Literacy and Mental Health Care

During a recent literacy study, we confronted compelling evidence that literacy is a critical, but largely overlooked, issue in the evaluation and treatment of individuals with mental disorders. For example, a 44-year-old patient with schizophrenia reported that he had obtained a college degree many years ago. He confidently indicated that he read “very well.” However, testing showed that he was reading at the fourth- to sixth-grade level.

This person has inadequate literacy skills to function well within most mental health care systems. Moreover, chronically mentally ill people are particularly vulnerable to the negative effects of low literacy. For them, low literacy is an added barrier to accessing and using mental health services effectively.

Low literacy is a much greater problem than many clinicians imagine. According to a national survey, 21 to 23 percent of all adults in the U.S. lack the basic literacy skills needed to function independently in society. Many cannot read an appointment slip, a prescription label, or a thermometer. Yet mental health professionals may assume patients can read and understand a variety of health care materials and directives. More than one adverse drug-drug interaction, medication error, or missed appointment has resulted from a patient's inability to read well. Unfortunately, the provider may attribute these events to deliberate noncompliance rather than to misunderstanding of the written word.

Clinicians overlook literacy problems for several reasons. First, they assume patients read adequately and thus almost never formally test literacy skills. Second, they may presume the last grade of school completed accurately reflects the individual's reading ability. Third, most patients with low literacy skills describe themselves as reading and writing English well; however, such self-estimates are highly unreliable. Finally, low literacy may go unrecognized in mental health settings due to a surprising lack of empirical research in this area.

The first step in addressing this issue is acknowledging that the problem exists. We believe that clinicians should routinely evaluate their patients' literacy skills. Screening devices such as the Rapid Estimate of Adult Literacy in Medicine (REALM) allow reading level to be determined quickly and easily. Once literacy problems are identified, patients can receive written information appropriate to their reading level or, if needed, can obtain additional help.

Clearly, literacy is a mental health care issue. For our patients' sake, we cannot afford to let it go unrecognized.—Glenn D. Grace, Ph.D., director of the psychology training program, Veterans Affairs Medical Center, Gainesville, Florida, and Richard C. Christensen, M.D., assistant professor and director of the community mental health program, University of Florida College of Medicine