010) 63–1151
Keeping stress to oneself Risk factor Emotional exhaustion r: 0.23, p < 0.0001 Very low 1 (Lemaire & Wallace, 2010) 1151
Depression
Counseling by laypeople Effective Depression (various questionnaires) Narrative conclusionb Low 2 (Nagel et al., 1988; Wickberg & Hwang, 1996) 41–60
Listening Visits Effective Depression (various questionnaires) MD c: 5.89, 95%CI [3.62;8.15]
I² = 0%, p = 0.37
Narrative conclusionb
Moderate 2 c, (Brock et al., 2017; Segre et al., 2010) +1 (Segre et al., 2015) 19–66
Perinatal peer support Effective Depression (various questionnaires) Narrative conclusionb Moderate 2 (Dennis et al., 2009; Roman et al., 1995) 58–701
Communication with family members Association not shown Depression (various questionnaires) Narrative conclusionb Very low 2 (Fite et al., 2014; Teo et al., 2015) 289–10055
Communication with friends Protective factor Depression (CES-D8) OR: 0.57, 95%CI [0.44;0.76], p < 0.001 Very low 1 (Teo et al., 2015) 9907
End-of-life conference Effective Depression (HADS) Narrative conclusionb Moderate 2 (Garrouste-Orgeas et al., 2016; Lautrette et al., 2007) 86–108
Condolence letter Effect not shown Depression (HADS) OR: 1.72, 95%CI [1.00;2.99], p = 0.051 Moderate 1 (Kentish-Barnes et al., 2017) 208
Eating Disorder
(Good) Communication with mother Protective factor Eating disorder,
Anorexia severity
MD c: –3.79, 95%CI [–7.31;–0.26]
I² = 57%, p = 0.04
Narrative conclusionb
Very low 2 c, (Cunha et al., 2009; Orzolek-Kronner, 2002) +1 (Pelletier Brochu et al., 2018) 68–186
(Good) Communication with father Association not shown Eating disorder,
Anorexia severity
MD c: –4.10, 95%CI [–8.42;0.22]
I² = 56%, p = 0.06
Narrative conclusionb
Very low 2 c, (Cunha et al., 2009; Orzolek-Kronner, 2002) +1 (Pelletier Brochu et al., 2018) 68–186
(Good) Communication with peers Protective factor Anorexia (severity), Bulimic symptoms, Eating pathology Narrative conclusionb Very low 4 (Cunha et al., 2009; Pelletier Brochu et al., 2018; Schutz & Paxton, 2007; Sharpe et al., 2014) 68–216
(Good) Family communication from patient perspective Protective factor Eating disorder,
Anorexia (severity), Bulimia Nervosa, Bulimia Simplex
MD c: 0.78, 95%CI [0.50;1.05]
I² = 56%, p < 0.00001
Narrative conclusionb
Very low 7 c, (Emanualli et al., 2004; Garfinkel et al., 1983; Laghi et al., 2017; North et al., 1995; Shisslak et al., 1990; Steiger et al., 1991; Waller et al., 1990) +2 (Gowers & North, 1999; Waller et al., 1989) 35–93
(Good) Family communication from parent perspective Protective factor Eating disorder,
Anorexia severity, Eating disorder
MD b: 0.19, 95%CI [0.05;0.32]
I² = 71%, p < 0.01
Narrative conclusionb
Very low 4 c, (Emanualli et al., 2004; Friedmann et al., 1997; North et al., 1995; Waller et al., 1990) +2 (Friedmann et al., 1997; Gowers & North, 1999) 35–379
High perceived level of expressed emotion Risk factor Eating disorder MD: 18.33, 95%CI [14.78;21.88], p < 0.05 Very low 1 (Di Paola et al., 2010) 126
Grief following bereavement
Communication avoidance Risk factor Grief, anxiety (various questionnaires) Narrative conclusionb Very low 4 (Davis et al., 2016; Lovgren et al., 2018; Stroebe et al., 2013; Wallin et al., 2016) 97–438
Grief-related communication Protective factor Grief, anxiety, depression, distress (various questionnaires) Narrative conclusionb Very low 8 (Kamm & Vandenberg, 2001; Liew & Servaty-Seib, 2018; Lovgren et al., 2018; Shapiro et al., 2014; Stroebe et al., 2013; Stroebe et al., 2002; Wallin et al., 2016; Wardecker et al., 2017) 38–438
Phone call from the hospital Effective Loneliness/depression, guilt, anger/hostility OR: 0.06, 95%CI [0.01;0.61],p = 0.02 Low 1 (Schreiner et al., 1979) 29
Communication in general Protective factor Grief, anxiety, depression (various questionnaires) Narrative conclusionb Very low 3 (Raveis et al., 1999; Rich, 2000; Traylor et al., 2003) 66–114
Psychosis
Parental communication deviance Risk factor Schizophrenia, schizophrenia relapse Narrative conclusionb Very low 3 (Goldstein, 1985; Rund, 1986; Velligan et al., 1996) 20–82
High parental affective style Risk factor Schizophrenia OR c: 10.19, 95%CI [2.66;39.01]
I² = 0%, p = 0.0007
Very low 2 (Goldstein, 1985; Hamilton et al., 1999) 38–64
Parental criticism Risk factor Schizophrenia OR c: 10.34, 95%CI [2.97;35.99]
I² = 0%, p = 0.0002
Very low 2 (Goldstein, 1985; Hamilton et al., 1999) 38–64
Parental problem solving Protective factor Schizophrenia, social functioning (SCOS) Narrative conclusionb Very low 2 (O’Reilly et al., 2011; Rund, 1986) 33–41
Parental egocentrism Risk factor Schizophrenia Narrative conclusionb Very low 1 (Rund, 1986) 41
Non-suicidal self-injury
Talking as a coping strategy Protective factor Non-suicidal self-injury OR c: 0.54, 95%CI [0.33;0.89]
I² = 91%, p = 0.02
Very low 3 (Batey et al., 2010; Evans et al., 2005; Watanabe et al., 2012) 432–17671
Ease of communication with parents Protective factor Non-suicidal self-injury β: –0.12, p < 0.05 Very low 1 (Latina et al., 2015) 832
Not able to talk to mother Risk factor Non-suicidal self-injury
Thoughts of self-injury, self-injury repetition
OR c: 2.41, 95%CI [2.03;2.85]
I² = 90%, p < 0.0001
Narrative conclusionb
Very low 2 (Evans et al., 2005; Portzky et al., 2008) 5737–8889
Not able to talk to father Risk factor Non-suicidal self-injury (see meta-analysis),
Thoughts of self-injury, self-injury repetition
OR c: 2.19, 95%CI [1.81;2.65]
I² = 95%, p < 0.0001
Narrative conclusionb
Very low 2 (Evans et al., 2005; Portzky et al., 2008) 5737–8889
Not able to talk to sibling Risk factor Non-suicidal self-injury (see meta-analysis),
Thoughts of self-injury, self-injury repetition
OR c: 1.68, 95%CI [1.41;1.99]
I² = 96%, p < 0.0001
Narrative conclusionb
Very low 2 (Evans et al., 2005; Portzky et al., 2008) 5737–8889
Not able to talk to another relative Risk factor Non-suicidal self-injury (see results),
Thoughts of self-injury, self-injury repetition
OR: 1.80, 95%CI [1.43;2.28], p < 0.0001
Narrative conclusionb
Very low 1 (Evans et al., 2005) 5737
Not able to talk to a friend Association not shown Non-suicidal self-injury (see meta-analysis),
Thoughts of self-injury, self-injury repetition
OR c: 0.95, 95%CI [0.75;1.20]
I² = 0%, p = 0.65
Narrative conclusionb
Very low 2 c,(Evans et al., 2005; Portzky et al., 2008) + 1 (Latina et al., 2015) 709–8889
Not able to talk to a teacher Risk factor Non-suicidal self-injury (see meta-analysis),
Thoughts of self-injury, self-injury repetition
OR c: 1.63, 95%CI [1.28;2.09]
I² = 22%, p < 0.0001
Narrative conclusionb
Very low 2 (Evans et al., 2005; Portzky et al., 2008) 5737–8889
Not able to talk to someone else Risk factor Non-suicidal self-injury (see meta-analysis),
Thoughts of self-injury, self-injury repetition
OR c: 1.20, 95%CI [1.01;1.43]
I² = 63%, p = 0.04
Narrative conclusionb
Very low 2 (Evans et al., 2005; Portzky et al., 2008) 367–8889
Stress complaints
Communication avoidance Risk factor Stress (DASS) Narrative conclusionb Very low 1 (Yu & Sherman, 2015) 338
Emotional/informational support Association not shown Stress (DASS) r: –0.14, p > 0.05 Very low 1 (Soo & Sherman, 2015) 185
Suicidality
Sending postcards Effective Suicidal death after x years, suicidal ideation, suicide attempt Narrative conclusionb Low 3 (Carter et al., 2013; Hassanian-Moghaddam et al., 2017; Motto & Bostrom, 2001) 772–2300
Befriending Effective Psychological distress (CORE) post-intervention and 3m follow-up MD: –1.42, p < 0.001
MD: –1.65,
p < 0.001
Very low 1 (Briggs et al., 2007) 24
Appraisal/having a confidant Protective factor Suicidality, Suicide MD c: –1.04, 95%CI [–1.68;–0.40]
I² = 0%, p = 0.001
Narrative conclusionb
Very low 3 c,(Harrison et al., 2010; Szanto et al., 2012; Vanyukov et al., 2017) + 1 (Hawton et al., 2002) 62–135
Traumatic event
Talking to others about the traumatic event Risk factor Post-traumatic stress disorder (PTSD) resilience, caseness or symptom severity Narrative conclusionb Very low 3 (De Brier et al., 2021) 85–2627
Communication in general Protective factor PTSD symptom severity or caseness Narrative conclusionb Very low 4 (De Brier et al., 2021) 72–528
Expressive coping Protective factor PTSD (and other posttrauma) symptom severity β: –0.62, p = 0.0002 Very low 1 (De Brier et al., 2021) 119
Social-emotional coping Risk factor PTSD symptom severity r: 0.50, p=0.005 Very low 1 (De Brier et al., 2021) 270
  • a ‘Effective’(statistically significant)/’not effective’(not statistically significant, no imprecision according to GRADE)/’effect not shown’ (not statistically significant, imprecision according to GRADE) in case of experimental studies; ‘protective factor’/’risk factor’/’association not shown’ in case of observational studies. Protective factor: a statistically significant negative association between the factor and the mental health problem was shown (i.e., when the factor increases, the mental health problem decreases); Risk factor: a statistically significant positive association between the factor and the mental health problem was shown (i.e., when the factor increases, the mental health problem increases).

    b Narrative conclusions due to large heterogeneity in study methods and reporting (narrative conclusions are detailed in Supporting Information S3).

    c Studies combined in a meta-analysis; studies that could not be included in the meta-analysis due to heterogeneity were narratively summarized (narrative conclusions are detailed in Supporting Information S3).

    I²: measure of heterogeneity, β: parameter estimate in regression model, r: correlation coefficient, MD: mean difference, CI: confidence interval, OR: odds ratio, GAD2: Generalized Anxiety Disorder Scale-2, MASC: Multidimensional Anxiety Scale for Children, CES-D8: 8-item Centre for Epidemiological Studies Depression Scale, HADS: Hospital Anxiety and Depression Scale, SCOS: Strauss-Carpenter Outcome Scale, DASS: Depression Anxiety Stress Scale.

In summary, across all topics, the body of evidence provides very low to moderate evidence concerning the relationship between communication (characteristics) and mental health outcomes. The evidence showed favorable as well as harmful associations and effects. Talking as a coping strategy, trying to provide positive communication, minimizing negative statements, and finding mutual ground were examples of potential helpful protective factors, while risk factors included avoiding communication, expressing criticism, losing your calm, and escalation.

Translation of the Evidence to Guidance Materials

In total, 33 unique actions on how to provide communicative first aid to people experiencing mental health problems were formulated (Table 4). These first aid actions were based on the best available evidence, and on the input from other sources, as well as content experts and mental health peer workers in training (GPPs), as described in more detail in the Methods section. The actions were integrated into a manual (“Luister! Eerste hulp bij psychische problemen” (Belgian Red Cross-Flanders, 2019a), in Dutch), and later into a mobile application (“Houvast” (Belgian Red Cross-Flanders, 2020), in Dutch), in which each mental health topic was accompanied by relevant background information (e.g., definition, prevalence, risk factors, …).

Table 4

Recommendations included within the evidence-based manual on how to help people experiencing mental health problems.

RECOMMENDATION OVERARCHING ADVICE ADDICTION AGGRESSION ANXIETY BURNOUT DEPRESSION EATING DISORDER GRIEF FOLLOWING BEREAVEMENT PSYCHOSIS NON-SUICIDAL SELF-INJURY STRESS COMPLAINTS SUICIDALITY TRAUMATIC EVENT
Engage into conversation EB GPP EB EB EB GPP GPP EB GPP GPP EB GPP EB
Provide time and space to talk EB GPP EB GPP EB GPP GPP GPP GPP GPP GPP GPP
Stay calm EB GPP EB GPP GPP EB EB GPP GPP GPP GPP
Say that you are worried GPP GPP GPP GPP GPP EB GPP GPP GPP GPP GPP GPP
Listen without judging EB EB EB EB EB EB EB EB GPP EB EB EB EB
Be conscious of your body language GPP GPP GPP GPP GPP GPP GPP GPP GPP GPP GPP GPP GPP
Offer support and show compassion EB GPP GPP EB GPP EB EB EB EB GPP GPP EB EB
Respect privacy, but do not promise confidentiality GPP GPP GPP GPP GPP GPP GPP GPP GPP
Limit advice, but look for solutions together EB GPP EB GPP GPP EB GPP GPP GPP GPP GPP
Offer (limited) practical help GPP GPP GPP GPP GPP
Encourage them to talk about their issues with people who are close to them EB EB EB EB GPP EB EB GPP EB EB GPP GPP
If the person does not wish to talk, respect this GPP GPP GPP GPP GPP GPP GPP GPP GPP GPP GPP GPP
Stay in touch EB GPP GPP EB EB GPP EB GPP GPP GPP EB EB
Maintain your role as a family member, friend, colleague, … GPP GPP GPP GPP GPP GPP GPP GPP GPP GPP GPP GPP
Be alert for suicidal thoughts GPP GPP GPP GPP
Avoid criticism or accusations GPP EB
Do not support the maintenance of the behavior GPP GPP
Estimate whether the person is willing to change their behavior GPP GPP
Do not argue about what is real or not EB
Acknowledge the ideas and experiences, but do not confirm them GPP
Talk clearly GPP EB GPP
Be honest GPP GPP
Encourage a healthy lifestyle GPP
Ensure the safety of yourself, the person, and others GPP GPP GPP
Do not talk excessively about food, weight and appearances GPP
Estimate the seriousness GPP
Do not focus on the wounds or how they were caused GPP
Do not force the person to stop self-injury GPP
Together with the person, try to come up with different ways to deal with negative emotions and encourage them GPP
Keep a safe distance GPP
Get help from others GPP
Take an open posture GPP
Provide a calm and peaceful environment GPP
  • GPP: Good Practice Point; EB: Evidence-based.

Based on both scientific evidence and expert input, 14 actions seemed applicable to multiple mental health topics and were combined as overarching advice. Eighteen additional actions were restricted to one or few mental health topics and were either very specific (e.g., “Do not talk excessively about food, weight or appearance” for the topic ‘eating disorders’) or considered to require specific emphasis and/or guidance (e.g., “Estimate the seriousness” for the topic ‘suicidality’). All quoted first aid actions (Table 4) are core messages that are further clarified in the manual and contextualized to the specific topic where appropriate.

Below, we describe some examples to illustrate the complementary role of the evidence identified and the clinical expertise and practical experience of experts in the field.

The best available evidence was not always able to inform clear-cut interventions, as interventions or factors extracted from the studies were sometimes ambiguous concepts or contained multiple components, while good guidance ideally consists of clear and single actions. For example, there was moderate certainty evidence in support of “listening visits” as an effective layman intervention in the context of depression (Table 3; (Kentish-Barnes et al., 2017; Kim & Lee, 2009; Nagel et al., 1988)). This intervention consisted of repeated visits focusing on empathic listening and collaborative problem-solving. Hence, this evidence – among other sources – contributed to the first aid actions “Provide time and space to talk,” “Listen without judging,” “Offer support and show compassion,” “Limit advice but look for solutions together,” and “Stay in touch.”

The expert panel critically revised the draft manual and was responsible for formulating additional GPPs. For example, for the advice “Encourage them to talk about their issues with people who are close to them,” the expert panel agreed to clarify that this action is recommended at the end of a conversation after the first aid provider has offered a listening ear. An example of a GPP formulated by the expert panel is “Maintain your role as a family member, friend, colleague, ….” The expert panel reached a consensus to recommend that first aid providers keep communicating from their natural role, staying in contact with everyday life, and taking sufficient time to talk about other subjects. This advice was considered broadly applicable to different mental health problems.

Discussion

This project aimed to develop guidance materials for Flanders, Belgium, with specific advice for laypeople on providing first aid to people experiencing mental health problems, based on the best available evidence and input from experts and relevant stakeholders. In a systematic literature search, we identified 90 individual studies that evaluated different types of communication, either as a concrete intervention (in experimental studies) or as exposure or risk factor (in observational studies), for 12 mental health topics (Table 3). These studies predominantly informed to recommend providing the opportunity to talk, listening to the person’s concerns, and offering empathic support as actions to help people experiencing mental health problems. Based on the scientific evidence and additional GPPs, a draft first aid manual was written and presented to a multidisciplinary expert panel involving both content experts and people with lived experience. In total, 33 unique first aid actions were integrated into the manual (Table 4), embedded in a dynamic framework including four key components: recognizing mental health problems, providing informal support, guiding towards more help, and taking care of themselves while helping others. Guidance is provided in the context of daily life as well as crisis support. The manual is currently available for purchase (as standalone guidance), and training based on the manual was implemented by the Belgian Red Cross (Belgian Red Cross-Flanders, 2019b). A mobile application based on the content of the training manual was launched in November 2020 and is freely available for download (App “Houvast”, available via the App stores, content in Dutch). Our evidence summaries and guidance were also used as a scientific foundation for the “mental distress” section of the IFRC “International first aid, resuscitation, and education guidelines 2020” (International Federation of Red Cross and Red Crescent Societies, 2020). This project has several strengths. First of all, we systematically searched several scientific databases to collect the best available evidence, and study quality was thoroughly examined using the GRADE methodology. In addition, content experts and mental health peer workers with lived experience had a complementary role within the expert panel and ensured that the manual was adapted to the Flemish context and meaningful for practice. Finally, based on the extensive experience of the Belgian Red Cross with the organization of (physical) first aid training, these new materials were immediately implemented. The training was piloted internally with Red Cross volunteers and externally with members of the general public in the closing months of 2019. Training is currently organized as four 3-hour sessions and can be followed free of cost by people from the general public (Belgian Red Cross-Flanders, 2019b). The mobile application, which can be downloaded for free, was launched as a low-threshold initiative against the Covid-19 context at the end of 2020 and was further disseminated and promoted in 2021 (Belgian Red Cross-Flanders, 2020). At present, the number of downloads is approaching 20,000.

There are limitations to consider as well. First, the systematic literature searches we performed are not full systematic reviews: no protocols were registered beforehand, only one reviewer conducted the study selection and data extraction (however, a second reviewer was consulted in case of uncertainties), and a focused set of selection criteria was used. This methodology is being used by many practice guideline developers because of feasibility reasons, given that developing a guideline requires many different evidence reviews in parallel (De Buck et al., 2014). However, as part of the guideline methodology, this is always done in combination with consulting a multidisciplinary expert panel, which was also the case in the current project.

Second, the available scientific evidence is currently limited, both in quantity and quality. For six mental health topics in particular, the scientific evidence was based on five studies or less. In addition, the certainty of the evidence was generally considered to be very low, and causal relationships could not be inferred due to the frequent use of cross-sectional study designs. By design, cross-sectional studies cannot prove the temporality of association since the relevant exposures and outcomes are collected simultaneously. As a consequence, we had to rely more heavily on expert opinion and practice experience, and many additional GPPs had to be formulated with the help of the expert panel to inform the guidance materials. Although several efforts were made to compose a representative expert panel and to limit the impact of the bandwagon effect (the tendency of an individual to acquire a particular opinion because everyone else has this opinion) or social desirability bias during the expert meetings, a formal consensus method, as used in several existing mental health first aid guideline projects (Jorm & Ross, 2018), was not used. When planning the update of the current materials (which is done every 5 years), our methods could be further improved by focusing more elaborately on expert input and exploring possibilities of formal consensus methods, such as the Delphi method, the nominal group technique, the RAND/UCLA method, or a consensus conference, all methods for obtaining expert consensus when developing guidelines in the health field (Black et al., 1999; Fitch et al., 2001; Hasson et al., 2000; Murphy et al., 1998). With the Delphi method, participants never meet or interact directly, but can provide their input through different rounds of questionnaires. This rigorous methodology to obtain expert consensus has been used widely in the field of mental health research when evidence is not available, incomplete, not directly applicable, or too complex, particularly in the topic of mental health first aid (Jorm, 2015; Jorm & Ross, 2018). Third, the guidelines were developed to be implemented in a Flemish, or more generally, a Western context and might be less applicable in other countries or cultures. However, we gathered evidence without geographical limitations and key first aid actions could be largely transferrable beyond Flanders (International Federation of Red Cross and Red Crescent Societies, 2020).

Our systematic literature search identified several research gaps in communicative actions that are feasible for laypeople to help others experiencing mental health problems. More specifically, high-quality, experimental research on the identification of communicative actions is currently lacking. In addition, it would be valuable to know whether training laypeople in communicative actions effectively improve the mental health outcomes of people receiving help. In this regard, several studies have already shown that training laypeople in psychosocial support resulted in an increase of general mental health and first aid knowledge (Burns et al., 2017; Jensen et al., 2016; Jorm, Kitchener, Sawyer, et al., 2010; Kidger et al., 2016; Svensson & Hansson, 2014), improved recognition of mental disorders (Burns et al., 2017; Jensen et al., 2016; Jorm, Kitchener, Fischer, et al., 2010; Jorm et al., 2004; Jorm, Kitchener, Sawyer, et al., 2010; Kitchener & Jorm, 2004; O’Reilly et al., 2011; Wong et al., 2015), and increased confidence in and intention of helping (Burns et al., 2017; Davies et al., 2018; Jensen et al., 2016; Jorm, Kitchener, Fischer, et al., 2010; Jorm et al., 2004; Jorm, Kitchener, Sawyer, et al., 2010; Kidger et al., 2016; Mohatt et al., 2017; Morgan et al., 2018; Svensson & Hansson, 2014), improved people’s attitudes towards mental disorders (Kidger et al., 2016), and was associated with a reduction of stigma (Burns et al., 2017; Davies et al., 2018; Jensen et al., 2016; Jorm, Kitchener, Fischer, et al., 2010; Jorm et al., 2004; Mohatt et al., 2017; Svensson & Hansson, 2014). Although existing results on the effectiveness of mental health literacy training are thus promising, they largely focused on short-term results and it is difficult to assess the impact of such training on the actual mental health outcomes of people receiving help, in essence, the real targets of such programs (Mei & McGorry, 2020). A recent systematic review found insufficient evidence that Mental Health First Aid improves the helping behaviors of trainees or the mental health of aid recipients (Forthal et al., 2022). Therefore, a long-term, controlled study on the effectiveness of training with our materials could provide useful insights into the impact of our work in Flanders.

In conclusion, a guidance manual on how to provide communicative first aid to people experiencing mental health problems was developed based on the best available evidence and the input of a multidisciplinary expert panel. Training based on the manual is currently implemented by the Belgian Red Cross, and a mobile application based on the content of the manual is currently freely available for download.

Additional Files

The additional files for this article can be found as follows:

S1

PRISMA checklist. DOI: https://doi.org/10.25894/ijfae.6.1.8.s1

S2

Search strategy for systematic literature search. DOI: https://doi.org/10.25894/ijfae.6.1.8.s2

S3

Evidence summaries per mental health topic. DOI: https://doi.org/10.25894/ijfae.6.1.8.s3

S4

Narrative description of evidence conclusions. DOI: https://doi.org/10.25894/ijfae.6.1.8.s4

Abbreviations

Centre for Evidence-Based Practice (CEBaP)

Confidence Interval (CI)

Disability Adjusted Life Years (DALYs)

Good Practice Point (GPP)

Grading of Recommendations Assessment, Development and Evaluation (GRADE)

Mean Difference (MD)

Odds Ratio (OR)

Population, Intervention, Comparison, Outcome (PICO)

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)

Post-Traumatic Stress Disorder (PTSD)

Randomized Controlled Trial (RCT)

Risk Ratio (RR)

Standardized Mean Difference (SMD)

Acknowledgements

This project is a collaboration between the Belgian Red Cross-Flanders and Zorgnet-Icuro, the Flemish Federation of healthcare organizations. We would like to acknowledge Bert Avau, Jorien Laermans, Anne-Catherine Vanhove, and Hans Van Remoortel for help with the title and abstract screening and Natalie Schroyens for critically reviewing the manuscript and providing valuable comments (CEBaP, Belgian Red Cross). We would like to thank Gorik Kaesemans who coordinated the project at the side of Zorgnet-Icuro and who helped compose the expert panel. We would also like to thank the members of the multidisciplinary expert panel who did not co-author this paper, but have made invaluable contributions to this project by providing their expert insights and opinions: Dr. Livia Anquinet (Suïcidepreventiewerking van de Centra voor Geestelijke Gezondheidszorg), Stéphanie Arnhem (Flemish Suicide Prevention Centre), Prof. dr. Laurence Claes (Faculty of Psychology and Educational Sciences, KU Leuven & Collaborative Antwerp Psychiatric Research Institute, Faculty of Medicine and Health Sciences, University of Antwerp), Marlien De Coen (Steunpunt Geestelijke Gezondheid), Prof. dr. Alexis Dewaele (Faculty of Psychology and Educational Sciences, Ghent University), Prof. dr. Filip Raes (Faculty of Psychology and Educational Sciences, KU Leuven), Prof. dr. Maarten Van Den Bossche (University Psychiatric Centre, KU Leuven), Prof. dr. Kris Van den Broeck (Flemish Society for Psychiatry & Faculty of Medicine and Health Sciences, University of Antwerp), Paul Van Deun (VAD Vereniging voor Alcohol- en andere Drugproblemen), and Prof. dr. Elke Van Hoof (Faculty of Psychology and Educational Sciences, Vrije Universiteit Brussel). Elly Bergen, Reginald Buyle, Monique Claassens, Mathijs Van de Staey, Britt Geerts and Lindsay Hacke were all mental health peer workers in training who took part in the expert panel under the coordination of Grace Verween (UCLL graduaats- en volwassenenonderwijs campus Sociale School Heverlee).

Funding information

This work was supported by the Flemish Ministry of Welfare, Public Health and Family and the Foundation for Scientific Research of the Belgian Red Cross. The funding body did not influence the content of the training manual.

Competing Interests

The activities of the Belgian Red Cross include the provision of psychosocial first aid to laypeople.

Publisher’s Note

This article was originally published displaying the submission date as 23 February 2023 and the acceptance date as 06 March 2023. This metadata was incorrect due to the article being added to the OJS3 system after a migration to a new publisher when it had already been through the review process. As of 05 October 2023, the data has been corrected to display the correct submission and acceptance dates.

References

1 Arcelus, J., Haslam, M., Farrow, C., & Meyer, C. (2013). The role of interpersonal functioning in the maintenance of eating psychopathology: a systematic review and testable model. Clin Psychol Rev, 33(1), 156–167. DOI:  http://doi.org/10.1016/j.cpr.2012.10.009

2 Batey, H., May, J., & Andrade, J. (2010). Negative intrusive thoughts and dissociation as risk factors for self-harm. Suicide Life Threat Behav, 40(1), 35–49. DOI:  http://doi.org/10.1521/suli.2010.40.1.35

3 Belgian Red Cross-Flanders. (2019a). Luister! Eerste hulp bij psychische problemen [Listen! First aid for mental health problems]. Belgian Red Cross-Flanders.

4 Belgian Red-Cross Flanders. (2019b). Opleiding ‘Eerste hulp bij psychische problemen’. https://www.rodekruis.be/wat-kan-jij-doen/volg-een-opleiding/eerste-hulp-bij-psychische-problemen/

5 Belgian Red-Cross Flanders. (2020). Houvast (Version 1.3.21) [Mobile app]. https://play.google.com/store/apps/details?id=be.rodekruis.houvast&hl=nl&gl=US https://apps.apple.com/us/app/houvast/id1533784893

6 Billingham, R. E., & Sack, A. R. (1986). Courtship violence and the interactive status of the relationship. Journal of Adolescent Research, 1(3), 315–325. DOI:  http://doi.org/10.1177/074355488613006

7 Black, N., Murphy, M., Lamping, D., McKee, M., Sanderson, C., Askham, J., & Marteau, T. (1999). Consensus development methods: a review of best practice in creating clinical guidelines. J Health Serv Res Policy, 4(4), 236–248. DOI:  http://doi.org/10.1177/135581969900400410

8 Borders, T. F., Curran, G. M., Mattox, R., & Booth, B. M. (2010). Religiousness among at-risk drinkers: is it prospectively associated with the development or maintenance of an alcohol-use disorder? J Stud Alcohol Drugs, 71(1), 136–142. DOI:  http://doi.org/10.15288/jsad.2010.71.136

9 Briggs, S., Webb, L., Buhagiar, J., & Braun, G. (2007). Maytree: A respite center for the suicidal: an evaluation. Crisis, 28(3), 140–147. DOI:  http://doi.org/10.1027/0227-5910.28.3.140

10 Brock, R. L., O’Hara, M. W., & Segre, L. S. (2017). Depression Treatment by Non-Mental-Health Providers: Incremental Evidence for the Effectiveness of Listening Visits. Am J Community Psychol, 59(1–2), 172–183. DOI:  http://doi.org/10.1002/ajcp.12129

11 Bryan, A. E., & Arkowitz, H. (2015). Meta-analysis of the effects of peer-administered psychosocial interventions on symptoms of depression. Am J Community Psychol, 55(3–4), 455–471. DOI:  http://doi.org/10.1007/s10464-015-9718-y

12 Brymer, M., Taylor, M., Escudero, P., Jacobs, A., Kronenberg, M., Macy, R., … Vogel, J. (2012). Psychological first aid for schools: Field operations guide (2nd ed). Los Angeles: National Child Traumatic Stress Network.

13 Burns, S., Crawford, G., Hallett, J., Hunt, K., Chih, H. J., & Tilley, P. J. (2017). What’s wrong with John? a randomised controlled trial of Mental Health First Aid (MHFA) training with nursing students. BMC Psychiatry, 17(1), 111. DOI:  http://doi.org/10.1186/s12888-017-1278-2

14 Carter, G. L., Clover, K., Whyte, I. M., Dawson, A. H., & D’Este, C. (2013). Postcards from the EDge: 5-year outcomes of a randomised controlled trial for hospital-treated self-poisoning. Br J Psychiatry, 202(5), 372–380. DOI:  http://doi.org/10.1192/bjp.bp.112.112664

15 Centre, T. N. C. (2014). Review Manager (RevMan). In (Version Version 5.3) The Cochrane collaboration.

16 Cornelius, T. L., Shorey, R. C., & Beebe, S. M. (2010). Self-reported communication variables and dating violence: Using Gottman’s Marital Communication Conceptialization. J Fam Viol, 25, 439–448. DOI:  http://doi.org/10.1007/s10896-010-9305-9

17 Cunha, A. I., Relvas, A. P., & Soares, I. (2009). Anorexia nervosa and family relationships: Perceived family functioning, coping strategies, beliefs, and attachment to parents and peers. International Journal of Clinical and Health Psychology, 9(2), 229–240.

18 Davies, E. B., Beever, E., & Glazebrook, C. (2018). A pilot randomised controlled study of the mental health first aid eLearning course with UK medical students. BMC Med Educ, 18(1), 45. DOI:  http://doi.org/10.1186/s12909-018-1154-x

19 Davis, E. L., Deane, F. P., & Lyons, G. C. (2016). Prediction of individual differences in adjustment to loss: Acceptance and valued-living as critical appraisal and coping strengths. Death Stud, 40(4), 211–222. DOI:  http://doi.org/10.1080/07481187.2015.1122677

20 De Brier, N., Borra, V., Dockx, K., Scheers, H., Stroobants, S., De Buck, E., … Vandekerckhove, P. (2021). Best Available Evidence on Communicative First Aid Interventions by Laypeople for Preventing and Relieving Posttraumatic Stress Disorder-Related Symptomatology Following Traumatic Events. J Trauma Stress, 34(3), 538–550. DOI:  http://doi.org/10.1002/jts.22625

21 De Brier, N., Stroobants, S., Vandekerckhove, P., & De Buck, E. (2020). Factors affecting mental health of health care workers during coronavirus disease outbreaks (SARS, MERS & COVID-19): A rapid systematic review. PLoS One, 15(12), 1–19. DOI:  http://doi.org/10.1371/journal.pone.0244052

22 De Buck, E., Pauwels, N. S., Dieltjens, T., & Vandekerckhove, P. (2014). Use of evidence-based practice in an aid organisation: a proposal to deal with the variety in terminology and methodology. Int J Evid Based Healthc, 12(1), 39–49. DOI:  http://doi.org/10.1097/01.XEB.0000444637.88465.a3

23 Dennis, C. L., Hodnett, E., Kenton, L., Weston, J., Zupancic, J., Stewart, D. E., & Kiss, A. (2009). Effect of peer support on prevention of postnatal depression among high risk women: multisite randomised controlled trial. BMJ, 338, a3064. DOI:  http://doi.org/10.1136/bmj.a3064

24 Di Paola, F., Faravelli, C., & Ricca, V. (2010). Perceived expressed emotion in anorexia nervosa, bulimia nervosa, and binge-eating disorder. Compr Psychiatry, 51(4), 401–405. DOI:  http://doi.org/10.1016/j.comppsych.2009.10.002

25 Dyregrov, A., Kristoffersen, J. I., Matthiesen, S. B., & Mitchell, J. T. (1994). Gender differences in adolescents’ reactions to the murder of their teacher. Journal of Adolescent Research, 9(3), 363–383. DOI:  http://doi.org/10.1177/074355489493005

26 Edwards, B., & Clarke, V. (2004). The psychological impact of a cancer diagnosis on families: the influence of family functioning and patients’ illness characteristics on depression and anxiety. Psychooncology, 13(8), 562–576. DOI:  http://doi.org/10.1002/pon.773

27 Emanualli, F., Ostuzzi, R., Cuzzolaro, M., Baggio, F., Lask, B., & Waller, G. (2004). Family functioning in adolescent anorexia nervosa: a comparison of family members’ perceptions. Eating Weight Disord, 9, 1–6. DOI:  http://doi.org/10.1007/BF03325038

28 Evans, E., Hawton, K., & Rodham, K. (2005). In what ways are adolescents who engage in self-harm or experience thoughts of self-harm different in terms of help-seeking, communication and coping strategies? J Adolesc, 28(4), 573–587. DOI:  http://doi.org/10.1016/j.adolescence.2004.11.001

29 Fazel, M., Reed, R. V., Panter-Brick, C., & Stein, A. (2012). Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet, 379(9812), 266–282. DOI:  http://doi.org/10.1016/S0140-6736(11)60051-2

30 Fisher, H. H., Eke, A. N., Cance, J. D., Hawkins, S. R., & Lam, W. K. (2008). Correlates of HIV-related risk behaviors in African American adolescents from substance-using families: patterns of adolescent-level factors associated with sexual experience and substance use. J Adolesc Health, 42(2), 161–169. DOI:  http://doi.org/10.1016/j.jadohealth.2007.08.006

31 Fitch, K., Bernstein, S. J., Aguilar, M. D., Burnand, B., LaCalle, J. R., Lazaro, P., … Kahan, J. P. (2001). The RAND/UCLA Appropriateness Method User’s Manual. RAND. https://www.rand.org/pubs/monograph_reports/MR1269.html

32 Fite, P. J., Rubens, S. L., Preddy, T. M., Raine, A., & Pardini, D. A. (2014). Reactive/Proactive aggression and the development of internalizing problems in males: the moderating effect of parent and peer relationships. Aggressive Behavior, 40, 69–78. DOI:  http://doi.org/10.1002/ab.21498

33 Forthal, S., Sadowska, K., Pike, K. M., Balachander, M., Jacobsson, K., & Hermosilla, S. (2022). Mental Health First Aid: A Systematic Review of Trainee Behavior and Recipient Mental Health Outcomes. Psychiatr Serv, 73(4), 439–446. DOI:  http://doi.org/10.1176/appi.ps.202100027

34 Friedmann, M. S., McDermut, W. H., Solomon, D. A., Ryan, C. E., Keitner, G. I., & Miller, I. W. (1997). Family functioning and mental illness: a comparison of psychiatric and nonclinical families. Fam Process, 36(4), 357–367. DOI:  http://doi.org/10.1111/j.1545-5300.1997.00357.x

35 Garfinkel, P. E., Garner, D. M., Rose, J., Darby, P. L., Brandes, J. S., O’Hanlon, J., & Walsh, N. (1983). A comparison of characteristics in the families of patients with anorexia nervosa and normal controls. Psychol Med, 13(4), 821–828. https://www.ncbi.nlm.nih.gov/pubmed/6665098. DOI:  http://doi.org/10.1017/S0033291700051539

36 Garrouste-Orgeas, M., Max, A., Lerin, T., Gregoire, C., Ruckly, S., Kloeckner, M., … Misset, B. (2016). Impact of Proactive Nurse Participation in ICU Family Conferences: A Mixed-Method Study. Crit Care Med, 44(6), 1116–1128. DOI:  http://doi.org/10.1097/CCM.0000000000001632

37 GBD 2019 Diseases and Injuries Collaborators. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet, 396(10258), 1204–1222. DOI:  http://doi.org/10.1016/S0140-6736(20)30925-9

38 GBD 2019 Mental Disorders Collaborators. (2022). Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry, 9(2), 137–150. DOI:  http://doi.org/10.1016/S2215-0366(21)00395-3

39 Goldstein, M. J. (1985). Family factors that antedate the onset of schizophrenia and related disorders: the results of a fifteen year prospective longitudinal study. Acta Psychiatr Scand Suppl, 319, 7–18. https://www.ncbi.nlm.nih.gov/pubmed/3863461. DOI:  http://doi.org/10.1111/j.1600-0447.1985.tb08520.x

40 Goussinsky, R., Michael, K., & Yassour-Borochowitz, D. (2017). Relationship Dynamics and Intimate Partner Violence Among Israeli College Students: The Moderating Effect of Communication Problems. J Interpers Violence, 886260517724833. DOI:  http://doi.org/10.1177/0886260517724833

41 Gowers, S., & North, C. (1999). Difficulties in family functioning and adolescent anorexia nervosa. Br J Psychiatry, 174, 63–66. DOI:  http://doi.org/10.1192/bjp.174.1.63

42 Gupta, S., Paterson, M. L., Lysaght, R. M., & von Zweck, C. M. (2012). Experiences of burnout and coping strategies utilized by occupational therapists. Can J Occup Ther, 79(2), 86–95. DOI:  http://doi.org/10.2182/cjot.2012.79.2.4

43 Hallett, N., & Dickens, G. L. (2017). De-escalation of aggressive behaviour in healthcare settings: Concept analysis. Int J Nurs Stud, 75, 10–20. DOI:  http://doi.org/10.1016/j.ijnurstu.2017.07.003

44 Hamilton, E. B., Asarnow, J. R., & Tompson, M. C. (1999). Family interaction styles of children with depressive disorders, schizophrenia-spectrum disorders, and normal controls. Fam Process, 38(4), 463–476. https://www.ncbi.nlm.nih.gov/pubmed/10668623. DOI:  http://doi.org/10.1111/j.1545-5300.1999.00463.x

45 Harrison, K. E., Dombrovski, A. Y., Morse, J. Q., Houck, P., Schlernitzauer, M., Reynolds, C. F., 3rd, & Szanto, K. (2010). Alone? Perceived social support and chronic interpersonal difficulties in suicidal elders. Int Psychogeriatr, 22(3), 445–454. DOI:  http://doi.org/10.1017/S1041610209991463

46 Harvey, S., Snowdon, C., & Elbourne, D. (2008). Effectiveness of bereavement interventions in neonatal intensive care: a review of the evidence. Semin Fetal Neonatal Med, 13(5), 341–356. DOI:  http://doi.org/10.1016/j.siny.2008.03.011

47 Hassanian-Moghaddam, H., Sarjami, S., Kolahi, A. A., Lewin, T., & Carter, G. (2017). Postcards in Persia: A Twelve to Twenty-four Month Follow-up of a Randomized Controlled Trial for Hospital-Treated Deliberate Self-Poisoning. Arch Suicide Res, 21(1), 138–154. DOI:  http://doi.org/10.1080/13811118.2015.1004473

48 Hasson, F., Keeney, S., & McKenna, H. (2000). Research guidelines for the Delphi survey technique. J Adv Nurs, 32(4), 1008–1015. DOI:  http://doi.org/10.1046/j.1365-2648.2000.t01-1-01567.x

49 Haun, M. W., Sklenarova, H., Brechtel, A., Herzog, W., & Hartmann, M. (2014). Distress in cancer patients and their caregivers and association with the caregivers’ perception of dyadic communication. Oncol Res Treat, 37(7–8), 384–388. DOI:  http://doi.org/10.1159/000364885

50 Hawton, K., Simkin, S., Rue, J., Haw, C., Barbour, F., Clements, A., … Deeks, J. (2002). Suicide in female nurses in England and Wales. Psychol Med, 32(2), 239–250. https://www.ncbi.nlm.nih.gov/pubmed/11866319. DOI:  http://doi.org/10.1017/S0033291701005165

51 Hodgson, C., Higginson, I., McDonnell, M., & Butters, E. (1997). Family anxiety in advanced cancer: a multicenter prospective study in Ireland. British Journal of Cancer, 76(9), 1211–1214. DOI:  http://doi.org/10.1038/bjc.1997.535

52 Hoffmann, R., Kaiser, J., & Kersting, A. (2018). Psychosocial outcomes in cancer-bereaved children and adolescents: A systematic review. Psychooncology, 27(10), 2327–2338. DOI:  http://doi.org/10.1002/pon.4863

53 Holt-Lunstad, J., Smith, T. B., & Layton, J. B. (2010). Social relationships and mortality risk: a meta-analytic review. PLoS Med, 7(7), e1000316. DOI:  http://doi.org/10.1371/journal.pmed.1000316

54 Holtom-Viesel, A., & Allan, S. (2014). A systematic review of the literature on family functioning across all eating disorder diagnoses in comparison to control families. Clin Psychol Rev, 34(1), 29–43. DOI:  http://doi.org/10.1016/j.cpr.2013.10.005

55 Howell, K. H., Barrett-Becker, E. P., Burnside, A. N., Wamser-Nanney, R., Layne, C. M., & Kaplow, J. B. (2015). Children facing parental cancer versus parental death: The buffering effects of positive parenting and emotional expression. J Child Fam Stud, 25, 152–164. https://psycnet.apa.org/doi/10.1007/s10826-015-0198-3. DOI:  http://doi.org/10.1007/s10826-015-0198-3

56 IFRC Reference Centre for Psychosocial Support. (2018). A guide to Psychological First Aid for Red Cross and Red Crescent Societies. Copenhagen: IFRC Reference Centre for Psychosocial Support. https://pscentre.org/?resource=a-guide-to-psychological-first-aid-for-red-cross-red-crescent-societies&selected=single-resource

57 International Federation of Red Cross and Red Crescent Societies. (2020). International first aid, resuscitation, and education guidelines 2020. Geneva: International Federation of Red Cross and Red Crescent Societies. https://www.globalfirstaidcentre.org/first-aid-guidelines-2020/

58 Jensen, K. B., Morthorst, B. R., Vendsborg, P. B., Hjorthoj, C., & Nordentoft, M. (2016). Effectiveness of Mental Health First Aid training in Denmark: a randomized trial in waitlist design. Soc Psychiatry Psychiatr Epidemiol, 51(4), 597–606. DOI:  http://doi.org/10.1007/s00127-016-1176-9

59 Jeong, A., Shin, D. W., Kim, S. Y., Yang, H. K., & Park, J.-H. (2016). Avoidance of cancer communication, perceived social support, and anxiety and depression among patients with cancer. Psycho-oncology, 25, 1301–1307. DOI:  http://doi.org/10.1002/pon.4060

60 Jorm, A. F. (2012). Mental health literacy: empowering the community to take action for better mental health. Am Psychol, 67(3), 231–243. DOI:  http://doi.org/10.1037/a0025957

61 Jorm, A. F. (2015). Using the Delphi expert consensus method in mental health research. Aust N Z J Psychiatry, 49(10), 887–897. DOI:  http://doi.org/10.1177/0004867415600891

62 Jorm, A. F., Kitchener, B. A., Fischer, J. A., & Cvetkovski, S. (2010). Mental health first aid training by e-learning: a randomized controlled trial. Aust N Z J Psychiatry, 44(12), 1072–1081. DOI:  http://doi.org/10.3109/00048674.2010.516426

63 Jorm, A. F., Kitchener, B. A., O’Kearney, R., & Dear, K. B. (2004). Mental health first aid training of the public in a rural area: a cluster randomized trial [ISRCTN53887541]. BMC Psychiatry, 4, 33. DOI:  http://doi.org/10.1186/1471-244X-4-33

64 Jorm, A. F., Kitchener, B. A., Sawyer, M. G., Scales, H., & Cvetkovski, S. (2010). Mental health first aid training for high school teachers: a cluster randomized trial. BMC Psychiatry, 10, 51. DOI:  http://doi.org/10.1186/1471-244X-10-51

65 Jorm, A. F., & Ross, A. M. (2018). Guidelines for the public on how to provide mental health first aid: narrative review. BJPsych Open, 4(6), 427–440. DOI:  http://doi.org/10.1192/bjo.2018.58

66 Kamm, S., & Vandenberg, B. (2001). Grief communication, grief reactions and marital satisfaction in bereaved parents. Death Stud, 25(7), 569–582. DOI:  http://doi.org/10.1080/07481180126576

67 Kentish-Barnes, N., Chevret, S., Champigneulle, B., Thirion, M., Souppart, V., Gilbert, M., … Famirea Study, G. (2017). Effect of a condolence letter on grief symptoms among relatives of patients who died in the ICU: a randomized clinical trial. Intensive Care Med, 43(4), 473–484. DOI:  http://doi.org/10.1007/s00134-016-4669-9

68 Kidger, J., Stone, T., Tilling, K., Brockman, R., Campbell, R., Ford, T., … Gunnell, D. (2016). A pilot cluster randomised controlled trial of a support and training intervention to improve the mental health of secondary school teachers and students – the WISE (Wellbeing in Secondary Education) study. BMC Public Health, 16(1), 1060. DOI:  http://doi.org/10.1186/s12889-016-3737-y

69 Kim, H., & Lee, S. Y. (2009). Supervisory communication, burnout, and turnover intention among social workers in health care settings. Soc Work Health Care, 48(4), 364–385. DOI:  http://doi.org/10.1080/00981380802598499

70 Kitchener, B. A., & Jorm, A. F. (2002). Mental health first aid training for the public: evaluation of effects on knowledge, attitudes and helping behavior. BMC Psychiatry, 2, 10. DOI:  http://doi.org/10.1186/1471-244X-2-10

71 Kitchener, B. A., & Jorm, A. F. (2004). Mental health first aid training in a workplace setting: a randomized controlled trial [ISRCTN13249129]. BMC Psychiatry, 4, 23. DOI:  http://doi.org/10.1186/1471-244X-4-23

72 Laghi, F., Pompili, S., Zanna, V., Castiglioni, M. C., Criscuolo, M., Chianello, I., … Baiocco, R. (2017). How adolescents with anorexia nervosa and their parents perceive family functioning? J Health Psychol, 22(2), 197–207. DOI:  http://doi.org/10.1177/1359105315597055

73 Latina, D., Giannotta, F., & Rabaglietti, E. (2015). Do friends’ co-rumination and communication with parents prevent depressed adolescents from self-harm? Journal of Applied Developmental Psychology, 41, 120–128. DOI:  http://doi.org/10.1016/j.appdev.2015.10.001

74 Lautrette, A., Darmon, M., Megarbane, B., Joly, L. M., Chevret, S., Adrie, C., … Azoulay, E. (2007). A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med, 356(5), 469–478. DOI:  http://doi.org/10.1056/NEJMoa063446

75 Lemaire, J. B., & Wallace, J. E. (2010). Not all coping strategies are created equal: a mixed methods study exploring physicians’ self reported coping strategies. BMC Health Serv Res, 10, 208. DOI:  http://doi.org/10.1186/1472-6963-10-208

76 Leonidas, C., & Dos Santos, M. A. (2014). Social support networks and eating disorders: an integrative review of the literature. Neuropsychiatr Dis Treat, 10, 915–927. DOI:  http://doi.org/10.2147/NDT.S60735

77 Liang, M., Chen, Q., Guo, J., Mei, Z., Wang, J., Zhang, Y., … Li, Y. (2021). Mental health first aid improves mental health literacy among college students: A meta-analysis. J Am Coll Health, 1–10. DOI:  http://doi.org/10.1080/07448481.2021.1925286

78 Liew, C. H., & Servaty-Seib, H. M. (2018). College student grief, grief differences, family communication, and family satisfaction. Death Stud, 42(4), 228–238. DOI:  http://doi.org/10.1080/07481187.2017.1334014

79 Lovgren, M., Sveen, J., Nyberg, T., Eilegard Wallin, A., Prigerson, H. G., Steineck, G., & Kreicbergs, U. (2018). Care at End of Life Influences Grief: A Nationwide Long-Term Follow-Up among Young Adults Who Lost a Brother or Sister to Childhood Cancer. J Palliat Med, 21(2), 156–162. DOI:  http://doi.org/10.1089/jpm.2017.0029

80 Macdonald, G., Livingstone, N., Hanratty, J., McCartan, C., Cotmore, R., Cary, M., … Churchill, R. (2016). The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis. Health Technol Assess, 20(69), 1–508. DOI:  http://doi.org/10.3310/hta20690

81 Mei, C., & McGorry, P. D. (2020). Mental health first aid: strengthening its impact for aid recipients. Evid Based Ment Health, 23(4), 133–134. DOI:  http://doi.org/10.1136/ebmental-2020-300154

82 Messinger, A. M., Rickert, V. I., Fry, D. A., Lessel, H., & Davidson, L. L. (2012). Revisiting the role of communication in adolescent intimate partner violence. J Interpers Violence, 27(14), 2920–2935. DOI:  http://doi.org/10.1177/0886260512438276

83 Minen, M., Jinich, S., & Vallespir Ellett, G. (2019). Behavioral Therapies and Mind-Body Interventions for Posttraumatic Headache and Post-Concussive Symptoms: A Systematic Review. Headache, 59(2), 151–163. DOI:  http://doi.org/10.1111/head.13455

84 Mohatt, N. V., Boeckmann, R., Winkel, N., Mohatt, D. F., & Shore, J. (2017). Military Mental Health First Aid: Development and Preliminary Efficacy of a Community Training for Improving Knowledge, Attitudes, and Helping Behaviors. Mil Med, 182(1), e1576–e1583. DOI:  http://doi.org/10.7205/MILMED-D-16-00033

85 Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med, 6(7), e1000097. DOI:  http://doi.org/10.1371/journal.pmed.1000097

86 Morgan, A. J., Ross, A., & Reavley, N. J. (2018). Systematic review and meta-analysis of Mental Health First Aid training: Effects on knowledge, stigma, and helping behaviour. PLoS One, 13(5), e0197102. DOI:  http://doi.org/10.1371/journal.pone.0197102

87 Motto, J. A., & Bostrom, A. G. (2001). A randomized controlled trial of postcrisis suicide prevention. Psychiatr Serv, 52(6), 828–833. DOI:  http://doi.org/10.1176/appi.ps.52.6.828

88 Murphy, M. K., Black, N. A., Lamping, D. L., McKee, C. M., Sanderson, C. F., Askham, J., & Marteau, T. (1998). Consensus development methods, and their use in clinical guideline development. Health Technol Assess, 2(3), i–iv, 1–88. DOI:  http://doi.org/10.3310/hta2030

89 Nagel, J., Cimbolic, P., & Newlin, M. (1988). Efficacy of elderly and adolescent volunteer counselors in a nursing home setting. Journal of Counseling Psychology, 35(1), 81–86. https://psycnet.apa.org/doi/10.1037/0022-0167.35.1.81. DOI:  http://doi.org/10.1037/0022-0167.35.1.81

90 Nieuwenhuijsen, K., Verbeek, J. H., de Boer, A. G., Blonk, R. W., & van Dijk, F. J. (2004). Supervisory behaviour as a predictor of return to work in employees absent from work due to mental health problems. Occup Environ Med, 61(10), 817–823. DOI:  http://doi.org/10.1136/oem.2003.009688

91 North, C., Gowers, S., & Byram, V. (1995). Family functioning in adolescent anorexia nervosa. Br J Psychiatry, 167(5), 673–678. DOI:  http://doi.org/10.1192/bjp.167.5.673

92 O’Reilly, C. L., Bell, J. S., Kelly, P. J., & Chen, T. F. (2011). Impact of mental health first aid training on pharmacy students’ knowledge, attitudes and self-reported behaviour: a controlled trial. Aust N Z J Psychiatry, 45(7), 549–557. DOI:  http://doi.org/10.3109/00048674.2011.585454

93 Orzolek-Kronner, C. (2002). The effect of attachment theory in the development of eating disorders: Can symptoms be proximity-seeking? Child and Adolescent Social Work Journal, 19(6), 421–435. DOI:  http://doi.org/10.1023/A:1021141612634

94 Parcesepe, A., Martin, S. L., Pollock, M. D., & Garcia-Moreno, C. (2015). The effectiveness of mental health interventions for adult female survivors of sexual assault: a systematic review. Aggress Violent Behav, 25, 15–25. DOI:  http://doi.org/10.1016/j.avb.2015.06.004

95 Pelletier Brochu, J., Meilleur, D., DiMeglio, G., Taddeo, D., Lavoie, E., Erdstein, J., … Frappier, J. Y. (2018). Adolescents’ perceptions of the quality of interpersonal relationships and eating disorder symptom severity: The mediating role of low self-esteem and negative mood. Eat Disord, 26(4), 388–406. DOI:  http://doi.org/10.1080/10640266.2018.1454806

96 Portzky, G., De Wilde, E. J., & van Heeringen, K. (2008). Deliberate self-harm in young people: differences in prevalence and risk factors between the Netherlands and Belgium. Eur Child Adolesc Psychiatry, 17(3), 179–186. DOI:  http://doi.org/10.1007/s00787-007-0652-x

97 Price, O., Baker, J., Bee, P., & Lovell, K. (2015). Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression. Br J Psychiatry, 206(6), 447–455. DOI:  http://doi.org/10.1192/bjp.bp.114.144576

98 Raveis, V., Siegel, K., & Karus, D. (1999). Children’s psychological distress following the death of a parent. J Youth Adolesc, 28(2), 165–180. DOI:  http://doi.org/10.1023/A:1021697230387

99 Reis, A. C., Saheb, R., Moyo, T., Smith, C., & Sperandei, S. (2021). The Impact of Mental Health Literacy Training Programs on the Mental Health Literacy of University Students: a Systematic Review. Prev Sci. DOI:  http://doi.org/10.1007/s11121-021-01283-y

100 Rich, D. E. (2000). The impact of postpregnancy loss services on grief outcome: integrating research and practice in the design of perinatal bereacement programs. Illness, Crisis and Loss, 8(3), 244–264. DOI:  http://doi.org/10.1177/105413730000800303

101 Robertson, K., & Murachvor, T. (2007). It takes two to tangle: gender symmetry in intimate partner violence. Basic and Applied Social Psychology, 29(2), 109–118. https://psycnet.apa.org/doi/10.1080/01973530701331247. DOI:  http://doi.org/10.1080/01973530701331247

102 Roman, L. A., Lindsay, J. K., Boger, R. P., DeWys, M., Beaumont, E. J., Jones, A. S., & Haas, B. (1995). Parent-to-parent support initiated in the neonatal intensive care unit. Res Nurs Health, 18(5), 385–394. https://www.ncbi.nlm.nih.gov/pubmed/7676072. DOI:  http://doi.org/10.1002/nur.4770180504

103 Rund, B. R. (1986). Communication deviances in parents of schizophrenics. Fam Process, 25(1), 133–147. https://www.ncbi.nlm.nih.gov/pubmed/3956704. DOI:  http://doi.org/10.1111/j.1545-5300.1986.00133.x

104 Santini, Z. I., Koyanagi, A., Tyrovolas, S., Mason, C., & Haro, J. M. (2015). The association between social relationships and depression: a systematic review. J Affect Disord, 175, 53–65. DOI:  http://doi.org/10.1016/j.jad.2014.12.049

105 Schreiner, R. L., Gresham, E. L., & Green, M. (1979). Physician’s responsibility to parents after death of an infant. Beneficial outcome of a telephone call. Am J Dis Child, 133(7), 723–726. DOI:  http://doi.org/10.1001/archpedi.1979.02130070059012

106 Schünemann, H., Brozek, J., Guyatt, G., & Oxman, A. D. (2013). GRADE handbook for grading quality of evidence and strength of recommendations. The GRADE Working Group (eds). https://gdt.gradepro.org/app/handbook/handbook.html

107 Schutz, H. K., & Paxton, S. J. (2007). Friendship quality, body dissatisfaction, dieting and disordered eating in adolescent girls. Br J Clin Psychol, 46(Pt 1), 67–83. https://www.ncbi.nlm.nih.gov/pubmed/17472202. DOI:  http://doi.org/10.1348/014466506X115993

108 Segre, L. S., Brock, R. L., & O’Hara, M. W. (2015). Depression treatment for impoverished mothers by point-of-care providers: A randomized controlled trial. J Consult Clin Psychol, 83(2), 314–324. DOI:  http://doi.org/10.1037/a0038495

109 Segre, L. S., Stasik, S. M., O’Hara, M. W., & Arndt, S. (2010). Listening visits: an evaluation of the effectiveness and acceptability of a home-based depression treatment. Psychother Res, 20(6), 712–721. DOI:  http://doi.org/10.1080/10503307.2010.518636

110 Shapiro, D. N., Howell, K. H., & Kaplow, J. B. (2014). Associations among mother-child communication quality, childhood maladaptive grief, and depressive symptoms. Death Stud, 38(1–5), 172–178. DOI:  http://doi.org/10.1080/07481187.2012.738771

111 Sharpe, H., Schober, I., Treasure, J., & Schmidt, U. (2014). The role of high-quality friendships in female adolescents’ eating pathology and body dissatisfaction. Eat Weight Disord, 19(2), 159–168. DOI:  http://doi.org/10.1007/s40519-014-0113-8

112 Shin, D. W., Shin, J., Kim, S. Y., Yang, H. K., Cho, J., Youm, J. H., … Park, J. H. (2016). Family Avoidance of Communication about Cancer: A Dyadic Examination. Cancer Res Treat, 48(1), 384–392. DOI:  http://doi.org/10.4143/crt.2014.280

113 Shisslak, C. M., McKeon, R. T., & Crago, M. (1990). Family dysfunction in normal weight bulimic and bulimic anorexic families. J Clin Psychol, 46(2), 185–189. https://www.ncbi.nlm.nih.gov/pubmed/2324302. DOI:  http://doi.org/10.1002/1097-4679(199003)46:2<185::AID-JCLP2270460210>3.0.CO;2-B

114 Soo, H., & Sherman, K. A. (2015). Rumination, psychological distress and post-traumatic growth in women diagnosed with breast cancer. Psychooncology, 24(1), 70–79. DOI:  http://doi.org/10.1002/pon.3596

115 Steiger, H., Liquornik, K., Chapman, J., & Hussain, N. (1991). Personality and family disturbances in eating-disorder patients: comparison of “restricters” and “bingers” to normal controls. International Journal of Eating Disorders, 10(5), 501–512. https://psycnet.apa.org/doi/10.1002/1098-108X(199109)10:5%3C501::AID-EAT2260100502%3E3.0.CO;2-Z. DOI:  http://doi.org/10.1002/1098-108X(199109)10:5<501::AID-EAT2260100502>3.0.CO;2-Z

116 Stroebe, M., Finkenauer, C., Wijngaards-de Meij, L., Schut, H., van den Bout, J., & Stroebe, W. (2013). Partner-oriented self-regulation among bereaved parents: the costs of holding in grief for the partner’s sake. Psychol Sci, 24(4), 395–402. DOI:  http://doi.org/10.1177/0956797612457383

117 Stroebe, M., Stroebe, W., Schut, H., Zech, E., & van den Bout, J. (2002). Does disclosure of emotions facilitate recovery from bereavement? Evidence from two prospective studies. J Consult Clin Psychol, 70(1), 169–178. https://www.ncbi.nlm.nih.gov/pubmed/11860043. DOI:  http://doi.org/10.1037/0022-006X.70.1.169

118 Svensson, B., & Hansson, L. (2014). Effectiveness of mental health first aid training in Sweden. A randomized controlled trial with a six-month and two-year follow-up. PLoS One, 9(6), e100911. DOI:  http://doi.org/10.1371/journal.pone.0100911

119 Szanto, K., Dombrovski, A. Y., Sahakian, B. J., Mulsant, B. H., Houck, P. R., Reynolds, C. F., 3rd, & Clark, L. (2012). Social emotion recognition, social functioning, and attempted suicide in late-life depression. Am J Geriatr Psychiatry, 20(3), 257–265. DOI:  http://doi.org/10.1097/JGP.0b013e31820eea0c

120 Teo, A. R., Choi, H., Andrea, S. B., Valenstein, M., Newsom, J. T., Dobscha, S. K., & Zivin, K. (2015). Does Mode of Contact with Different Types of Social Relationships Predict Depression in Older Adults? Evidence from a Nationally Representative Survey. J Am Geriatr Soc, 63(10), 2014–2022. DOI:  http://doi.org/10.1111/jgs.13667

121 Tough, H., Siegrist, J., & Fekete, C. (2017). Social relationships, mental health and wellbeing in physical disability: a systematic review. BMC Public Health, 17(1), 414. DOI:  http://doi.org/10.1186/s12889-017-4308-6

122 Traylor, E. S., Hayslip, B., Jr., Kaminski, P. L., & York, C. (2003). Relationships between grief and family system characteristics: a cross lagged longitudinal analysis. Death Stud, 27(7), 575–601. DOI:  http://doi.org/10.1080/07481180302897

123 Vanyukov, P. M., Szanto, K., Hallquist, M., Moitra, M., & Dombrovski, A. Y. (2017). Perceived burdensomeness is associated with low-lethality suicide attempts, dysfunctional interpersonal style, and younger rather than older age. Int J Geriatr Psychiatry, 32(7), 788–797. DOI:  http://doi.org/10.1002/gps.4526

124 Velligan, D. I., Miller, A. L., Eckert, S. L., Funderburg, L. G., True, J. E., Mahurin, R. K., … Hazelton, B. C. (1996). The relationship between parental communication deviance and relapse in schizophrenic patients in the 1-year period after hospital discharge. A pilot study. J Nerv Ment Dis, 184(8), 490–496. https://www.ncbi.nlm.nih.gov/pubmed/8752078. DOI:  http://doi.org/10.1097/00005053-199608000-00006

125 Waller, G., Calam, R., & Slade, P. (1989). Eating disorders and family interaction. Br J Clin Psychol, 28(Pt 3), 285–286. https://www.ncbi.nlm.nih.gov/pubmed/2790323. DOI:  http://doi.org/10.1111/j.2044-8260.1989.tb01381.x

126 Waller, G., Slade, P., & Calam, R. (1990). Who knows best? Family interaction and eating disorders. Br J Psychiatry, 156, 546–550. DOI:  http://doi.org/10.1192/bjp.156.4.546

127 Wallin, A. E., Steineck, G., Nyberg, T., & Kreicbergs, U. (2016). Insufficient communication and anxiety in cancer-bereived siblings: A nationwide long-term follow-up. Palliative and Supportive Care, 48(1), 384–392. DOI:  http://doi.org/10.1017/S1478951515001273

128 Wang, J., Keown, L. A., Patten, S. B., Williams, J. A., Currie, S. R., Beck, C. A., … El-Guebaly, N. A. (2009). A population-based study on ways of dealing with daily stress: comparisons among individuals with mental disorders, with long-term general medical conditions and healthy people. Soc Psychiatry Psychiatr Epidemiol, 44(8), 666–674. DOI:  http://doi.org/10.1007/s00127-008-0482-2

129 Wardecker, B. M., Kaplow, J. B., Layne, C. M., & Edelstein, R. S. (2017). Caregivers’ positive emotional expression and children’s psychological functioning after parental loss. J Child Fam Stud, 26(12), 3490–3501. DOI:  http://doi.org/10.1007/s10826-017-0835-0

130 Watanabe, N., Nishida, A., Shimodera, S., Inoue, K., Oshima, N., Sasaki, T., … Okazaki, Y. (2012). Deliberate self-harm in adolescents aged 12–18: a cross-sectional survey of 18,104 students. Suicide Life Threat Behav, 42(5), 550–560. DOI:  http://doi.org/10.1111/j.1943-278X.2012.00111.x

131 Wickberg, B., & Hwang, C. P. (1996). Counselling of postnatal depression: a controlled study on a population based Swedish sample. J Affect Disord, 39(3), 209–216. https://www.ncbi.nlm.nih.gov/pubmed/8856425. DOI:  http://doi.org/10.1016/0165-0327(96)00034-1

132 Wills, T. A., Gibbons, F. X., Gerrard, M., Murry, V. M., & Brody, G. H. (2003). Family communication and religiosity related to substance use and sexual behavior in early adolescence: a test for pathways through self-control and prototype perceptions. Psychol Addict Behav, 17(4), 312–323. DOI:  http://doi.org/10.1037/0893-164X.17.4.312

133 Wong, D. F. K., Lau, Y., Kwok, S., Wong, P., & Tori, C. (2015). Evaluating the effectiveness of mental health first aid program for Chinese people in Hong Kong. Research on Social Work Practice (pp. 1–9). DOI:  http://doi.org/10.1177/1049731515585149

134 World Health Organization, & War Trauma Foundation and World Vision International. (2011). Psychological first aid: Guide for field workers. Geneva: World Health Organization. https://www.who.int/publications/i/item/9789241548205

135 Yu, Y., & Sherman, K. A. (2015). Communication avoidance, coping and psychological distress of women with breast cancer. J Behav Med, 38(3), 565–577. DOI:  http://doi.org/10.1007/s10865-015-9636-3