Mental Health First Aid: A Systematic Review of Trainee Behavior and Recipient Mental Health Outcomes

We conducted a systematic review by using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement (28). (A table showing a PRISMA checklist of items is available as an online supplement.)

The search identified 9,855 records, of which 1,093 were duplicates, 7,827 were excluded after title review, and 786 were excluded after abstract review. Of the 149 articles reviewed in full, 119 were excluded. These articles were excluded because they evaluated an intervention that was not MHFA (e.g., psychological first aid, N=57 studies), they did not measure at least one trainee behavior or recipient mental health outcome (N=36), the full papers were unavailable or not in English (N=11), they were systematic reviews (N=8), or they were other nonevaluation studies (N=7). One additional study (31) was identified through an anonymous peer reviewer of this study, leaving 31 studies to be included in the synthesis.

Of these 31 studies, nine (31–39) were rigorous enough to be used to evaluate MHFA efficacy. Studies that did not meet minimum rigor criteria lacked a control group and reported posttraining outcomes only (40–47), had no control groups and reported pre- and posttraining outcomes (9, 10, 48–57), were a cluster-randomized controlled trial (RCT) with relevant outcomes not measured in the control group (58), or were a cluster RCT that did not evaluate the ALGEE or the “Look, Ask, Listen, Help Your Friend” action plan (59) (see online supplement).

We identified 31 studies that evaluated the behaviors of MHFA trainees and the mental health of recipients. All of the included studies asked trainees whether they used MHFA skills in real-life situations. However, few evaluated the helpfulness of their actions or their effects on recipient mental health. Only nine studies assessed MHFA efficacy in a rigorous manner. On the basis of these nine studies, we found mixed (positive and neutral) evidence of changes in trainees’ use of MHFA skills and no evidence of improvements in the helpfulness of trainees’ behaviors or recipient mental health.

Few of the included studies used rigorous study designs needed to establish effects of the MHFA program. Although several studies included pre- and posttraining outcomes (9, 31–33, 35–39, 48–59), fewer used a control group (31–39, 58, 59); randomly assigned participants to treatment (31–39, 58, 59); were adequately powered (31, 33–35, 37, 49); or accounted for participant-level characteristics that might influence MHFA helping behaviors (31–34, 36–39, 46, 47, 49, 55, 57–59), such as profession or previous mental health experience. Furthermore, most outcomes were reported by trainees. Although this form of assessment is an important first step and facilitates data collection, it is based on the subjective impression of the trainee and may be susceptible to social desirability and recall biases. Trainee reports are particularly undesirable for evaluating the impact of MHFA on recipients, because they involve making assumptions about recipients’ experiences. Some studies included both trainee and recipient reports for the same outcomes, which helped address reliability but did not address the aforementioned biases. Ideally, studies would use standardized surveys or professional assessments to evaluate mental health outcomes. Finally, although follow-up periods varied, none of the studies measured recipient mental health immediately after MHFA-guided trainee interventions. Because MHFA trainees are trained to provide a first-line response to a crisis situation, initial reductions in mental health difficulties of recipients may be more appropriate to measure than medium- and long-term effects. Overall, the risk for bias of the included studies was medium to high.

Previous systematic reviews of MHFA evaluations have addressed behavioral outcomes only minimally and alongside training outcomes. Systematic reviews and meta-analyses by Hadlaczky et al. (21) and Maslowski et al. (24) found moderate improvements in trainees’ use of MHFA skills, whereas Morgan et al. (22) found small improvements. Morgan et al. also considered the quality of helping behaviors offered, reporting no significant improvements on this measure. Neither Morgan et al. nor Maslowski et al. found significant improvements in recipients’ mental health. Ng et al.’s 2020 systematic review (25) focused on teen and youth MHFA and found that both training curricula generally resulted in more helping behavior of trainees. However, findings in a 2020 systematic review of youth MHFA for educators by Sánchez et al. (26) were inconclusive for this measure. Differences in results for trainee use of MHFA skills were likely due to a mixture of study inclusion criteria and search dates. Hadlaczky et al. (21), Ng et al. (25), and Sánchez et al. (26) did not restrict by study type, and Morgan et al. (22) and Maslowski et al. (24) included all controlled trials. Also of note, Maslowski et al.’s reporting of trainee use of MHFA skills included confidence measures, which increased the number of eligible studies used to assess this outcome. In our systematic review, we used only RCTs measuring actual helping behaviors and their effects on recipients to assess MHFA efficacy. Three of the nine studies we used to evaluate efficacy had not been synthesized in previous reviews. Finally, unlike in other reviews, we solely focused on posttraining behavioral outcomes and on whether outcomes were reported by trainees or recipients, an essential element in program evaluations.

Given that there currently are few studies of MHFA with adequate rigor, and that findings from these studies are mixed, we conclude that there is insufficient evidence that MHFA achieves the desired impact on the helping behaviors of trainees and the mental health of recipients. MHFA implementers should take particular care when describing the intervention as evidence based and be specific about outcomes when evidence does exist, such as improving trainee knowledge, attitudes, and behavioral intent (21–26), and when evidence is insufficient, such as whether MHFA measurably affects trainee behavior or recipient mental health. Notably, some evidence suggests that MHFA trainees who rated themselves as having high intent to help were more likely to report at follow-up that they had actually provided help (60–62). Thus, it is possible that training outcomes such as behavioral intent are mediating the relationship between MHFA training and trainee helping behavior, but this possibility requires further investigation. Future research could seek to isolate the specific training components and mechanisms that affect trainee behavior and recipient mental health to ultimately inform updates to the curricula.

A lack of good-quality evidence does not necessarily render MHFA an unhelpful intervention; in fact, it has been shown to positively affect trainees’ knowledge of mental health issues, attitudes toward mental illness, and intent to help (21–26). Rather, it highlights the gaps in our understanding of how it affects trainee behavior and recipient mental health. More—and more rigorous—evaluations of these outcomes are necessary. Researchers interested in building the evidence base for MHFA can draw on decades of development and evolution in program evaluation. Rigorous designs including MHFA trainee randomization, control groups, and longitudinal follow-up (beyond pre- and posttraining designs) are the minimum required to establish the efficacy of MHFA on trainee helping behavior and recipient mental health outcomes. To address the primary weaknesses in the existing literature, such as lack of power to detect statistically significant effects and bias introduced by a reliance on trainee reports, we consider it very critical that all future study designs prepare for substantial loss to follow-up and measure recipient responses to MHFA-guided helping behaviors. Moreover, future studies should choose more dynamic follow-up times that allow adequate time for trainees to encounter a situation requiring MHFA actions (22) but also capture the initial, short-term impact of these actions on recipients. To overcome challenges related to data collection and design, study designs that use pre- and post-MHFA training assessments of trainee-recipient dyad outcomes (e.g., parents trained in MHFA and their children) (38, 39) can serve as exemplar designs for future studies.

To facilitate data collection among potential recipients, studies may first be restricted to smaller populations in which recipients can be monitored more easily (e.g., families and schools) (33, 38, 39); then, as programmatic effect is established, surveillance can be expanded to larger populations of potential recipients. Using a validated rubric to observe and rate simulated role-play may also help to address self-reporting biases of trainee behavior (63). Several challenges are associated with evaluating posttraining outcomes, and, notably, evaluations of the even more ubiquitous physical first aid have been similarly limited (64). However, innovative research designs (33, 38, 39) and tools (63) have begun to address these challenges and should continue to be supported and further improved. To enable this essential research, it is crucial that MHFA-supporting institutions and funding mechanisms (20) allocate sufficient funds to evaluations of trainee behavior and recipient mental health that meet at least the aforementioned standards of rigor.

The main strengths of this review were its focus on trainee behavior and recipient mental health outcomes and conclusions that were based only on studies that met a standard of adequate rigor. This allowed us to highlight the current state of the evidence for outcomes that are infrequently studied yet crucial to understanding MHFA’s practical, real-world applications. The review was limited by the exclusion of non-English studies and of studies that were not available online, although there were relatively few such studies. Additionally, several of the included studies were underpowered, raising the possibility of type II error. Although pooling the studies into a meta-analysis would have addressed this, measurements for each outcome were too few and varied to do so in a meaningful way. Last, most evaluations were performed in high-income Western countries—Australia, in particular—thus limiting the generalizability of our findings. MHFA has been licensed and adapted in 24 countries (6) and will likely continue to expand. Rigorous evaluations should be conducted in every setting where MHFA is performed, if possible, and particularly in low- and middle-income countries.

Our review found insufficient evidence that MHFA improves the helping behaviors of trainees or the mental health of recipients of such behaviors. Our findings highlight a crucial research and evaluation gap whose closure must be prioritized as MHFA continues to become more popular. As a psychoeducational intervention, MHFA addresses critical barriers to improving community mental health, such as stigma and public education. Furthermore, the rapid proliferation of (5) and funding allocated to (20) MHFA indicates a growing desire to understand and address mental health issues in the United States, and this momentum should not be lost. However, as MHFA trainees are expected and encouraged to provide first-line support to people experiencing mental distress, it is just as, if not more, important to understand how their actions affect those they intend to help.