research paper example about mental health

ORIGINAL RESEARCH article

Mental health and well-being of university students: a bibliometric mapping of the literature.

• 1 Graduate School of Education, Nazarbayev University, Nur-Sultan, Kazakhstan
• 2 Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
• 3 Psychological Counseling Center, Nazarbayev University, Nur-Sultan, Kazakhstan

The purpose of this study is to map the literature on mental health and well-being of university students using metadata extracted from 5,561 journal articles indexed in the Web of Science database for the period 1975–2020. More specifically, this study uses bibliometric procedures to describe and visually represent the available literature on mental health and well-being in university students in terms of the growth trajectory, productivity, social structure, intellectual structure, and conceptual structure of the field over 45 years. Key findings of the study are that research on mental health and well-being in university students: (a) has experienced a steady growth over the last decades, especially since 2010; (b) is disseminated in a wide range of journals, mainly in the fields of psychology, psychiatry, and education research; (c) is published by scholars with diverse geographical background, although more than half of the publications are produced in the United States; (d) lies on a fragmented research community composed by multiple research groups with little interactions between them; (e) is relatively interdisciplinary and emerges from the convergence of research conducted in the behavioral and biomedical sciences; (f) tends to emphasize pathogenic approaches to mental health (i.e., mental illness); and (g) has mainly addressed seven research topics over the last 45 years: positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement. The findings are discussed, and the implications for the future development of the field are highlighted.

Introduction

The entrance to the university marks a period of transition for young people. Through this transition, students face new challenges, such as making independent decisions about their lives and studies, adjusting to the academic demands of an ill-structured learning environment, and interacting with a diverse range of new people. In addition, many students must, often for the first time, leave their homes and distance themselves from their support networks ( Cleary et al., 2011 ). These challenges can affect the mental health and well-being of higher education students. Indeed, there is evidence that a strain on mental health is placed on students once they start at the university, and although it decreases throughout their studies ( Macaskill, 2013 ; Mey and Yin, 2015 ), it does not return to pre-university levels ( Cooke et al., 2006 ; Bewick et al., 2010 ). Also, the probabilities of experiencing common psychological problems, such as depression, anxiety, and stress, increase throughout adolescence and reach a peak in early adulthood around age 25 ( Kessler et al., 2007 ) which makes university students a particularly vulnerable population.

The interest in mental health and well-being in university students has grown exponentially in the last decades. This is likely due to three interrelated challenges. First, although university students report levels of mental health similar to their non-university counterparts ( Blanco et al., 2008 ), recent studies suggest an increase and severity of mental problems and help-seeking behaviors in university students around the world in the last decade ( Wong et al., 2006 ; Hunt and Eisenberg, 2010 ; Verger et al., 2010 ; Auerbach et al., 2018 ; Lipson et al., 2019 ). Some researchers refer to these trends as an emerging “mental health crisis” in higher education ( Kadison and DiGeronimo, 2004 ; Evans et al., 2018 ). Second, psychological distress in early adulthood is associated with adverse short-term outcomes, such as poor college attendance, performance, engagement, and completion (e.g., King et al., 2006 ; Antaramian, 2015 ), and others in the long term, such as dysfunctional relationship ( Kerr and Capaldi, 2011 ), recurrent mental health problems, university dropout, lower rates of employment, and reduced personal income ( Fergusson et al., 2007 ). Third, there is a widespread agreement that higher education institutions offer unique opportunities to promote the mental health and well-being of young adults as they provide a single integrated setting that encompasses academic, professional, and social activities, along with health services and other support services ( Eisenberg et al., 2009 ; Hunt and Eisenberg, 2010 ). However, the majority of university students experiencing mental health problems and low levels of well-being are not receiving treatment ( Blanco et al., 2008 ; Eisenberg et al., 2011 ; Lipson et al., 2019 ) and, while universities continue to expand, there is a growing concern that the services available to provide support to students are not developing at an equivalent rate ( Davy et al., 2012 ).

In response to the increasing volume of research on the mental health and well-being of university students, there have been several attempts to synthesize the accumulating knowledge in the field and to provide an illustration of the theoretical core and structure of the field using traditional content analysis of the literature (e.g., Kessler et al., 2007 ; Gulliver et al., 2010 ; Hunt and Eisenberg, 2010 ; Sharp and Theiler, 2018 ). This study aims to extend the understanding of mental health in university students by providing a bird’s eye view of the research conducted in this field in recent decades using a bibliometric approach. Bibliometric overviews provide an objective and systematic approach to discover knowledge flows and patterns in the structure of a field ( Van Raan, 2014 ) reveal its scientific roots, identify emerging thematic areas and gaps in the literature ( Skute et al., 2019 ) and, ultimately, contribute to moving the field forward. Accordingly, this study employs several bibliometric indicators to explore the evolution of the field based on publication and citation trends, key actors and venues contributing to the advancement of research on mental health and well-being of university students, and the structure of the field in terms of patterns of scientific collaborations, disciplines underlying the foundations of the field, and recurrent research themes explored in the literature. This is important because, despite significant advances in the field, research on mental health and well-being remains a diverse and fragmented body of knowledge ( Pellmar and Eisenberg, 2000 ; Bailey, 2012 ; Wittchen et al., 2014a ). Indeed, mental health and well-being are nebulous concepts and their history and development are quite intricate, with a multitude of perspectives and contributions emerging from various disciplines and contexts (see section “Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview”). Therefore, mapping research on mental health and well-being in university students is essential to identify contributions and challenges to the development of the field, to help guide policy, research, and practice toward areas, domains, populations, and contexts that should be further explored, and to provide better care of students at higher education institutions ( Naveed et al., 2017 ).

Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview

This section provides an overview of the different perspectives adopted in the literature to conceptualize mental health, well-being, and other relevant constructs in order to identify the glossary of key terms that will be used in the search strategy to create a comprehensive corpus of documents on mental health and well-being in university students for this bibliometric review.

Perspectives on Mental Health and Mental Illness

There is no general agreement on the definition of mental health. For a long time, the term mental health has been used as a euphemism for mental illness ( Manwell et al., 2015 ). However, mental health and mental illness are regarded as distinct constructs nowadays and two main perspectives differentiating between mental health and illness are available in the literature. The continuum approach considers that mental health and mental illness are the two opposite poles of a continuum. Thus, there are various degrees of health and illness between these poles, with most of us falling somewhere in between. The categorical approach, on the other hand, represents mental health and illness as a dichotomy. People who manifest mental illness symptoms would belong to that category and labeled correspondingly, while those absent of these symptoms can be considered as mentally healthy ( Scheid and Brown, 2010 ).

Disciplinary Approaches to the Conceptualization of Mental Health/Illness

Conceptualizations of mental health/illness are largely dependent on the theoretical and paradigmatic foundations of the disciplines from which they emerge. In this context, the field has progressively evolved through the accumulation of knowledge generated in a diverse range of disciplines in the biomedical, behavioral, and social sciences. Biomedical disciplines are grounded in the medical paradigm focused on disease and (ab)normality and often emphasize dichotomous conceptions of mental health/illness ( Scheid and Brown, 2010 ). Research on mental health and well-being in this domain has been traditionally conducted from a psychiatric perspective, which aims to understand the dysfunctionality in the brain that leads to psychiatric symptoms and to also offer a pharmacological treatment to correct neuronal dysfunctions. Consequently, psychiatrists have historically considered mental health as a disease of the brain (e.g., depression), similar to any other physical disease, caused by genetic, biological, or neurological factors ( Schwartz and Corcoran, 2010 ). While the prevalence of psychiatric approaches to mental health is currently incontestable, the development of other biomedical disciplines has tremendously contributed to the progression of the field in recent decades. For example, Insel and Wang (2010) argue that insights gained from genetics and neuroscience contribute to the reconceptualization of “the disorders of the mind as disorders of the brain and thereby transform the practice of psychiatry.” (1979). In addition to that, other disciplines such as behavioral medicine have made important contributions to the field, although it has recently argued that mental health and behavioral medicine should be as two separate fields ( Dekker et al., 2017 ).

Within the behavioral sciences, the study of mental health focuses on the distinct psychological processes and mechanisms that prompt thoughts, feelings, and behaviors ( Peterson, 2010 ). Clinical psychology has the longest tradition in the psychological study of mental health and tends to focus on the assessment and treatment of mental illness and disorders that can alleviate psychological distress or promote positive states of being ( Haslam and Lusher, 2011 ). However, significant contributions to the field have also emerged from other branches of psychology less focused on psychopathology, including personality and social psychology, psychoanalysis, humanistic psychology, and cognitive psychology ( Peterson, 2010 ). Despite the diversity of theories, principles, and methodological approaches to understanding mental health within the behavioral sciences, these disciplines acknowledge that mental health have a biological basis and reside in the social context, and tend to prioritize continuum approaches to mental health ( Scheid and Brown, 2010 ).

Perspectives from the social sciences complement the biomedical and behavioral approaches by considering the influence of social and cultural environments in mental health/illness ( Horwitz, 2010 ). For example, sociologists are interested in how social circumstances (e.g., level of support available) affect levels of mental health/illness and how social structures shape the understanding and response to mental health issues [see Compton and Shim (2015) for an overview of the social determinants of mental health]. Similarly, medical anthropologists attend to the mental health beliefs and practices that form the cultural repertory within and across populations ( Foster, 1975 ). Beyond sociology and anthropology, social researchers in the fields of business and economics, family and ethnic studies, and educational research have also played a key role in advancing research on mental health in different directions.

The Importance of the Context in Mental Health

Certainly, most notions of mental health/illness in the literature derive from prevailing psychiatric and psychological traditions developed in Western countries ( Gopalkrishnan, 2018 ). However, cultural values and traditions do shape how mental health and mental illness are conceptualized across contexts ( Vaillant, 2012 ). In this regard, Eshun and Gurung (2009) pointed out that “culture influences how individuals manifest symptoms, communicate their symptoms, cope with psychological challenges, and their willingness to seek treatment.” (4). Fernando (2019) argued that issues related to the ‘mind’ developed and are often interpreted very differently in non-Western and Low- and Middle-Income Countries (LMICs). For example, cultures explain the manifestation of certain feelings and behaviors based on a range of motives including biological, psychological, social, religious, spiritual, supernatural, and cosmic. Failure to acknowledge alternative non-Western approaches to mental health and mental illness has resulted in imbalances of knowledge exchange and the permeation of dominating Western narratives into LMICs (i.e., so-called medical imperialism) ( Timimi, 2010 ; Summerfield, 2013 ). To address this issue, scholars have advocated for a greater willingness to embrace pluralism in the conceptualization of mental health and illness, which might help people to engage with particular forms of support that they deem to be appropriate for them, and to explore how knowledge and practices developed in LMICs can benefit those living in higher-income countries (i.e., knowledge “counterflow”) (see White et al., 2014 ).

Prioritizing Positive Mental Health: The Science of Well-Being

Despite the diversity of disciplinary and contextual approaches to mental health, current definitions of mental health have two things in common. First, mental health is considered from a biopsychosocial point of view that incorporates biological, psychological, and social factors. Second, mental health implies something beyond the absence of mental illness (e.g., Bhugra et al., 2013 ; Galderisi et al., 2015 ). An example is the definition by the World Health Organization which refers to mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” ( World Health Organization, 2004 ). This definition contributed to substantial progress in research and practice in the field as it expanded the notion of mental health beyond the absence of mental illness and integrated the presence of positive features ( Galderisi et al., 2015 ).

Research on positive mental health is relatively new but has grown rapidly in the last decades fueled by advocates of positive medicine and psychology, who have argued for a change of paradigm from medical and psychopathological-oriented models of mental health that focus on disorders and illness toward more strength-based approaches, which pay more attention to what is right about people and positive attributes and assets ( Kobau et al., 2011 ). In this regard, the term mental well-being has been progressively incorporated into the study of mental health to account for the positive aspects of mental health beyond the absence of negative factors. While there is not a universally accepted definition of well-being, two perspectives have dominated the discourses on well-being in the literature: subjective well-being (SBW) and psychological well-being (PWB). SWB is based on hedonic perspectives of pleasure and represents “people’s beliefs and feelings that they are living a desirable and rewarding life” ( Diener, 2012 ). SBW is strongly linked with the idea of happiness and is typically understood as the personal experience of high levels of positive affect, low levels of negative affect, and high satisfaction with one’s life ( Deci and Ryan, 2008 ). PWB is grounded in Aristotelian ideas about eudaimonia, i.e., self-realization, with the ultimate aim in life being to strive to realize one’s true potential ( Ryff and Singer, 2008 ). PWB has been broadly defined as a state of positive psychological functioning and encompasses six dimensions: purpose in life (i.e., the extent to which respondents felt their lives had meaning, purpose, and direction); autonomy (i.e., whether they viewed themselves as living in accord with their own convictions); personal growth (i.e., the extent to which they were making use of their personal talents and potential); environmental mastery (i.e., how well they were managing their life situations); positive relationships (i.e., the depth of connection they had in ties with significant others); and self-acceptance (i.e., the knowledge and acceptance they had of themselves, including awareness of personal limitations) ( Ryff, 1989 ).

Integrating Mental Health, Mental Illness, and Well-Being

The contribution of positive mental health frameworks to the advancement of the field has been undeniable. However, definitions that overemphasize positive emotions and productive functioning as key indicators of mental health have been recently challenged because of the potential they have to discriminate against individuals and groups that, for example, might not be able to work productively or function within the environment because of individual physical characteristics or contextual constraints ( Galderisi et al., 2015 ). To address these issues, Keyes has successfully integrated the notions of mental illness, mental health, well-being, and other related terms in the literature into a conceptual framework that allows for a more comprehensive understanding of mental health ( Keyes, 2005 , 2007 ; Keyes and Michalec, 2010 ). The model argues that neither pathogenic approaches focusing on the negative (e.g., mental illness) nor salutogenic approaches focusing on the positive (e.g., well-being) can alone accurately describe the mental health of a person ( Keyes and Michalec, 2010 ). Instead, the model proposes that mental illness and well-being represent two correlated but differentiated latent continua in defining mental health. More specifically, mental illness and well-being lie on two separate spectra, the first going from absent to present mental illness and the second running from low to high well-being ( Slade, 2010 ). The absence of mental illness, therefore, does not necessarily imply high levels of well-being. Correspondingly, low levels of well-being do not always indicate the presence of mental illness. Further, in this model, mental health is defined as not only the absence of mental illness, not the mere presence of high well-being. Complete mental health (i.e., flourishing) is a result of experiencing low mental illness and high levels of well-being. Incomplete mental health (i.e., languishing), on the other hand, refers to the absence of mental illness symptoms and low reported levels of well-being. Two other conditions are possible within this framework. Incomplete mental illness (i.e., struggling) refers to high levels of well-being accompanied by high mental illness symptoms. Lastly, complete mental illness (i.e., floundering) accounts for low levels of well-being and high mental illness symptoms ( Keyes and Lopez, 2002 ).

The Present Study

In light of the complexity of the constructs of mental health and well-being and the multiple theoretical, disciplinary, and contextual approaches to their conceptualization, this study seeks to map out the terrain of international research and scholarship on mental health and university students for the period 1975–2020. More specifically, this study aims to provide new insights into the development and current state of mental health research in university students by mapping and visually representing the literature on mental health and well-being of university students over the last 45 years in terms of the growth trajectory, productivity, and social, intellectual, and conceptual structure of the field. First, the study describes the development of research mental health and well-being in university students examining the trends in publication and citation data between 1975 and 2020 (i.e., growth trajectory). Second, the study identifies the core journals and the research areas contributing most to the development of the field, as well as the key authors and countries leading the generation and dissemination of research on mental health and well-being in university populations (i.e., productivity). Third, the study outlines the networks of scientific collaboration between authors, and countries (i.e., social structure). Fourth, the scientific disciplines underlying the intellectual foundations of research on mental health and well-being in university settings (i.e., intellectual structure) are uncovered. Fifth, the study elucidates the topical foci (i.e., conceptual structure) of the research on the mental health and well-being of university students over the last 45 years.

Materials and Methods

A bibliometric approach was used in this study to map the literature on mental health and well-being in university students over the last 45 years using metadata extracted from four indexes of the Web of Science (WoS): The Science Citation Index-Expanded (SCI-Expanded); the Social Sciences Citation Index (SSCI); the Arts & Humanities Citation Index (A&HCI); and the Emerging Sources Citation Index (ESCI). Several reasons justified the selection of the WoS database in this study. First, the WoS remains as the standard and most widely used for bibliometric analysis ( Meho and Yang, 2007 ). Second, the WoS is a multidisciplinary database and includes publications on mental health and well-being emerging from distinctive research areas and disciplines published in more than 20,000 journals ( McVeigh, 2009 ). Using specialized databases such as PubMed would introduce biases into the search strategy favoring biomedical research disciplines. Still, it is important to note that interdisciplinary databases such as WoS and Scopus discriminate against publications in the Social Sciences and Humanities and publications in languages other than the English language ( Mongeon and Paul-Hus, 2016 ), so the picture provided by WoS is still imperfect. Third, while other databases might provide wider coverage, WoS includes publication and citation information from 1900. For example, Scopus has complete citation information only from 1996 ( Li et al., 2010 ). Moreover, Google Scholar provides results of inconsistent accuracy in terms of citations, and citation analyses in PubMed are not available ( Falagas et al., 2008 ). Fourth, WoS has demonstrated better accuracy in its journal classification system compared to Scopus database ( Wang and Waltman, 2016 ).

The methodological approach used in this study is presented in Figure 1 and further elaborated in the following paragraphs.

Figure 1. Methodological framework.

Search Strategy

To create a comprehensive corpus of documents on the mental health and well-being of university students, three parallel searches were performed, which accounted for the multiple approaches and perspectives that have been used in the field, as identified in the Section “Conceptualization of Mental Health, Mental Illness, and Well-Being: An Overview.” All the searches were conducted in the last week of January 2020. The first search aimed at capturing research on mental health broadly and included one single keyword in the topic field: [“mental health”]. The second search was implemented to capture research focusing on pathogenic approaches to mental health. Key terms used in the literature to refer to the negative side of mental health, as well as the most frequent mental health problems experienced by university students, were introduced in this search in the title field: [“mental illness,” “mental disorder ∗ ,” “mental distress,” “psychological distress,” “psychopathology,” “depression,” “anxiety,” “stress,” “suicide,” “eating disorder ∗ ,” “substance use”]. In the third search, keywords reflecting salutogenic approaches to mental health were input. These included terms related to mental health from a positive mental health perspective (i.e., well-being). These key terms were added in the title field and included the following: [“well-being,” “wellbeing,” “wellness,” “life satisfaction,” “happiness,” “positive affect,” “purpose in life,” “personal growth,” “self-determination”].

To retrieve research relevant only to higher education students, another set of keywords was imputed in all three searches in the title field. These included: [“university,” “college,” “higher education,” “tertiary education,” “post-secondary education,” “postsecondary education,” “undergrad ∗ student,” “grad ∗ student,” “master’s student,” “doctoral student,” “Ph.D. student”]. The Boolean operator OR was used between keywords in all the three searches to secure a higher number of relevant hits. Also, asterisks were used as wildcards to account for multiple variations in several keywords (e.g., disorder and disorder-s). All searches were limited to journal articles published between 1975 and 2020 (both inclusive). No restrictions on language were implemented in the search.

The search strategy retrieved a total of 6,356 hits ( n search 1 = 2782; n search 2 = 2814, n search 3 = 760). After the removal of duplicates, 5,561 research articles were finally selected and retained for the study. For each of the documents obtained in the search, the authors extracted metadata about the title of the paper, the year of publication, the journal, the number of citations, and the authors’ name, organization, and country. Also, the title, the abstract, the author’s keywords, and cited references were retrieved.

Data Analysis Procedures

The corpus of the literature was then analyzed using descriptive and bibliometric approaches to provide an overall picture of the evolution and current state of the research on mental health and wellbeing in university settings. Frequency counts of the number of publications and citations per year were obtained to describe the growth trajectory of research on the mental health and well-being of university students. Rank ordered tables were produced to describe the productivity of the field in terms of core journals and research areas, as well as leading scholars and countries contributing to the development of the field.

Bibliometric analyses in VOSViewer software were implemented to examine and visually represent the social, intellectual, and conceptual structure of the field. VOSViewer is a freely available computer software for viewing and constructing bibliometric maps 1 . In VOSViewer, the units of analysis are journals, publications, citations, authors, or countries, depending on the focus of the analysis. The units of analysis are represented in the maps as circular nodes. The size of the node accounts for volume (e.g., number of publications in the dataset by an author) and the position represents the similarity with other nodes in the map. Closer nodes are more alike than nodes far apart from each other. The lines connecting nodes represent the relationship between nodes and their thickness indicates the strength of that relationship. Finally, the color of the node denotes the cluster to which each node has been allocated. Nodes are clustered together based on relatedness ( Van Eck et al., 2010 ). The software uses a distance-based approach to constructing the bibliometric maps in three steps ( Van Eck and Waltman, 2014 ). In the first step, the software normalizes the differences between nodes. In the second step, the software builds a two-dimensional map where the distance between the nodes reflects the similarity between these nodes. In the third step, VOSViewer groups closely related nodes into clusters ( Van Eck and Waltman, 2014 ).

A series of co-authorship analyses were performed to examine the social structure of research on mental health and well-being in university students. In these analyses, the units of analysis were authors and countries/territories. Each node in the map represents an author or a country/territory and the lines connecting them reflect the relationship between nodes. Clusters represent networks of scientific collaboration, which might be interpreted as groups of authors or countries frequently publishing together (e.g., research groups in the case of authors).

Co-citation analysis of journals was implemented to explore the intellectual structure of the field. Here, the units of analysis were journals in the dataset and the map reflects co-citation relationships between journals. Two journals are co-cited if there is a third journal citing these two. The more times a pair of journals are cited by other journals, the stronger their co-citation relationship will be. Frequently co-cited journals are assumed to share theoretical and semantical grounds. Therefore, in our study, clusters of frequently co-cited journals can be interpreted as disciplines underlying the foundations of research on mental health and well-being in university students.

Finally, a co-occurrence analysis of keywords was used to uncover the conceptual structure of the field. The units of analysis, in this case, were the authors’ keywords. The more often two keywords appear in the same record, the stronger their co-occurrence relationship. Clusters of co-occurring keywords represent in this study the topical foci (i.e., knowledge base) that have been addressed in the literature in mental health and well-being in university students in the last 45 years.

Findings and Discussion

Growth trajectory: evolution of publications and citations in the field.

The developmental patterns of a particular field can be well demonstrated by trends in publications and citations. The 5,561 publications in the dataset have been cited 87,096 times, with an average of 15.6 citations per item. Figure 2 shows the growth trajectory of publication data of research on mental health and well-being in university students from 1975 to January 2020. Overall, the trends demonstrate a gradual increase in the scholarly interest in the mental health of university students over the last 45 years that can be organized in three stages: an emergence stage, in which publications rose slowly (1975–2000); a fermentation stage, with a notable increase in publications in the field (2000–2010); and a take-off stage, during which the number of records published per year in the field has almost risen 10 times (2010–2020). The steady increase of publications in the last 15 years coincides with the first calls for attention on the increase and severity of mental problems and help-seeking behaviors of college students ( Kadison and DiGeronimo, 2004 ; Evans et al., 2018 ), potentially indicating a growing interest in exploring the epidemiology of mental disorders and the role of universities in promoting the mental health and well-being of students. A similar pattern has also been observed in a recent bibliometric study examining global research on mental health both in absolute terms and as a proportion of all papers published in medicine and across disciplines, which certainly reflects an increase in the general interest in the field ( Larivière et al., 2013 ).

Figure 2. Growth of research on mental health and well-being of university students.

Productivity I: Core Journals and Research Areas

In total, 1,560 journals published the 5,561 records included in the dataset. Table 1 presents the ten core journals in the field. The Journal of American College stands out as the main publication venue in the field, accumulating around 5% of the publications in the dataset ( n = 270). Psychological Reports and Journal of College Student Development also stand out, publishing 119 and 102 studies, respectively. The Journal of Counseling Psychology ranks fourth in the list with 83 records. Despite being an interdisciplinary and relatively young journal, Plos One appears in the top five journal publishing research on mental health and well-being in university students.

Table 1. Core journals ranked by number of records.

The top research areas contributing to the publication of research on the mental health and well-being of university students are presented in Table 2 . Nearly half of the records in the dataset are published in psychology journals. Another influential research area in the field is psychiatry , which captures almost 20% of the publications. Journals on education and educational research also accumulate a considerable number of publications in the field (15%). Other relevant research areas in the field are connected with health and medicine, including public environmental occupational health , substance abuse , general internal medicine , neurosciences neurology , health care sciences services , and nursing . Finally, the field is also grounded, although to a lower extent, in the publications emerging from journals in the social sciences , family studies , and social work research.

Table 2. Top research areas ranked by number of records.

All in all, the productivity analysis for journals and research areas showed that most research on mental health and well-being in university students is disseminated in journals in the “psy disciplines”’ (i.e., psychology and psychiatry) ( McAvoy, 2014 ), which is consistent with previous research on mental health in general populations (e.g., Haslam and Lusher, 2011 ). However, our findings demonstrated that the volume of research in psychology doubles that of research emerging from psychiatric journals. This contrasts with the findings by Haslam and Lusher (2011) , who demonstrated that psychiatry journals had a greater influence on mental health research compared to clinical psychology journals and that psychiatry journals accumulate a higher volume of research and citations on mental health research. This is probably because our study includes publications emerging from all branches of psychology, unlike the study by Haslam and Lusher, which included only journals in the field of clinical psychology. Additionally, mental health services in higher education are typically provided by counseling centers led and staffed by non-medical professionals (e.g., psychologists, social workers, counselors, and family therapists) who tend to adopt developmental models of practice grounded in the behavioral sciences and focused on adjustment issues, vocational training, employment, and other personal needs rather than diagnosis and symptom reduction, more common in the biomedical sciences (i.e., psychiatry) ( LeViness et al., 2018 ; Mitchell et al., 2019 ).

Productivity II: Leading Authors and Countries/Territories

The 5,561 publications in the dataset were published by a total of 16,161 authors from 119 countries worldwide. Table 3 shows the researchers with the highest number of publications in the field. D. Eisenberg appears as the most productive researcher, followed by K. Peltzer and S. Pengpid. Authors on the list come from diverse geographical backgrounds. Five of the authors work at three different American universities (University of Michigan, Harvard Medical School, and Boston University), two researchers work at KU Leuven University (Belgium), and two other authors are affiliated to the same two universities in Thailand and South Africa. Other prolific researchers are affiliated with higher education institutions in the Netherlands, Egypt, and Germany.

Table 3. Leading authors ranked by number of records.

Countries and territories leading research on mental health and well-being of university students are presented in Table 4 . The United States is the indisputable leader in this field, publishing more than half of the records in the dataset. This is nearly 10 times the number of publications produced in China, which occupies the second position in the ranking and accounts for nearly 6% of the volume of research in the dataset. Three predominantly English speaking countries/territories complete the top five of the ranking: Canada (265 records), Australia (254), and England (243). The rest of the countries in the list are situated in Europe (Spain, Germany, Turkey), Western Asia (Iran), Africa (South Africa), and East Asia (Japan), which demonstrates that research on college students’ mental health and well-being is a matter of concern in different regions of the world, at least to some extent.

Table 4. Leading countries/territories ranked by number of records.

Overall, the productivity analysis for authors and countries indicated that the research of mental health and well-being of university students occurs in a variety of locations around the world, especially in developed countries, and in a very prominent way, in the United States. This is not surprising since it is in those countries where better infrastructures and more abundant resources for research are available ( Wong et al., 2006 ), and a more lasting tradition in the study of mental health, in general, exists ( Gopalkrishnan, 2018 ). However, Larivière et al. (2013) found that the productivity of the United States on mental health research has dropped significantly and remained stable in other two English speaking countries (the United Kingdom and Canada) since 1980. On the contrary, the number of publications from European countries and the five major emerging national economies (Brazil, Russia, India, China, and South Africa), has experienced remarkable growth, and collectively account nearly for half of the publications in the field. Still, the predominance of knowledge generated in the developed world today, which tends to be grounded on psychiatric and psychological perspectives, might be eclipsing non-traditional views on mental health and well-being that are popular in other regions of the world and, therefore, limiting the development of effective initiatives that align better with local norms, values, and needs in LMICs ( Timimi, 2010 ; Summerfield, 2013 ).

Social Structure: Networks of Scientific Collaboration

Research collaboration is regarded as an indicator of quality research and a means to improve research productivity and academic impact (i.e., citations) ( Kim, 2006 ; Abramo et al., 2009 ). In particular, international research collaboration is considered a key contributor to the social construction of science and the evolution of scientific disciplines ( Coccia and Wang, 2016 ). There is recent evidence that national and international research collaborations have been accelerating in recent years ( Gazni et al., 2012 ; Wagner et al., 2015 ), especially in applied fields such as medical and psychological disciplines ( Coccia and Bozeman, 2016 ). In this study, co-authorship analyses were performed to find out patterns in the scientific collaboration between researchers and countries/territories on the mental health and well-being of university students.

Figure 3 demonstrates collaborative ties among authors who published at least 5 articles in the dataset ( n = 179). The map shows the existence of multiple productive collaborative networks of five or more researchers contributing to the development of the field. The largest collaboration network (red cluster) represents an international research group composed of 15 scholars affiliated to universities in the United States, Belgium, and Netherlands. This cluster groups some of the leading scholars in the field, including R. P. Auerbach, R. Brauffaerts, R. C. Kressler, and P. Cuijpers. Moreover, researchers in this cluster lead The WHO World Mental Health International College Student (WMH-ICS) Initiative, a large scale international project aimed at promoting the mental health and well-being of college students around the world through generating epidemiological data of mental health issues in university students worldwide, designing web-based interventions for the prevention and promotion of mental health, and disseminating evidence-based interventions ( Cuijpers et al., 2019 ). The second biggest cluster (green) represents an intra-national research network that includes 10 researchers from eight different higher education institutions in the United States. The dark blue cluster represents an institutional collaborative network, including nine researchers from the School of Public Health, Puerto Rico. Other prominent clusters in the map represent collaborative research networks between eight (olive color) and seven researchers (turquoise, violet, orange, and mellow mauve). This contrasts, however, with the limited collaboration that exists between clusters. Only four of the clusters on the map demonstrate some kind of scientific collaboration in the field (light blue, pink, brown, and yellow).

Figure 3. Collaborative research networks between researchers. Only researchers with five or more publications were considered in the analysis ( n = 179).

Cross-country collaboration networks in mental health and well-being of university students study are presented in Figure 4 . Research collaborations between countries with 20 or more publications were considered in this analysis ( n = 45). The United States occupies the central position of the map and shares collaborative ties with all other countries/territories, forming a cluster together with China, South Korea, and Taiwan. Overall, the results suggest that international collaborations in the field are framed to a large extent by cultural, linguistic, and geographical proximity. For instance, the largest cluster (red) is formed by two European countries (Spain and Portugal) and other South American countries with whom they share historical and cultural backgrounds. Other European countries form the purple cluster. Similarly, the blue cluster clearly brings together predominantly English-speaking countries and territories, while the green cluster agglomerates a range of Asian countries.

Figure 4. Collaborative research networks between countries and territories. Only countries with 20 or more publications were considered in the analysis ( n = 45).

Collectively, the results of our study suggest that research collaboration in the field of mental health and well-being in university students remains relatively scarce and localized to date. The social structure of the field at the author level could be described as an archipelago formed by a large number of islands (research groups) of different composition and size but with few bridges connecting them, which suggests a relatively fragmented research community. Moreover, while the existence of international collaborative networks was evident in the analysis, they seem to be formed within national borders, between researchers in neighboring countries/territories, or between countries that share cultural, linguistic, and historical heritages. This may be due to the important role that cultural and traditional values play in the conceptualization of mental health and well-being across contexts ( Eshun and Gurung, 2009 ; Vaillant, 2012 ; Fernando, 2019 ). Also, language differences, divergent cross-national institutional and organizational traditions, and increased costs of extramural collaboration, have been found to complicate the formation and continuity of research partnerships in health research ( Hooper et al., 2005 ; Freshwater et al., 2006 ). Nevertheless, limited within- and between-country research collaboration arguably poses challenges to the development of a field in terms of lost opportunities to challenge assumptions taken for granted and move toward fresh perspectives, push boundaries in methods and techniques, meet diverse groups of people from differing cultures and get immersed in those cultures, share information, resources, and skills, and address common mental health problems through the pooling of resources ( Rolfe et al., 2004 ; Freshwater et al., 2006 ).

Intellectual Structure: Disciplines Underlying the Foundations of the Field

Interdisciplinarity is considered as a valuable approach to address the complex and multidimensional nature of health and well-being ( Mabry et al., 2008 ). Buckton (2015) argues that the integration of medical, psychological, and social sciences have contributed to generate “new insights into theory, practice, and research in mental health and development.” (3). To examine the disciplines underlying research on the mental health and well-being of university students, a journal co-citation analysis was performed. In this analysis, only journals with at least 50 citations were considered ( n = 593). The nodes on the map represent journals and their size reflects the number of co-citation relationships with other journals. Colors account for journal clusters, which agglutinate journals with higher co-citation relationships and stronger semantic connectedness. Clusters were interpreted and labeled accounting for the WoS categorization of the journals with the highest co-citation links within each cluster. For example, if the Journal of Personality and Social Psychology , the Journal of Counseling Psychology , and Personality and Individual Differences clustered together, this group was interpreted as the personality, social, and counseling psychology cluster.

In general, the findings of this study suggest that research on mental health and well-being in university students is interdisciplinary, to a certain extent, and mainly emerges from the convergence of research conducted in the behavioral and biomedical sciences, as it has been suggested elsewhere ( Schumann et al., 2014 ; Wittchen et al., 2014b ). More specifically, the map shows that the research in the mental health and well-being of university students is constructed through the integration of knowledge generated in five interconnected disciplines (see Figure 5 ). To the left of the map, the red cluster integrates journals on personal, social, and counseling psychology . To the right, the blue cluster represents the contribution of psychiatric journals to research to the formation and development of the field. At the top, the yellow cluster groups journals on substance abuse and issues related to alcohol consumption, addiction, and interpersonal violence. At the bottom of the map, journals covering topics on eating behaviors, sleep, and other issues related to physical health converge on the green cluster. At the center of the map is the purple cluster, which includes journals in the area of clinical psychology and behavioral therapy .

Figure 5. Map of clustered network journals based on co-citation data. Only publications with 50 or more citations were considered in the analysis ( n = 593).

More broadly, the findings suggest that biomedical sciences contribute to a large extent to the composition of the field. Psychiatric research emerged in our study as an obvious building block in the study of university students’ mental health and well-being, which is not surprising considering the historical contributions of biomedical disciplines to mental health research ( Schwartz and Corcoran, 2010 ). Within the behavioral sciences, personality and social psychology, which explores processes and mechanisms through which social phenomena influence mental health and well-being ( Sánchez Moreno and Barrón López de Roda, 2003 ), appears as a key discipline underlying the foundations of the field. Surprisingly, clinical psychology journals occupy a central position in the map and demonstrate co-citation relationships with journals from all other clusters but make up the most dispersed network and account for a considerably lower volume of co-citation relationships in the field. This suggests that clinical psychology journals are more subordinate to journals in other disciplines in terms of citations flows, and ultimately, play a less unique role in research on the mental health and well-being of university students, as suggested by Haslam and Lusher (2011) . Interestingly, research arising from the social sciences (e.g., sociology and anthropology) does not seem to make a distinctive contribution to the intellectual structure of the field, which suggests that the influence of social contexts and cultures on university students’ mental health and well-being (e.g., inequality, social norms, public policies, cultural beliefs, and values) is an underexplored research area. Still, the density of co-citation network relationships within and between clusters is particularly noteworthy, considering the lack of common language between disciplines, the absence of a shared philosophy of practice on mental health, and the tensions between medical, psychological, and social explanations of mental distress ( Bailey, 2012 ).

Conceptual Structure: Topical Foci Addressed in the Literature Over the Last 45 Years

The topical foci of research on the mental health and well-being of university students during the 1975–January 2020 period are presented in Figure 6 . The map offers a visual representation of the co-occurrence analysis of author keywords of all the publications included in the dataset. Only the most frequently occurring keywords (25+ occurrences) were considered in the analysis ( n = 84). Items that were not related to others and do not belong to the existing clusters were excluded. The size of the nodes indicates the occurrence of author keywords in the dataset and the thickness of edges represents the co-occurrence strength between pairs of keywords.

Figure 6. Topical foci in mental health and well-being of university students research. Only keywords with 25 or more occurrences were considered in the analysis ( n = 84).

The most frequent keywords in the dataset, excluding students’ descriptors (e.g., college students and university students), refer to common mental health challenges experienced by university students such as depression ( n = 612), anxiety ( n = 353), and stress ( n = 341). Salutogenic-related keywords such as well-being and life satisfaction occurred less often ( n = 138, n = 113, respectively), suggesting that pathogenic approaches to the exploration of mental health issues in higher education are more widespread. More broadly, seven general themes seem to summarize the topical foci of interest in the field of mental health and well-being of university students over the last 45 years. First, there has been a general interest in positive mental health , as denoted by frequently co-occurring key terms such as well-being, self-esteem, life satisfaction, social support, emotional intelligence, and happiness (red cluster). Second, mental disorders stand as another theme widely addressed in the literature, with a special emphasis on depression, anxiety, and to a lesser extent, suicide and suicidal ideation (green cluster). A third topical area in this field has been substance abuse , most predominantly alcohol consumption (blue cluster). The fourth theme reflects college counseling for mental health , including interventions and protective factors such as mindfulness, stress management, spirituality, and help-seeking (yellow cluster). Other topics reflected in the map are mental illness stigma (purple), stress (e.g., psychological distress and coping) (light blue), and mental health measurement (orange).

This study provides a comprehensive overview of the research on university students’ mental health and well-being in the last 45 years using bibliometric indicators. In general, the results reveal interesting trends in the evolution of the field over the last four decades and promising scientific patterns toward a better understanding of the mental health and well-being of university students internationally. First, the interest in the mental health and well-being of university students has grown in the last decades and in a very significant way during the last 10 years, indicating that this area has not still reached its maturity period and will continue developing in the future. Second, research in the field is relatively interdisciplinary and emerges from the convergence of research conducted in several disciplines within the behavioral and biomedical sciences. Third, research in this field is produced by a community of productive researchers coming from several regions around the world, most notably in the United States, which secures a generation of scholars that will continue shaping the field in the years to come. Fourth, over the last 45 years, researchers have been able to address a multitude of research topics in the field, including positive mental health, mental disorders, substance abuse, counseling, stigma, stress, and mental health measurement.

However, this study also identified some issues that could be hindering the development of the study of the mental health and well-being of university students. For example, the research available overrepresents theoretical and disciplinary approaches from the developed world. Additional studies on the field from developing economies and LMICs are needed to provide a more comprehensive picture and ensure a fair representation of the multiple perspectives available in the field. Such studies would inform administrators and practitioners on how to broaden and enrich available programs and initiatives to promote mental health and well-being in higher education contexts in order to offer alternative forms of support that university students find appropriate for their social and cultural values. Moreover, the research community contributing to the development of the field is relatively fragmented. There are multiple research groups but little research collaborations between them and, at the international level, these connections tend to be limited by geographic, cultural, and language proximity. In this context, more actions like the WMH-ICS Initiative could provide a partial solution to this problem by strengthening national and international research partnerships and facilitating knowledge exchange across regions. Also, special issues in the core journals in the field inviting cross-cultural studies on the topic could contribute to promoting research collaboration across regions and research in less represented countries. The field would also benefit from a greater volume of research from the social sciences and humanities exploring the influence of social, cultural, economic, and educational factors on the conceptualization, manifestation, and experience of mental health and well-being. Moreover, more studies emerging from disciplines such as sociology, anthropology, business, and education, would likely increase the permeability of positive mental health concepts into the field and contribute to the promotion of salutogenic approaches to the study of mental health and well-being of university students.

This study has several limitations. First, publications were retrieved only from the WoS database, which limits the generalizability of the findings. Second, WoS provides stronger coverage of Life Sciences, Biomedical Sciences, and Engineering, and includes a disproportionate number of publications in the English language ( Mongeon and Paul-Hus, 2016 ). This could partially explain the low number of publications emerging from the Social Sciences, the Arts, and the Humanities, and research conducted in non-English speaking countries in the present study. Third, only journal articles were retrieved for analysis, excluding other relevant publications in the field such as reviews, book chapters, and conference proceedings. Future studies could replicate the findings of this study using alternative databases (e.g., Scopus and PubMed) or a combination of them, as well as different filters in the search strategy, to provide an alternative coverage of research conducted in the field. Nevertheless, we believe that the bibliometric approach used in this study offers novel insights about the development and current status of the field and some of the challenges that undermine its progression.

Data Availability Statement

The datasets generated for this study are available on request to the corresponding author.

Author Contributions

DH-T and LI contributed to conception and design of the study, organized the database, and performed the statistical analysis. DH-T, LI, and JS wrote the first draft of the manuscript. NL, AC, AA, YN, and AM wrote the sections of the manuscript.

This research was funded by the Nazarbayev University Faculty-Development Competitive Research Grants Program (Reference Number 240919FD3902).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords : mental health, mental illness, well-being, psychological distress, university students, higher education, bibliometric review, VOSViewer

Citation: Hernández-Torrano D, Ibrayeva L, Sparks J, Lim N, Clementi A, Almukhambetova A, Nurtayev Y and Muratkyzy A (2020) Mental Health and Well-Being of University Students: A Bibliometric Mapping of the Literature. Front. Psychol. 11:1226. doi: 10.3389/fpsyg.2020.01226

Received: 03 March 2020; Accepted: 11 May 2020; Published: 09 June 2020.

Reviewed by:

Copyright © 2020 Hernández-Torrano, Ibrayeva, Sparks, Lim, Clementi, Almukhambetova, Nurtayev and Muratkyzy. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Daniel Hernández-Torrano, [email protected] ; [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Research article
• Open access
• Published: 24 October 2019

A scoping review of the literature on the current mental health status of physicians and physicians-in-training in North America

• Mara Mihailescu   ORCID: orcid.org/0000-0001-6878-1024 1 &
• Elena Neiterman 2  

BMC Public Health volume  19 , Article number:  1363 ( 2019 ) Cite this article

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This scoping review summarizes the existing literature regarding the mental health of physicians and physicians-in-training and explores what types of mental health concerns are discussed in the literature, what is their prevalence among physicians, what are the causes of mental health concerns in physicians, what effects mental health concerns have on physicians and their patients, what interventions can be used to address them, and what are the barriers to seeking and providing care for physicians. This review aims to improve the understanding of physicians’ mental health, identify gaps in research, and propose evidence-based solutions.

A scoping review of the literature was conducted using Arksey and O’Malley’s framework, which examined peer-reviewed articles published in English during 2008–2018 with a focus on North America. Data were summarized quantitatively and thematically.

A total of 91 articles meeting eligibility criteria were reviewed. Most of the literature was specific to burnout ( n  = 69), followed by depression and suicidal ideation ( n  = 28), psychological harm and distress ( n  = 9), wellbeing and wellness ( n  = 8), and general mental health ( n  = 3). The literature had a strong focus on interventions, but had less to say about barriers for seeking help and the effects of mental health concerns among physicians on patient care.

Conclusions

More research is needed to examine a broader variety of mental health concerns in physicians and to explore barriers to seeking care. The implication of poor physician mental health on patients should also be examined more closely. Finally, the reviewed literature lacks intersectional and longitudinal studies, as well as evaluations of interventions offered to improve mental wellbeing of physicians.

Peer Review reports

The World Health Organization (WHO) defines mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” [ 41 ] One in four people worldwide are affected by mental health concerns [ 40 ]. Physicians are particularly vulnerable to experiencing mental illness due to the nature of their work, which is often stressful and characterized by shift work, irregular work hours, and a high pressure environment [ 1 , 21 , 31 ]. In North America, many physicians work in private practices with no access to formal institutional supports, which can result in higher instances of social isolation [ 13 , 27 ]. The literature on physicians’ mental health is growing, partly due to general concerns about mental wellbeing of health care workers and partly due to recognition that health care workers globally are dissatisfied with their work, which results in burnout and attrition from the workforce [ 31 , 34 ]. As a consequence, more efforts have been made globally to improve physicians’ mental health and wellness, which is known as “The Quadruple Aim.” [ 34 ] While the literature on mental health is flourishing, however, it has not been systematically summarized. This makes it challenging to identify what is being done to improve physicians’ wellbeing and which solutions are particularly promising [ 7 , 31 , 33 , 37 , 38 ]. The goal of our paper is to address this gap.

This paper explores what is known from the existing peer-reviewed literature about the mental health status of physicians and physicians-in-training in North America. Specifically, we examine (1) what types of mental health concerns among physicians are commonly discussed in the literature; (2) what are the reported causes of mental health concerns in physicians; (3) what are the effects that mental health concerns may have on physicians and their patients; (4) what solutions are proposed to improve mental health of physicians; and (5) what are the barriers to seeking and providing care to physicians with mental health concerns. Conducting this scoping review, our goal is to summarize the existing research, identifying the need for a subsequent systematic review of the literature in one or more areas under the study. We also hope to identify evidence-based interventions that can be utilized to improve physicians’ mental wellbeing and to suggest directions for future research [ 2 ]. Evidence-based interventions might have a positive impact on physicians and improve the quality of patient care they provide.

A scoping review of the academic literature on the mental health of physicians and physicians-in-training in North America was conducted using Arksey and O’Malley’s [ 2 ] methodological framework. Our review objectives and broad focus, including the general questions posed to conduct the review, lend themselves to a scoping review approach, which is suitable for the analysis of a broader range of study designs and methodologies [ 2 ]. Our goal was to map the existing research on this topic and identify knowledge gaps, without making any prior assumptions about the literature’s scope, range, and key findings [ 29 ].

Stage 1: identify the research question

Following the guidelines for scoping reviews [ 2 ], we developed a broad research question for our literature search, asking what does the academic literature tell about mental health issues among physicians, residents, and medical students in North America ? Burnout and other mental health concerns often begin in medical training and continue to worsen throughout the years of practice [ 31 ]. Recognizing that the study and practice of medicine plays a role in the emergence of mental health concerns, we focus on practicing physicians – general practitioners, specialists, and surgeons – and those who are still in training – residents and medical students. We narrowed down the focus of inquiry by asking the following sub-questions:

What types of mental health concerns among physicians are commonly discussed in the literature?

What are the reported causes of mental health problems in physicians and what solutions are available to improve the mental wellbeing of physicians?

What are the barriers to seeking and providing care to physicians suffering from mental health problems?

Stage 2: identify the relevant studies

We included in our review empirical papers published during January 2008–January 2018 in peer-reviewed journals. Our exclusive focus on peer-reviewed and empirical literature reflected our goal to develop an evidence-based platform for understanding mental health concerns in physicians. Since our focus was on prevalence of mental health concerns and promising practices available to physicians in North America, we excluded articles that were more than 10 years old, suspecting that they might be too outdated for our research interest. We also excluded papers that were not in English or outside the region of interest. Using combinations of keywords developed in consultation with a professional librarian (See Table  1 ), we searched databases PUBMed, SCOPUS, CINAHL, and PsychNET. We also screened reference lists of the papers that came up in our original search to ensure that we did not miss any relevant literature.

Stage 3: literature selection

Publications were imported into a reference manager and screened for eligibility. During initial abstract screening, 146 records were excluded for being out of scope, 75 records were excluded for being outside the region of interest, and 4 papers were excluded because they could not be retrieved. The remaining 91 papers were included into the review. Figure  1 summarizes the literature search and selection.

PRISMA Flow Diagram

Stage 4: charting the data

A literature extraction tool was created in Microsoft Excel to record the author, date of publication, location, level of training, type of article (empirical, report, commentary), and topic. Both authors coded the data inductively, first independently reading five articles and generating themes from the data, then discussing our coding and developing a coding scheme that was subsequently applied to ten more papers. We then refined and finalized the coding scheme and used it to code the rest of the data. When faced with disagreements on narrowing down the themes, we discussed our reasoning and reached consensus.

Stage 5: collating, summarizing, and reporting the results

The data was summarized by frequency and type of publication, mental health topics, and level of training. The themes inductively derived from the data included (1) description of mental health concerns affecting physicians and physicians-in-training; (2) prevalence of mental health concerns among this population; (3) possible causes that can explain the emergence of mental health concerns; (4) solutions or interventions proposed to address mental health concerns; (5) effects of mental health concerns on physicians and on patient outcomes; and (6) barriers for seeking and providing help to physicians afflicted with mental health concerns. Each paper was coded based on its relevance to major theme(s) and, if warranted, secondary focus. Therefore, one paper could have been coded in more than one category. Upon analysis, we identified the gaps in the literature.

Characteristics of included literature

The initial search yielded 316 records of which 91 publications underwent full-text review and were included in our scoping review. Our analysis revealed that the publications appear to follow a trend of increase over the course of the last decade reflecting the growing interest in physicians’ mental health. More than half of the literature was published in the last 4 years included in the review, from 2014 to 2018 ( n  = 55), with most publications in 2016 ( n  = 18) (Fig.  2 ). The majority of papers ( n  = 36) focused on practicing physicians, followed by papers on residents ( n  = 22), medical students ( n  = 21), and those discussing medical professionals with different level of training ( n  = 12). The types of publications were mostly empirical ( n  = 71), of which 46 papers were quantitative. Furthermore, the vast majority of papers focused on the United States of America (USA) ( n  = 83), with less than 9% focusing on Canada ( n  = 8). The frequency of identified themes in the literature is broken down into prevalence of mental health concerns ( n  = 15), causes of mental health concerns ( n  = 18), effects of mental health concerns on physicians and patients ( n  = 12), solutions and interventions for mental health concerns ( n  = 46), and barriers to seeking and providing care for mental health concerns ( n  = 4) (Fig.  3 ).

Number of sources by characteristics of included literature

Frequency of themes in literature ( n  = 91)

Mental health concerns and their prevalence in the literature

In this thematic category ( n  = 15), we coded the papers discussing the prevalence of specific mental health concerns among physicians and those comparing physicians’ mental health to that of the general population. Most papers focused on burnout and stress ( n  = 69), which was followed by depression and suicidal ideation ( n  = 28), psychological harm and distress ( n  = 9), wellbeing and wellness ( n  = 8), and general mental health ( n  = 3) (Fig.  4 ). The literature also identified that, on average, burnout and mental health concerns affect 30–60% of all physicians and residents [ 4 , 5 , 8 , 9 , 15 , 25 , 26 ].

Number of sources by mental health topic discussed ( n  = 91)

There was some overlap between the papers discussing burnout, depression, and suicidal ideation, suggesting that work-related stress may lead to the emergence of more serious mental health problems [ 3 , 12 , 21 ], as well as addiction and substance abuse [ 22 , 27 ]. Residency training was shown to produce the highest rates of burnout [ 4 , 8 , 19 ].

Causes of mental health concerns

Papers discussing the causes of mental health concerns in physicians formed the second largest thematic category ( n  = 18). Unbalanced schedules and increasing administrative work were defined as key factors in producing poor mental health among physicians [ 4 , 5 , 6 , 13 , 15 , 27 ]. Some papers also suggested that the nature of the medical profession itself – competitive culture and prioritizing others – can lead to the emergence of mental health concerns [ 23 , 27 ]. Indeed, focus on qualities such as rigidity, perfectionism, and excessive devotion to work during the admission into medical programs fosters the selection of students who may be particularly vulnerable to mental illness in the future [ 21 , 24 ]. The third cluster of factors affecting mental health stemmed from structural issues, such as pressure from the government and insurance, fragmentation of care, and budget cuts [ 13 , 15 , 18 ]. Work overload, lack of control over work environment, lack of balance between effort and reward, poor sense of community among staff, lack of fairness and transparency by decision makers, and dissonance between one’s personal values and work tasks are the key causes for mental health concerns among physicians [ 20 ]. Govardhan et al. conceptualized causes for mental illness as having a cyclical nature - depression leads to burnout and depersonalization, which leads to patient dissatisfaction, causing job dissatisfaction and more depression [ 19 ].

Effects of mental health concerns on physicians and patients

A relatively small proportion of papers (13%) discussed the effects of mental health concerns on physicians and patients. The literature prioritized the direct effect of mental health on physicians ( n  = 11) with only one paper focusing solely on the indirect effects physicians’ mental health may have on patients. Poor mental health in physicians was linked to decreased mental and physical health [ 3 , 14 , 15 ]. In addition, mental health concerns in physicians were associated with reduction in work hours and the number of patients seen, decrease in job satisfaction, early retirement, and problems in personal life [ 3 , 5 , 15 ]. Lu et al. found that poor mental health in physicians may result in increased medical errors and the provision of suboptimal care [ 25 ]. Thus physicians’ mental wellbeing is linked to the quality of care provided to patients [ 3 , 4 , 5 , 10 , 17 ].

Solutions and interventions

In this largest thematic category ( n  = 46) we coded the literature that offered solutions for improving mental health among physicians. We identified four major levels of interventions suggested in the literature. A sizeable proportion of literature discussed the interventions that can be broadly categorized as primary prevention of mental illness. These papers proposed to increase awareness of physicians’ mental health and to develop strategies that can help to prevent burnout from occurring in the first place [ 4 , 12 ]. Some literature also suggested programs that can help to increase resilience among physicians to withstand stress and burnout [ 9 , 20 , 27 ]. We considered the papers referring to the strategies targeting physicians currently suffering from poor mental health as tertiary prevention . This literature offered insights about mindfulness-based training and similar wellness programs that can increase self-awareness [ 16 , 18 , 27 ], as well as programs aiming to improve mental wellbeing by focusing on physical health [ 17 ].

While the aforementioned interventions target individual physicians, some literature proposed workplace/institutional interventions with primary focus on changing workplace policies and organizational culture [ 4 , 13 , 23 , 25 ]. Reducing hours spent at work and paperwork demands or developing guidelines for how long each patient is seen have been identified by some researchers as useful strategies for improving mental health [ 6 , 11 , 17 ]. Offering access to mental health services outside of one’s place of employment or training could reduce the fear of stigmatization at the workplace [ 5 , 12 ]. The proposals for cultural shift in medicine were mainly focused on promoting a less competitive culture, changing power dynamics between physicians and physicians-in-training, and improving wellbeing among medical students and residents. The literature also proposed that the medical profession needs to put more emphasis on supporting trainees, eliminating harassment, and building strong leadership [ 23 ]. Changing curriculum for medical students was considered a necessary step for the cultural shift [ 20 ]. Finally, while we only reviewed one paper that directly dealt with the governmental level of prevention, we felt that it necessitated its own sub-thematic category because it identified the link between government policy, such as health care reforms and budget cuts, and the services and care physicians can provide to their patients [ 13 ].

Barriers to seeking and providing care

Only four papers were summarized in this thematic category that explored what the literature says about barriers for seeking and providing care for physicians suffering from mental health concerns. Based on our analysis, we identified two levels of factors that can impact access to mental health care among physicians and physicians-in-training.

Individual level barriers stem from intrinsic barriers that individual physicians may experience, such as minimizing the illness [ 21 ], refusing to seek help or take part in wellness programs [ 14 ], and promoting the culture of stoicism [ 27 ] among physicians. Another barrier is stigma associated with having a mental illness. Although stigma might be experienced personally, literature suggests that acknowledging the existence of mental health concerns may have negative consequences for physicians, including loss of medical license, hospital privileges, or professional advancement [ 10 , 21 , 27 ].

Structural barriers refer to the lack of formal support for mental wellbeing [ 3 ], poor access to counselling [ 6 ], lack of promotion of available wellness programs [ 10 ], and cost of treatment. Lack of research that tests the efficacy of programs and interventions aiming to improve mental health of physicians makes it challenging to develop evidence-based programs that can be implemented at a wider scale [ 5 , 11 , 12 , 18 , 20 ].

Our analysis of the existing literature on mental health concerns in physicians and physicians-in-training in North America generated five thematic categories. Over half of the reviewed papers focused on proposing solutions, but only a few described programs that were empirically tested and proven to work. Less common were papers discussing causes for deterioration of mental health in physicians (20%) and prevalence of mental illness (16%). The literature on the effects of mental health concerns on physicians and patients (13%) focused predominantly on physicians with only a few linking physicians’ poor mental health to medical errors and decreased patient satisfaction [ 3 , 4 , 16 , 24 ]. We found that the focus on barriers for seeking and receiving help for mental health concerns (4%) was least prevalent. The topic of burnout dominated the literature (76%). It seems that the nature of physicians’ work fosters the environment that causes poor mental health [ 1 , 21 , 31 ].

While emphasis on burnout is certainly warranted, it might take away the attention paid to other mental health concerns that carry more stigma, such as depression or anxiety. Establishing a more explicit focus on other mental health concerns might promote awareness of these problems in physicians and reduce the fear such diagnosis may have for doctors’ job security [ 10 ]. On the other hand, utilizing the popularity and non-stigmatizing image of “burnout” might be instrumental in developing interventions promoting mental wellbeing among a broad range of physicians and physicians-in-training.

Table  2 summarizes the key findings from the reviewed literature that are important for our understanding of physician mental health. In order to explicitly summarize the gaps in the literature, we mapped them alongside the areas that have been relatively well studied. We found that although non-empirical papers discussed physicians’ mental wellbeing broadly, most empirical papers focused on medical specialty (e.g. neurosurgeons, family medicine, etc.) [ 4 , 8 , 15 , 19 , 25 , 28 , 35 , 36 ]. Exclusive focus on professional specialty is justified if it features a unique context for generation of mental health concerns, but it limits the ability to generalize the findings to a broader population of physicians. Also, while some papers examined the impact of gender on mental health [ 7 , 32 , 39 ], only one paper considered ethnicity as a potential factor for mental health concerns and found no association [ 4 ]. Given that mental health in the general population varies by gender, ethnicity, age, and sexual orientation, it would be prudent to examine mental health among physicians using an intersectional analysis [ 30 , 32 , 39 ]. Finally, of the empirical studies we reviewed, all but one had a cross-sectional design. Longitudinal design might offer a better understanding of the emergence and development of mental health concerns in physicians and tailor interventions to different stages of professional career. Additionally, it could provide an opportunity to evaluate programs’ and policies’ effectiveness in improving physicians’ mental health. This would also help to address the gap that we identified in the literature – an overarching focus on proposing solutions with little demonstrated evidence they actually work.

This review has several limitations. First, our focus on academic literature may have resulted in overlooking the papers that are not peer-reviewed but may provide interesting solutions to physician mental health concerns. It is possible that grey literature – reports and analyses published by government and professional organizations – offers possible solutions that we did not include in our analysis or offers a different view on physicians’ mental health. Additionally, older papers and papers not published in English may have information or interesting solutions that we did not include in our review. Second, although our findings suggest that the theme of burnout dominated the literature, this may be the result of the search criteria we employed. Third, following the scoping review methodology [ 2 ], we did not assess the quality of the papers, focusing instead on the overview of the literature. Finally, our research was restricted to North America, specifically Canada and the USA. We excluded Mexico because we believed that compared to the context of medical practice in Canada and the USA, which have some similarities, the work experiences of Mexican physicians might be different and the proposed solutions might not be readily applicable to the context of practice in Canada and the USA. However, it is important to note that differences in organization of medical practice in Canada and the USA do exist, as do differences across and within provinces in Canada and the USA. A comparative analysis can shed light on how the structure and organization of medical practice shapes the emergence of mental health concerns.

The scoping review we conducted contributes to the existing research on mental wellbeing of American and Canadian physicians by summarizing key knowledge areas and identifying key gaps and directions for future research. While the papers reviewed in our analysis focused on North America, we believe that they might be applicable to the global medical workforce. Identifying key gaps in our knowledge, we are calling for further research on these topics, including examination of medical training curricula and its impact on mental wellbeing of medical students and residents, research on common mental health concerns such as depression or anxiety, studies utilizing intersectional and longitudinal approaches, and program evaluations assessing the effectiveness of interventions aiming to improve mental wellbeing of physicians. Focus on the effect physicians’ mental health may have on the quality of care provided to patients might facilitate support from government and policy makers. We believe that large-scale interventions that are proven to work effectively can utilize an upstream approach for improving the mental health of physicians and physicians-in-training.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

United States of America

World Health Organization

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Mihailescu, M., Neiterman, E. A scoping review of the literature on the current mental health status of physicians and physicians-in-training in North America. BMC Public Health 19 , 1363 (2019). https://doi.org/10.1186/s12889-019-7661-9

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Research Topics & Ideas: Mental Health

100+ Mental Health Research Topic Ideas To Fast-Track Your Project

If you’re just starting out exploring mental health topics for your dissertation, thesis or research project, you’ve come to the right place. In this post, we’ll help kickstart your research topic ideation process by providing a hearty list of mental health-related research topics and ideas.

PS – This is just the start…

We know it’s exciting to run through a list of research topics, but please keep in mind that this list is just a starting point . To develop a suitable education-related research topic, you’ll need to identify a clear and convincing research gap , and a viable plan of action to fill that gap.

If this sounds foreign to you, check out our free research topic webinar that explores how to find and refine a high-quality research topic, from scratch. Alternatively, if you’d like hands-on help, consider our 1-on-1 coaching service .

Overview: Mental Health Topic Ideas

• Mood disorders
• Anxiety disorders
• Psychotic disorders
• Personality disorders
• Obsessive-compulsive disorders
• Post-traumatic stress disorder (PTSD)
• Neurodevelopmental disorders
• Eating disorders
• Substance-related disorders

Mood Disorders

Research in mood disorders can help understand their causes and improve treatment methods. Here are a few ideas to get you started.

• The impact of genetics on the susceptibility to depression
• Efficacy of antidepressants vs. cognitive behavioural therapy
• The role of gut microbiota in mood regulation
• Cultural variations in the experience and diagnosis of bipolar disorder
• Seasonal Affective Disorder: Environmental factors and treatment
• The link between depression and chronic illnesses
• Exercise as an adjunct treatment for mood disorders
• Hormonal changes and mood swings in postpartum women
• Stigma around mood disorders in the workplace
• Suicidal tendencies among patients with severe mood disorders

Anxiety Disorders

Research topics in this category can potentially explore the triggers, coping mechanisms, or treatment efficacy for anxiety disorders.

• The relationship between social media and anxiety
• Exposure therapy effectiveness in treating phobias
• Generalised Anxiety Disorder in children: Early signs and interventions
• The role of mindfulness in treating anxiety
• Genetics and heritability of anxiety disorders
• The link between anxiety disorders and heart disease
• Anxiety prevalence in LGBTQ+ communities
• Caffeine consumption and its impact on anxiety levels
• The economic cost of untreated anxiety disorders
• Virtual Reality as a treatment method for anxiety disorders

Psychotic Disorders

Within this space, your research topic could potentially aim to investigate the underlying factors and treatment possibilities for psychotic disorders.

• Early signs and interventions in adolescent psychosis
• Brain imaging techniques for diagnosing psychotic disorders
• The efficacy of antipsychotic medication
• The role of family history in psychotic disorders
• Misdiagnosis and delayed treatment of psychotic disorders
• Co-morbidity of psychotic and mood disorders
• The relationship between substance abuse and psychotic disorders
• Art therapy as a treatment for schizophrenia
• Public perception and stigma around psychotic disorders
• Hospital vs. community-based care for psychotic disorders

Personality Disorders

Research topics within in this area could delve into the identification, management, and social implications of personality disorders.

• Long-term outcomes of borderline personality disorder
• Antisocial personality disorder and criminal behaviour
• The role of early life experiences in developing personality disorders
• Narcissistic personality disorder in corporate leaders
• Gender differences in personality disorders
• Diagnosis challenges for Cluster A personality disorders
• Emotional intelligence and its role in treating personality disorders
• Psychotherapy methods for treating personality disorders
• Personality disorders in the elderly population
• Stigma and misconceptions about personality disorders

Obsessive-Compulsive Disorders

Within this space, research topics could focus on the causes, symptoms, or treatment of disorders like OCD and hoarding.

• OCD and its relationship with anxiety disorders
• Cognitive mechanisms behind hoarding behaviour
• Deep Brain Stimulation as a treatment for severe OCD
• The impact of OCD on academic performance in students
• Role of family and social networks in treating OCD
• Alternative treatments for hoarding disorder
• Childhood onset OCD: Diagnosis and treatment
• OCD and religious obsessions
• The impact of OCD on family dynamics
• Body Dysmorphic Disorder: Causes and treatment

Post-Traumatic Stress Disorder (PTSD)

Research topics in this area could explore the triggers, symptoms, and treatments for PTSD. Here are some thought starters to get you moving.

• PTSD in military veterans: Coping mechanisms and treatment
• Childhood trauma and adult onset PTSD
• Eye Movement Desensitisation and Reprocessing (EMDR) efficacy
• Role of emotional support animals in treating PTSD
• Gender differences in PTSD occurrence and treatment
• Effectiveness of group therapy for PTSD patients
• PTSD and substance abuse: A dual diagnosis
• First responders and rates of PTSD
• Domestic violence as a cause of PTSD
• The neurobiology of PTSD

Neurodevelopmental Disorders

This category of mental health aims to better understand disorders like Autism and ADHD and their impact on day-to-day life.

• Early diagnosis and interventions for Autism Spectrum Disorder
• ADHD medication and its impact on academic performance
• Parental coping strategies for children with neurodevelopmental disorders
• Autism and gender: Diagnosis disparities
• The role of diet in managing ADHD symptoms
• Neurodevelopmental disorders in the criminal justice system
• Genetic factors influencing Autism
• ADHD and its relationship with sleep disorders
• Educational adaptations for children with neurodevelopmental disorders
• Neurodevelopmental disorders and stigma in schools

Eating Disorders

Research topics within this space can explore the psychological, social, and biological aspects of eating disorders.

• The role of social media in promoting eating disorders
• Family dynamics and their impact on anorexia
• Biological basis of binge-eating disorder
• Treatment outcomes for bulimia nervosa
• Eating disorders in athletes
• Media portrayal of body image and its impact
• Eating disorders and gender: Are men underdiagnosed?
• Cultural variations in eating disorders
• The relationship between obesity and eating disorders
• Eating disorders in the LGBTQ+ community

Substance-Related Disorders

Research topics in this category can focus on addiction mechanisms, treatment options, and social implications.

• Efficacy of rehabilitation centres for alcohol addiction
• The role of genetics in substance abuse
• Substance abuse and its impact on family dynamics
• Prescription drug abuse among the elderly
• Legalisation of marijuana and its impact on substance abuse rates
• Alcoholism and its relationship with liver diseases
• Opioid crisis: Causes and solutions
• Substance abuse education in schools: Is it effective?
• Harm reduction strategies for drug abuse
• Co-occurring mental health disorders in substance abusers

Choosing A Research Topic

These research topic ideas we’ve covered here serve as thought starters to help you explore different areas within mental health. They are intentionally very broad and open-ended. By engaging with the currently literature in your field of interest, you’ll be able to narrow down your focus to a specific research gap .

It’s important to consider a variety of factors when choosing a topic for your dissertation or thesis . Think about the relevance of the topic, its feasibility , and the resources available to you, including time, data, and academic guidance. Also, consider your own interest and expertise in the subject, as this will sustain you through the research process.

Always consult with your academic advisor to ensure that your chosen topic aligns with academic requirements and offers a meaningful contribution to the field. If you need help choosing a topic, consider our private coaching service.

Good morning everyone. This are very patent topics for research in neuroscience. Thank you for guidance

What if everything is important, original and intresting? as in Neuroscience. I find myself overwhelmd with tens of relveant areas and within each area many optional topics. I ask myself if importance (for example – able to treat people suffering) is more relevant than what intrest me, and on the other hand if what advance me further in my career should not also be a consideration?

This information is really helpful and have learnt alot

Phd research topics on implementation of mental health policy in Nigeria :the prospects, challenges and way forward.

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Research-Practice Partnerships for the Development of School Mental Health Interventions: An Introduction to the Special Issue

• Review Paper
• Open access
• Published: 24 August 2024

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• Gwendolyn M. Lawson   ORCID: orcid.org/0000-0003-4363-3169 1 , 2 &
• Julie Sarno Owens   ORCID: orcid.org/0000-0002-4674-9637 3  

The rising prevalence of mental health challenges among youth has created a pressing need for effective, feasible, equitable, and contextually relevant interventions. Educators and school mental health professionals face critical challenges in helping students overcome such barriers to school success. This makes the need for school-based intervention development research particularly that conducted in the context of collaborative research-practice partnerships, greater than ever. Despite the critical importance of iterative intervention development work, such work often receives less in attention in the published literature compared to studies about the outcomes of interventions. The goal of this special issue is to highlight innovative and rigorous research that describes the process of iteratively developing school mental health services in partnership with educators. Each paper in the special issue describes how education partners (and others including students, families, and other community partners) contributed to the development of an intervention or implementation strategy (i.e., a method or technique to enhance intervention adoption, implementation, or sustainment), how data informed iterations of the intervention or strategy, considerations related to contextual appropriateness, and lessons learned related to community-partnered school-based intervention development. In this introduction paper, we provide a context for this work and highlight innovations across papers in the special issue.

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Mental health challenges represent a key cause of distress and impairment among children and adolescents (Merikangas et al., 2010 ), and these challenges have exacerbated in recent years (Deng et al., 2023 ). The COVID-19 pandemic significantly impacted the academic and social well-being of many children (Institute of Education Sciences, 2022 ; Murthy, 2022 ) with impacts amplified for students facing barriers to learning (e.g., those receiving special education), students of color, and students with other marginalized identities (Bitler et al., 2023 ; Fahle et al., 2023 ). Educators and school mental health professionals (SMHPs) play a critical role in addressing these mental health needs (Hoover & Bostic, 2021 ), yet they face many challenges in accessing and implementing interventions to support student mental health. For example, many educators and SMHPs have limited training in such interventions (e.g., Weiss et al., 2024 ) and typical school infrastructure, resources, and schedules often limit the availability of implementation supports (e.g. Connors et al., 2021 ). Similarly, among existing interventions, many are not accessible to educators, or viewed as feasible, acceptable, or culturally matched to the student body (e.g., Murray et al., 2022 ). Innovative research focused on intervention development in schools is needed to overcome these challenges. We argue that this research must use iterative development processes in the context of meaningful research-practice partnerships to develop feasible, equitable, contextually relevant interventions to meet the mental health needs of students in schools.

The goal of this special issue is to highlight innovative and rigorous research that describes the process of iteratively developing school mental health services in partnership with educators, school administrators, and intervention recipients. Each paper in the special issue describes how education partners contributed to the development or adaptation of an intervention or implementation strategy (i.e., a method or technique to enhance intervention adoption, implementation, or sustainment) and how data gathered from multiple sources and representing multiple voices informed iterations of the intervention or strategy. Each paper also highlights considerations related to contextual appropriateness (i.e., fit to a particular school, district, or cultural context) and lessons learned related to community-partnered, school-based intervention development. In this introduction paper, we describe the context and need for this work and highlight innovations across papers in this special issue that advance science and practice in the field of school mental health.

School-Based Intervention Development Research

In the early decades of youth psychotherapy research, most interventions were developed and tested in university or laboratory settings and later transported to community settings (Weisz, 2014 ). However, subsequent research revealed limitations of this approach. For example, interventions with demonstrated efficacy were not adopted or implemented consistently by many community- and school-based mental health providers, in part because the interventions are not viewed as feasible or contextually relevant to the practice setting (Evans et al., 2013 ; Garland et al., 2010 ; Owens et al., 2014 ; Weiss et al., 2024 ). In addition, evidence suggests (Assenany & McIntosh, 2002 ; Nilsen et al., 2013 ) that these interventions have limited effectiveness for a sizable minority of youth, as the samples with which the interventions were initially evaluated often did not generalize to the broader population served (e.g., with regard to economic status, race, immigration status, language, diagnostic status or severity).

In contrast to this linear approach, models such as the deployment-focused model (Weisz et al., 2005 ) call for interventions to be developed and evaluated in the context in which they will be used and in partnership with the providers and recipients of the interventions, so that fit and contextual relevance can be better considered from the earliest stages of development. Given that schools are a key setting in which youth receive mental health services (Ali et al., 2019 ; Duong et al., 2021 ), they represent an opportune context for partnered research in intervention development. Indeed, in the last two decades, the field has witnessed an increase in embedded intervention development research for youth in schools (see Evans et al., 2023 ).

However, given barriers to delivering effective mental health interventions in schools (Connors et al., 2021 ; Murray et al., 2022 ; Weiss et al., 2024 ), intervention development research-practice teams are tasked with several key challenges. First, they must develop interventions that are effective at improving the desired student outcomes . The development phase provides important opportunities for all partners to inform the goals and design of future efficacy and effectiveness studies, including who is included in the trial and what outcomes are assessed. Second, teams must also develop interventions that are feasible and contextually relevant so they can ultimately be implemented and sustained in school settings without support from a research or evaluation team. Third, teams must operate in a way that supports educators’ capacity to understand, prioritize, implement, and sustain use of interventions that have evidence of effectiveness. Addressing each of these goals at the development phase is critical for narrowing the gap between scientific discovery and uptake and implementation of interventions. Indeed, these goals are prioritized within the requirements of federal agencies that provide much of the funding for intervention development work for youth in schools, including the Institute of Education Sciences (IES) and the National Institute of Health (NIH; see Doolittle & Buckley, 2024 ; Rooney et al., 2024 ).

However, addressing these goals also likely requires an evolution from historical approaches to the development of mental health interventions, such as those that prioritize the perspectives of the researchers. Namely, it requires the science community to better incorporate the voices, perspectives, and challenges of educators and youth, and it requires the practice community to be accountable for prioritizing science-based interventions. The work featured in this special issue highlights ways in which this evolution has started to emerge in recent years. We believe that work using iterative and partner-engaged approaches, such as the approaches described here, can contribute to the development of interventions and implementation strategies that will more effectively address youth mental health problems in schools.

Benefits of Meaningful Partnerships in School-Based Research

The development of school mental health interventions for use in K-12 schools is an opportune context for research-practice partnerships. In recent years, there has been a growing emphasis on ensuring that these partnerships are meaningful; built upon the values of equality, mutuality, respect, and reciprocity; and that research projects incorporate educators’ perspectives across all stages of planning and execution (Pellecchia et al., 2018 ; Price et al., 2020 ). There are a number of models to guide community-partnered research, including community-based participatory research (Israel et al., 2001 ), participatory action research (Baum et al., 2006 ), co-creation science (Craig et al., 2021 ; Greenhalgh et al., 2019 ), community-partnered participatory research (Jones & Wells, 2007 ), and community-academic partnerships (Drahota et al., 2016 ). These models share common values of (a) collaboration and power sharing between researchers and community members across all research phases (e.g., selecting research questions and outcome measures, study design and execution, interpreting data, disseminating results), and (b) working toward shared goals that benefit all partners. If these goals are realized, it creates a critical context for work that bridges expertise and perspectives from science and practice. We use the term research-practice partnerships in this article, although we note that articles in this special issue use a range of terms for such partnerships.

When done well, such partnerships have the potential to produce science-informed and practice-informed interventions of high feasibility, utility, and impact. When educators, students and/or families are involved at the early stages of research projects (e.g., collaboratively deciding about the goals of the intervention to be developed and the research design) researchers derive benefit because those who deliver and receive interventions are in the best position to offer feedback and recommendations regarding intervention usability, acceptability, and contextual appropriateness (Lyon & Koerner, 2016 ; Schleider, 2023 ). Such information, when integrated, enhances the likelihood that the developed interventions address an important need and are relevant and valuable to all partners, as evidenced by the work of Bottiani and colleagues ( 2024 ). Such partnerships also enhance the likelihood that the research designs are acceptable and feasible, which sustains educator and student participation so that short- and long-term impacts can be assessed. Although meaningful partnered research may represent a more complex process than that which occurs in more superficial partnerships, it offers unparalleled advantages for science. Indeed, we argue that it is imperative for researchers to meaningfully involve educators, students, and families, particularly those whose voices have been historically under-represented in research, if we are going to adequately serve the increasingly diverse needs of educators and students in the United States. Several papers in this special issue describe processes for meaningfully involving groups who have been historically under-represented in research. For example, Bartuska and colleagues ( 2024 ) engaged ethnically and racially diverse high school students in a paid summer internship program to support intervention re-design. Other teams used focus groups to gather perspectives from Black youth experiencing social anxiety (Masia Warner et al., 2024 ) and autistic youth and their caregivers (Locke et al., 2024 ; Pugliese et al., 2024 ).

Research-practice partnerships also have the potential to benefit educators, students, and families as well. First, when given opportunity to provide input and share decision-making power during the early stages of intervention development, such partners can shape the intervention, research questions, and project deliverables to ensure they align with their priorities (Pellecchia et al., 2018 ). Second, active participation on research projects may offer unique access to trainings or interventions that would not otherwise be available, and meaningful partnerships help ensure that these trainings and interventions meet the needs of their staff and students. Lastly, school partner participation in research is thought to help create local expertise and build internal capacity that can support sustainment (Wallerstein et al., 2020 ). Partnered research involves an investment of time and resources and new ways of thinking for both research teams and school personnel. However, we argue that making this investment from the earliest stages of research projects can offer short and long-term dividends for both science and practice.

As is exemplified by the studies contained in this special issue, a number of approaches can be used to develop meaningful research-practice partnerships and to obtain partner input across research project phases. For example, many teams use advisory boards or other workgroups to engage and elicit input from education partners (e.g., Kuriyan et al., 2024 ; Lawson et al., 2024 ; Nguyen et al., 2024 ; Owens et al., 2014 ; Sharkey et al., 2024 ). Other projects use regular meeting structures for shared decision-making across key partners (e.g., Albright et al., 2024 ; Bottiani et al., 2024 ; Goodman et al. 2024 , May et al., 2024 ). Several studies in this special issue describe specific processes, such as cognitive walkthroughs (Collins et al. 2024 ) or concept mapping (Okamura et al., 2024 ) used to gather systematic input from educators. Regardless of the specific approaches used, activities should be guided by principles of shared decision-making power across all project stages, reciprocal resource sharing, and transparent communication, roles, and processes for evaluation (see Jones & Wells, 2007 ).

A recent scoping review identified characteristics and processes indicative of partnership success, which included strong and shared leadership, flexibility, effective communication strategies, shared allocation of resources, and structures to support partnership processes (Brush et al., 2020 ). Papers within this special issue highlight specific lessons learned about navigating these processes, such as the importance of intentional decisions about which activities and meetings are best led by research partners versus education partners, and which should be co-lead together (Albright et al., 2024 ; Pas et al., 2024 ), so that expertise of each partner is given equal attention and respect. Owens et al. ( 2024 ) also discuss how greater power is often ascribed to research partners relative to practice partners, as well ways to elevate the comfort, confidence, and voice of practice partners within this context. Lastly, May et al. ( 2024 ) discuss how to navigate the competing priorities and time constraints of all partners in a way that respects the realities of different work demands across partners and allows all partners to contribute meaningfully. Other key lessons highlighted within special issue papers include the importance of researchers spending informal time in community spaces (Goodman et al., 2024 ) and aligning the intervention development process with district-level initiatives and priorities (Bottiani et al., 2024 ); the utility of using motivational interviewing approaches to build trust and address partner needs and priorities (Pas et al., 2024 ); and the value of shifting the sense of ownership to key partners outside of the traditional research team (Bartuska et al, 2024 ).

Use of Data to Inform Iterative Development Process

It is recommended that iterative intervention development processes use data from multiple sources using multiple methodologies to guide revisions to the intervention in development (e.g., Institute of Education Sciences, 2023 ). The development process typically begins with developing a theory of change or logic model regarding the intended malleable factors, mechanisms of change, and outcomes targeted by the intervention. Gaining consensus within the research-practice partnership on the critical constructs within these models is important, as they guide what should be prioritized in the preliminary assessment of proximal and distal outcomes (e.g., reduction of problems, disproportionality in outcomes, enhancement of skills, goal achievements). Along with specifying student-level outcomes, it is also important to specify key constructs related to implementation. In particular, constructs such as acceptability (i.e., the perception that a given practice is satisfactory; Proctor et al., 2011 ), feasibility (i.e., the extent to which an innovation can be used in a given setting; Proctor et al., 2011 ), and usability (i.e., the extent to which a product can be used by the intended users to achieve the specified goals with effectiveness and satisfaction; Lyon & Bruns, 2019 ), are necessary precursors for interventions to be implemented and sustained.

These implementation constructs can be measured using quantitative, qualitative, or mixed-method approaches. Quantitative measurement approaches used in studies in this special include documenting the number of sessions or trainings completed to assess feasibility (e.g.,Albright et al., 2024 ; Masia Warner et al., 2024 ), employing observational measures of fidelity (Capps et al., 2024 ; Smith et al., 2024 ), and using rating scales to assess constructs such as acceptability (nearly all studies in this issue). Qualitative measurement approaches used include semi-structured interviews (e.g., Lawson et al., 2024 ) or focus groups (e.g., Pugliese et al., 2024 ), as well coding of field notes (e.g., Nguyen et al., 2024 ) and descriptive analysis of open-ended feedback responses (e.g., Sharkey et al., 2024 ). In addition, several author teams highlight the ways in which qualitative or mixed methods approaches can enable a deeper understanding of the constructs of interest compared to quantitative measurement alone (e.g., Capps et al., 2024 ; Lawson et al., 2024 ; Owens et al., 2024 ; Smith et al., 2024 ) and how measuring these constructs from the perspective of multiple participant groups (such as those who deliver and receive an intervention) with each iteration of the intervention can lead to a richer understanding of these constructs (e.g., Pugliese et al., 2024 , Masia Warner et al., 2024 ).

The research-practice partnership may also choose to assess the most relevant contextual factors (e.g., inner and outer setting characteristics) and implementer characteristics (Aarons et al., 2011 ; Moullin et al., 2019 ), as such factors are related to intervention adoption, implementation, and sustainability. The measurement and consideration of contextual factors across these levels is critical for developing interventions that are acceptable, feasible, and contextually appropriate. Studies in this special issue highlight the importance of constructs at the individual level, such as implementers’ knowledge, skills, attitudes, motivations and comfort (e.g., Pas et al., 2024 ; Sharkey et al., 2024 ). They also highlight the role of school leaders, champions, school climate and culture, and the organizational structure within schools needed to support interventions (Locke et al., 2024 ; Okamura et al., 2024 ; Ouellette et al., 2024 ). Other studies highlight important lessons learned about outer setting factors such as funding sources, partnering community agencies, policies and sociopolitical contexts (May et al., 2024 ; Owens et al., 2024 ).

Research-practice partnerships also must determine the process by which they will use the data to refine the intervention in a way that meets a stated need while ensuring that the core elements or mechanisms of change are retained. For example, with quantitative measures, a team might determine that a given score will indicate adequate acceptability, feasibility or usability, whereas scores below this threshold would indicate a need for refinement (e.g., Collins et al., 2024 ). With qualitative data (e.g., from interviews or focus groups), research teams might identify themes and use a structured process for these themes to guide the next iteration of the intervention (e.g., Kuriyan et al., 2024 ; Lawson et al., 2024 ; Nguyen et al., 2024 ). Several of the studies featured in this special issue highlight the potential utility of using frameworks from the field of implementation science to organize data or guide modification processes. For example, some author teams organized data according to the Framework for Reporting Adaptations and Modifications (FRAME; Albright et al. 2024 , Kuriyan et al. 2024 ) or the Consolidated Framework for Implementation Research (CFIR; Bartuska et al. 2024 , Kuriyan et al. 2024 ). Others used the Exploration Preparation Implementation Sustainment (EPIS) framework to guide study activities (Albright et al., 2024 , Locke et al., 2024 ; Ouellette et al., 2024 ). Regardless of the specific processes used, rigorous measurement of implementation and/or effectiveness outcomes at the intervention development stage provides opportunities to detect and address challenges with implementation and/or measurement of outcomes prior to expending resources on large-scale efficacy or effectiveness evaluation.

Purpose of the Special Issue

Given the significant mental health needs of youth in schools and the challenges faced by educators in meeting these needs, continued evolution in school mental health intervention development research is warranted. With this special issue, our goal is to advance the literature by providing examples of rigorous, systematic processes for the development or adaptation of interventions or implementation strategies informed by meaning partnerships with educators, youth, and family. The papers in this issue highlight ways to form meaningful partnerships as well as lessons learned about partnership development, balancing power differentials, elevating marginalized voices, and ensuring that developed interventions are contextually appropriate. We hope the lessons highlighted in these papers will contribute to the field’s continued evolution to using more collaborative and iterative approaches to intervention development. These studies reveal multiple methods for gathering data about feasibility, acceptability, utility and preliminary effectiveness, as well as strategies for how to use data to inform modifications. The interventions and implementation strategies described in these papers focus on a range of mental health concerns, including internalizing concerns (e.g., Masia Warner et al., 2024 ), externalizing concerns (e.g., Albright et al., 2024 ), and substance use prevention (Okamura et al., 2024 ). They are designed for a range of student age groups, from elementary (e.g., Ouellette et al., 2024 ) to secondary (e.g., Bartuska et al., 2024 ) and across multiple tiers of support. Moreover, the interventions and implementation strategies described in this special issue were developed or adapted with input from a range of educators and intervention recipients, including teachers (e.g., Smith et al., 2024 ), SMHPs (e.g., Kuriyan et al., 2024 ); care extender providers (e.g., Goodman et al., 2024 ); principals (e.g., Collins et al., 2024 ); school district leaders (e.g., May et al., 2024 ); students (e.g., Capps et al., 2024 ); and caregivers (e.g., Locke et al., 2024 ). The special issue also includes perspectives from scientists at IES (Doolittle et al., 2024 ) and NIMH (Rooney et al., 2024 ) describing their respective priorities related to school-based intervention development and optimization research. Lastly we are grateful for the commentaries provided by from leaders in the field (Evans & Bakhtiari, 2024 ; Lyon, 2024 ).

The development of contextually appropriate, usable, and effective interventions and implementation strategies to support children’s mental health within the school setting is more important than ever, given the role of schools in responding to the current pediatric mental health crisis. Given the sociopolitical climate related to mental health issues and socioemotional learning in schools, this work is also more challenging than ever. The papers in this special issue highlight key themes regarding community and school partnerships, data-based iterative development, and addressing contextual appropriateness in the unique school context. We hope that they will be a valuable resource for school-based intervention development research projects and stimulate innovations that narrow the research-practice gap.

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While writing this article, Dr. Lawson’s research was funded by the National Institute of Mental Health under Grant K23MH122577 and Dr. Owens’ research was funded by the Institute of Education Sciences, U.S. Department of Education, through Grants R350A210224, R305A200423, R324A190154 to Ohio University. The opinions expressed are those of the authors and do not represent views of the National Institute of Mental Health or the U.S. Department of Education.

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Lawson, G.M., Owens, J.S. Research-Practice Partnerships for the Development of School Mental Health Interventions: An Introduction to the Special Issue. School Mental Health (2024). https://doi.org/10.1007/s12310-024-09707-0

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Examining the mental health services among people with mental disorders: a literature review

• Yunqi Gao 1 ,
• Richard Burns 1 ,
• Liana Leach 1 ,
• Miranda R. Chilver 1 &
• Peter Butterworth 2 , 3  

BMC Psychiatry volume  24 , Article number:  568 ( 2024 ) Cite this article

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Mental disorders are a significant contributor to disease burden. However, there is a large treatment gap for common mental disorders worldwide. This systematic review summarizes the factors associated with mental health service use.

PubMed, Scopus, and the Web of Science were searched for articles describing the predictors of and barriers to mental health service use among people with mental disorders from January 2012 to August 2023. The initial search yielded 3230 articles, 2366 remained after removing duplicates, and 237 studies remained after the title and abstract screening. In total, 40 studies met the inclusion and exclusion criteria.

Middle-aged participants, females, Caucasian ethnicity, and higher household income were more likely to access mental health services. The use of services was also associated with the severity of mental symptoms. The association between employment, marital status, and mental health services was inconclusive due to limited studies. High financial costs, lack of transportation, and scarcity of mental health services were structural factors found to be associated with lower rates of mental health service use. Attitudinal barriers, mental health stigma, and cultural beliefs also contributed to the lower rates of mental health service use.

This systematic review found that several socio-demographic characteristics were strongly associated with using mental health services. Policymakers and those providing mental health services can use this information to better understand and respond to inequalities in mental health service use and improve access to mental health treatment.

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Introduction

Mental disorders such as depression and anxiety are prevalent, with nationally representative studies showing that one-fifth of Australians experience a mental disorder each year [ 5 ]. More recent estimates derived from a similar survey during the period of the COVID-19 pandemic were 21.5% [ 11 ]. Mental illness can reduce the quality of life, and increase the likelihood of communicable and non-communicable diseases [ 116 , 137 ], and is among the costliest burdens in developed countries [ 22 , 34 , 80 ]. The National Mental Health Commission [ 96 ] stated that the annual cost of mental ill-health in Australia was around $4000 per person or $60 billion. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 reported that mental disorders rank the seventh leading cause of disability-adjusted life years and the second leading cause of years lived with disability [ 48 ]. Helliwell et al. [ 56 ] indicated that chronic mental illness was a key determinant of unhappiness, and it triggered more pain than physical illness. Mental health issues can have a spillover effect on all areas of life, poor mental health conditions might lead to lower educational achievements and work performance, substance abuse, and violence [ 102 ]. In Australia, despite considerable additional investment in the provision of mental health services research suggests that the rate of psychological distress at the population level has been increasing [ 38 ], this has been argued to reflect that people who most need mental health treatment are not accessing services. Insufficient numbers of mental health services and mental healthcare professionals and inadequate health literacy have been reported as the pivotal determinants of poor mental health [ 18 ]. Previous studies have reported large treatment gaps in mental health services; finding only 42–44% of individuals with mental illness seek help from any medical or professional service provider [ 85 , 112 ] and this active proportion was much lower in low and middle-income countries [ 32 , 114 , 130 ].

Several studies have investigated factors associated with high and low rates of mental health service use and identified potential barriers to accessing mental health service use. Demographic, social, and structural factors have been associated with low rates of mental health service use. Structural barriers include the availability of mental health services and high treatment costs, social barriers to treatment access include stigma around mental health [ 125 ], fear of being perceived as weak or stigmatized [ 79 ], lack of awareness of mental disorders, and cultural stigma [ 17 ].

Existing studies that have systematically reviewed and evaluated the literature examining mental health service use have largely been constrained to specific population groups such as military service members [ 63 ] and immigrants [ 33 ], children and adolescents [ 35 ], young adults [ 76 ], and help-seeking among Filipinos in the Philippines [ 93 ]. These systematic reviews emphasize mental health service use by specific age groups or sub-groups, and the findings might not represent the patterns and barriers to mental health service use in the general population. One paper has reviewed mental health service use in the general adult population. Roberts et al. [ 112 ] found that need factors (e.g. health status, disability, duration of symptoms) were the strongest determinants of health service use for those with mental disorders.

The study results from Roberts et al. [ 112 ] were retrieved in 2016, and the current study seeks to build on this prior review with more recent research data by identifying publications since 2012 on mental health service use with a focus on high-income countries. This is in the context of ongoing community discussion and reform of the design and delivery of mental health services in Australia [ 140 ], and the need for current evidence to inform this discussion in Australia and other high-income countries. This systematic review aims to investigate factors associated with mental health service use among people with mental disorders and summarize the major barriers to mental health treatment. The specific objectives are (1) to identify factors associated with mental health service use among people with mental disorders in high-income countries, and (2) to identify commonly reported barriers to mental health service use.

Methodology

Selection procedures.

Our review adhered to PRISMA guidelines to present the results. We utilized PubMed, Scopus, and the Web of Science to search for articles describing the facilitators and barriers to mental health service use among people with mental illness from January 2012 up to August 2023. There were no specific factors that were of interest as part of conducting this systematic review, instead, the review had a broad focus intending to identify factors shown to be associated with mental health service use in the recent literature. The keywords used in our search of electronic databases were related to mental disorders and mental health service use. The full search terms and strategies were shown in Supplementary Table 1. We uploaded the search results to Covidence for deduplication and screening. After eliminating duplicates, the first author retrieved the title abstract and full-text articles for all eligible papers. Then each title and abstract were screened by two independent reviewers, to select those that would progress to full-text review. Subsequently, the two reviewers screened the full text of all the selected papers and conducted the data extraction for those that met the eligibility criteria. There were discrepancies in 12% of the papers reviewed, and all conflicts were resolved through discussion and agreed on by at least three authors.

Selection criteria

Inclusion and exclusion criteria.

In this systematic review, the scope was restricted to studies that draw samples from the general population, and the participants were either diagnosed with mental disorders or screened positive using a standardized scale. Case-control studies and cohort studies were considered for inclusion. The applied inclusion and exclusion criteria are listed in Table 1 .

Data extraction

After the full-text screening, details from all eligible studies were extracted by field into a data extraction table with thematic headings. The descriptive data includes the study title, author, publication year, geographic location, sample size, population details (gender, age), type of study design, mental disorder type (medical diagnosis or using scales) and quality grade (e.g. good, fair, and poor).

Quality assessment

The Newcastle Ottawa Scale [ 136 ] was used to evaluate the study quality for all eligible papers. We assessed the cross-sectional and cohort studies using separate assessment forms and graded each study as good, fair, or poor. The quality grade for each study was included in the data extraction table. The first author conducted the quality assessment using the Newcastle Ottawa Scale for cohort studies and the adapted scale for cross-sectional studies.

The search process is summarized in Fig. 1 . The initial search from PubMed, Scopus, and the Web of Science yielded 3230 articles: 2366 remained after removing duplicates; 2129 studies were considered not relevant; and 237 studies remained following title and abstract screening. In total, 40 studies met the inclusion criteria. Of these, four were cohort studies while thirty-six were cross-sectional studies. Ten studies (25.0%) were conducted in Canada, and nine (22.5%) were from the United States. Three studies used data from Germany (7.5%). Two studies each reported data from Australia, Denmark, Sweden, Singapore, or South Korea (5.0% of studies for each country). A single study was included with data from either the United Kingdom, Italy, Israel, Portugal, Switzerland, Chile, New Zealand, or reported pooled multinational data from six European countries (each country/ study representing 2.5% of the total sample of studies) (Table 2 ).

Flowchart for selections of studies

Study characteristics

As shown in Tables 2 ,  3 and 4 , the sample size of studies varies; a cross-sectional study from Canada had the largest sample which contained over seven million participants [ 39 ], while the smallest sample size was 362 [ 100 ]. Sixteen studies (40.0%) used DSM-IV diagnoses [ 4 ] to measure mental disorders, twelve studies (30.0%) applied the International Classification of Disease [ 138 ], and six studies used (15.0%) the Kessler Psychological Distress Scale [ 69 ]. Only three studies (7.5%) had a hospital diagnosis of mental disorders, while three studies (7.5%) used the Patient Health Questionnaire [ 72 ] to define mental disorders.

Twenty-seven studies (67.5%) analyzed the rate of mental health service use over the last 12 months, six studies (15.0%) focused on lifetime service use, and three studies (7.5%) assessed both 12-month and lifetime mental health service use. A few studies examined other time frames, with single studies investigating mental health service use over the past 3 months, 5 years, and 7 years, and one included study considered mental health service use during the 24 months before and after a sibling’s death.

Twenty of the forty studies were classified as good quality (50.0%), seventeen as fair (42.5%), and three as poor quality (7.5%).

Overview of samples and factors investigated

The included studies examined a range of different factors associated with mental health service use. These included gender, age, marital status, ethnic groups, alcohol and drug abuse, education and income level, employment status, symptom severity, and residential location. The review identified service utilization factors related to socio-demographics, differences in utilization across countries, emerging socio-demographic factors and contexts, as well as structural and attitudinal barriers. These are described in further detail below.

Socio-demographic characteristics

Fifteen studies analyzed the association between gender and mental health service use, with fourteen studies reporting that mental health service use was more frequent among females with mental disorders than males [ 2 , 37 , 42 , 43 , 47 , 54 , 66 , 67 , 90 , 103 , 119 , 123 , 128 , 130 ]. A South Korean study concluded that gender was not associated with mental health service use [ 100 ], which might be due to the small sample size of 362 participants in the study.

Fourteen studies investigated age in association with mental health service use. Nine studies concluded that mental health service use was lower among young and old adult groups, with middle-aged persons with a mental disorder being most likely to access treatment from a mental health professional [ 26 , 42 , 43 , 47 , 54 , 66 , 67 , 123 , 130 ]. Forslund et al. [ 43 ] reported that mental health service use for women in Sweden peaked in the 45-to-64-year age group, while amongst males, mental health service use was stable across the lifespan. In contrast, two articles from New Zealand and Singapore each reported that young adults were the age group most likely to access services [ 28 , 119 ]. Reich et al. [ 103 ] concluded that age was unrelated to mental health service use when considered for the whole population, but sex-specific analyses reported that mental health service use was higher in older than younger females, while the opposite pattern was observed for males. A Canadian study using community health survey data also observed no significant age-related differences in mental health service use [ 104 ].

Marital status

There was mixed evidence concerning marital status. Studies from the United States and Germany concluded that participants who were married or cohabiting had lower rates of mental health service use [ 26 , 90 ], while Silvia et al. [ 120 ] found that mental health service use was higher among married participants in Portugal. Shafie et al. [ 119 ] reported being widowed was associated with lower rates of mental health service use in Singapore.

Ethnic groups

Eight studies examined the relationship between ethnic background and mental healthcare service use. Non-Hispanic White respondents were more likely to use mental health services in Canada and the United States [ 24 , 26 , 30 , 130 , 139 ], while Asians showed lower rates of mental health service use [ 28 , 139 ]. Chow & Mulder [ 28 ] investigated mental health service use among Asians, Europeans, Maori, and Pacific peoples in New Zealand. They concluded that Maori had the highest rate of mental health service use compared with other ethnic groups. De Luca et al. [ 30 ] reported that mental health service use was lower among ethnic minority non-veterans compared to veterans in the United States, especially for those with Black or Hispanic backgrounds. In contrast, a study conducted in the UK found that mental health service use did not vary by ethnicity, with no difference between white and non-white persons [ 54 ].

Alcohol and drug abuse

Two studies reported risky alcohol use was negatively associated with mental health service use [ 26 , 132 ]. However, within the time frame of the current review, there was insufficient published evidence on the impact of drug abuse on mental health service use among people with mental disorders. Choi, Diana & Nathan [ 26 ] found that drug abuse can lead to lower rates of mental health service use in the United States. In contrast, Werlen et al. [ 132 ] reported that risky use of (non-prescribed) prescription medications was associated with higher rates of mental health service use in Switzerland.

Education, income, and employment status

Four studies analyzed the relationship between education level, income, and mental health service use. Higher levels of educational attainment [ 26 , 120 ] and higher income [ 26 ] were generally reported to be associated with an increased likelihood of mental health service use. However, Reich et al. [ 103 ] observed that in Germany, high education and perceived middle or high social class were associated with reduced mental health service use. One paper reported no significant difference in mental health service use in South Korea, possibly due to the small number of people accessing mental healthcare services [ 100 ].

Three studies reported that compared to those who are unemployed, those in work were less likely to use mental health services [ 26 , 90 , 119 ]. This outcome aligned with a Canadian study consisting of immigrants and general populations, Islam et al. [ 66 ] concluded that immigrants who were currently unemployed had higher odds of seeking treatment than those who were employed. However, an Italian [ 123 ] and a South Korean study [ 100 ] found that employment status was not related to mental health service use.

Symptom severity

Ten studies investigated the association between symptom severity and mental health service use and ten papers concluded that participants with moderate or serious psychological symptoms were more likely to use mental health services compared to those with mild symptoms [ 23 , 27 , 66 , 103 , 120 , 123 , 130 , 139 ]. Other studies showed that study participants who viewed their mental health as poor [ 42 ], who were diagnosed with more than one mental disorder [ 103 ], and those who recognized their own need for mental health treatment [ 54 , 139 ] were more likely to receive mental health services.

Residential location

Three studies investigated the association between residential location and mental health service use. Volkert et al. [ 128 ] concluded that the rates of mental health service use in Germany were significantly lower among those living in Canterbury than those living in Hamburg. A Canadian study found individuals living in neighborhoods where renters outnumber homeowners were less likely to access mental health services [ 42 ]. In the United States, for participants with low or moderate mental illness, mental health service use was lower for those residing closer to clinics [ 46 ].

Immigrants & refugees

The reviewed research found that non-refugee immigrants had slightly higher rates of mental health service use than refugees [ 10 ]. Other research found that long-term residents were more likely to access services than immigrants regardless of their origin [ 31 , 134 ]. For example, Italian citizens were found to have higher rates of mental health service use compared to immigrants, especially for affective disorders [ 123 ]. In Canada, immigrants from West and Central Africa were more likely to access mental health services compared to immigrants from East Asia and the Pacific [ 31 ]. Research from Chile found that the rates of mental health service use were similar for immigrants and non-immigrants [ 40 ]. Although, a positive association between the severity of symptoms and rates of mental health service use was only observed among immigrants [ 40 ]. Whitley et al. [ 134 ] found that immigrants born in Asia or Africa had lower rates of mental health service use, but higher rates of service satisfaction scores compared to immigrants from other countries.

Emerging areas

Our literature review identified several areas in which only a small number of studies were found. We briefly describe them here as these may reflect emerging areas of research interest. Few published articles examined mental health treatment among participants with mental disorders together with chronic physical health conditions, and we only included the papers in this systematic review if they contained a healthy comparison group. We identified two papers that focused on survivors of adolescent and young adult cancer [ 68 ] and participants with physical health problems [ 110 ]. Both studies reported that participants with other chronic conditions reported higher rates of mental health service use than the general population [ 68 , 110 ].

Two studies compared treatment seeking among people experiencing stressful life events. Erlangsen et al. [ 39 ] investigated the impact of spousal suicide, and Gazibara et al. [ 45 ] examined the effect of a sibling’s death on mental health service use. People bereaved by relatives’ deaths were more likely to use mental health services than the general population [ 39 , 45 ]. The peak effect was observed in the first 3 months after the death for both genders, while evidence of an increase in mental health service use was evident up to 24 months before a sibling’s death and remained evident for at least 24 months after the death [ 45 ].

One paper studied the impact of the COVID-19 pandemic lockdown on mental health service use. An Israeli study concluded that compared to 2018 and 2019, adults reported they were reluctant to receive treatment during the pandemic lockdown and observed a decrease in mental health service use [ 13 ].

Structural and attitudinal barriers

In addition to the research considering a range of population characteristics (e.g. male, younger, or older age), several papers examined how attitudinal and structural factors were associated with mental health service use. The most frequently reported of these factors were cost [ 23 , 46 , 68 , 120 ], lack of transportation [ 46 , 83 ], inadequate services/ lack of availability [ 23 , 46 , 83 , 128 ], poor understanding of mental disorders and what services were available [ 10 , 11 , 22 , 83 , 100 , 105 , 120 ], language difficulties [ 10 ], and stigma-related barriers [ 83 , 100 , 103 , 105 , 128 ]. Cultural issues and personal beliefs may influence the understanding of mental disorders and prevent people from using mental health services due to mistrust or fear of treatment [ 100 , 128 ]. The review also observed some unique barriers to different population groups. Choi, Diana & Nathan [ 26 ] mentioned that lack of readiness and treatment cost were the biggest difficulties for older adults, while young participants were more concerned about stigma. Females also reported childcare as a factor limiting their ability to use mental health services, while the evidence reviewed argued that males prefer to solve mental health issues on their own, with internal control beliefs and lack of social support likely reducing their use of mental health services [ 37 , 103 ].

Summary of evidence

This systematic review investigated mental health service use among people with mental disorders and identified the factors associated with service use in high-income countries.

Most studies found that females with mental health conditions were more likely to use mental health services than males. The relationship between age and mental health service use was bell-shaped, with middle-aged participants having higher rates of mental health service use than other age groups. Possible explanations included that the elderly might be reluctant to disclose mental health symptoms, they might attribute their mental health symptoms to increasing age [ 20 ], and they may prefer to self-manage instead of seeking help from health professionals [ 44 ]. Caucasian ethnicity and higher household income were also associated with higher rates of mental health service use. Greater use of mental health services was observed in participants with severe mental symptoms, including among veterans [ 19 , 37 , 92 ]. Two studies also concluded that compared to other cultural groups, Asian respondents were more likely to receive treatment when problems were severe or had disabling effects [ 86 , 97 ]. There was mixed evidence regarding employment status, although some studies found employment to be negatively related to receiving treatment [ 26 , 90 ], and unemployed people are more likely to seek help [ 119 ]. There was inconsistent evidence for the association between marital status and service utilization. This contradictory evidence on marital status might be attributed to a lack of specification, some papers categorize it as married and non-married [ 26 , 71 , 131 ], while others further differentiate between those who were widowed, separated, and divorced [ 90 , 119 ].

A number of studies showed that immigrants can face unique stressors owing to their experience of migration, which may exacerbate or be the source of their mental health issues, and impact the use of mental health services [ 1 , 8 ]. These include separation from families, support networks, linguistic and cultural barriers [ 9 , 113 ].

Due to the increased number of international migrants, immigrants’ mental health status and healthcare use has drawn growing attention [ 7 , 77 , 99 ]. Kirmayer et al. [ 70 ] and Helman [ 57 ] found that culture might be associated with people’s attitudes and understanding of mental health, influencing help-seeking behaviors. In general, the current results showed that immigrants and refugees were less likely to use mental health services than their native-born counterparts, and this finding was consistent with previous studies [ 75 , 82 , 127 ]. For immigrants, the length of stay in the host country was closely related to rates of mental health service use, which was argued to reflect increasing familiarity with the host culture and language proficiency [ 1 , 59 ].

Both mental disorders and chronic diseases contribute significantly to the global burden of disease. Prior studies have shown that people with chronic disease have a higher chance of experiencing psychological distress [ 6 , 14 , 68 , 73 ], and vice versa [ 49 , 74 ]. Hendrie et al. [ 58 ] concluded that respondents with chronic diseases were more likely to attend mental healthcare and reported higher costs. Negative experiences and stressful consequences related to chronic disease might contribute to the increased potential for mental illness but more opportunities to seek help from health professionals [ 60 , 108 , 135 ]. People with chronic diseases and mental health problems might experience more long-term pain and limitations in their daily lives, and these stressors can exacerbate their health conditions, and impact their attitude toward seeking help.

The COVID-19 pandemic had a major impact on mental health service use worldwide, the hospital admission and consultation rate decreased dramatically during the first pandemic year [ 118 ]. This reduction in service access might be a side effect of social distancing measures taken as mitigation measures, reducing both inciting incidents and physical access to services.

Financial difficulty, service availability, and stigma were frequently identified in the literature as structural and attitudinal factors associated with lower rates of mental health service use. These factors were associated with the different rates of mental health service use for different ethnicities. For example, Asian people were less likely than other groups to identify cost as a factor limiting their use of mental health services, with a major barrier for Asian people being stigma and cultural factors [ 139 ].

Limitations

This systematic review employed a broad search strategy with broad search terms to capture relevant articles. Rather than emphasizing a particular mental disorder, this review focused on the rates of mental health service use among adults aged 18 years or older who were experiencing a common mental disorder. However, this review still contained limitations. First was the potential for selection bias. Although we used various search terms for mental health service use and mental disorder, it is possible that the service use was not the primary research question for some papers, or that the relevant service use outcome was not statistically significant- in these cases, if the information was not reported in the abstract, relevant papers might have been missed. It is also important to note that this systematic review includes studies conducted in different countries and that the mental health systems and opportunities for access vary among countries. We only searched for full-text peer-reviewed articles published in English. Grey literature and papers published in other languages were excluded from the search. Most of the included literature used self-reported data to measure service access, and these data can be liable to recall bias. Studies using administrative data were also included in the systematic review, and we note that although they have large datasets, compared to survey data, there is often a lack of adequate control variables included to minimize possible confounding influences.

Future research

There is a need for more published articles on several aspects that may influence the service utilization among people with mental disorders, including the impact of residential or neighborhood areas, and household income across various income groups. These aspects are important population characteristics that require further research to inform the targeting and type of support (e.g. low-cost, accessible). Additionally, there was a lack of longitudinal research on mental health service use, future studies could use the data to identify changes over time and relate events to specific exposures (e.g. Covid-19 pandemic). Future studies can investigate the cost of mental health treatment in detailed aspects, (e.g. publicly funded mental health services, community-based support for free or low-cost mental health services). Overall, there was a lack of studies for ethnic minorities, given ethnic minority groups were more vulnerable to mental disorders but with less mental health service use. Future research can expand gender identity representation in data collection and move beyond the binary genders. People with non-binary gender identities can face greater challenges and disadvantages in mental health and mental health service use.

This review identified that middle-aged, female gender, Caucasian ethnicity, and severity of mental disorder symptoms were factors consistently associated with higher rates of mental health service use among people with a mental disorder. In comparison, the influence of employment and marital status on mental health service use was unclear due to the limited number of published studies and/ or mixed results. Financial difficulty, stigma, lack of transportation, and inadequate mental health services were the structural barriers most consistently identified as being associated with lower rates of mental health service use. Finally, ethnicity and immigrant status were also associated with differences in understanding of mental health (i.e. mental health literacy), effectiveness of mental health treatments, as well as language difficulties. The insights gained through this review on the factors associated with mental health service use can help clinicians and policymakers to identify and provide more targeted support for those least likely to access services, and this in turn may contribute to reducing inequalities in not only mental health service use but also the burden of mental disorders.

Availability of data and materials

All data and materials related to the study are available on request from the first author, [email protected].

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Gao, Y., Burns, R., Leach, L. et al. Examining the mental health services among people with mental disorders: a literature review. BMC Psychiatry 24 , 568 (2024). https://doi.org/10.1186/s12888-024-05965-z

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People with severe mental illness engage in considerably less physical activity than those without. They also experience premature mortality of around 10–25 years. A large proportion of these premature deaths are attributed to modifiable behaviours, including physical activity. The inpatient environment provides an opportunity to support people to become more physically active; however, there is limited evidence on which interventions are most successful and what contextual factors affect their delivery. A scoping review was conducted to help understand the extent and type of evidence in this area and identify research gaps. We included studies of physical activity correlates and interventions in adult inpatient mental health services published in peer-reviewed journals. Reviews, meta-analyses, and papers focusing on eating disorder populations were excluded. We searched the MEDLINE, CINAHL, PsycINFO, ASSIA and Web of Science databases for relevant studies published in English. We extracted data on study design, participant characteristics, intervention and control conditions, key findings, and research recommendations. We used a descriptive analytical approach and results are presented in tables and figures. Of 27,286 unique records screened, 210 reports from 182 studies were included. Sixty-one studies reported on correlates of physical activity, and 139 studies reported on physical activity interventions. Most intervention studies used a single-group, pre-post design (40%) and included fewer than 100 participants (86%). Ninety percent of interventions delivered physical activity directly to participants, and 50% included group-based sessions. The duration, type, frequency and intensity of sessions varied. Mental health was the most commonly reported outcome (64%), whereas physical activity was rarely an outcome (13%). Overall, there is a modest but growing body of research on physical activity in adult users of inpatient mental health services. More high-quality trials are needed to advance the field, and future research should target neglected intervention types, outcomes, populations and settings.

Citation: Tew GA, Peckham E, Ker S, Smith J, Hodgson P, Machaczek KK, et al. (2024) Physical activity in adult users of inpatient mental health services: A scoping review. PLoS ONE 19(8): e0301857. https://doi.org/10.1371/journal.pone.0301857

Editor: Maher Abdelraheim Titi, King Saud University Medical City, SAUDI ARABIA

Received: November 4, 2023; Accepted: March 22, 2024; Published: August 19, 2024

Copyright: © 2024 Tew et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting information files.

Funding: This study was supported by Research Capability Funding from Tees Esk and Wear Valleys NHS Trust The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

People who use mental health services, including people with severe mental illness (SMI), depression, anxiety or stress disorders and people with alcohol and substance use disorders, experience worse health outcomes and a shortened life expectancy when compared to people without these disorders (10–25 years for SMI, 7–20 years for anxiety/stress disorders and alcohol and substance use disorders) [ 1 – 4 ]. Much of this reduced life expectancy is due to modifiable risk factors such as engaging in health risk behaviours, one of which is physical inactivity [ 5 – 7 ]; and it has been reported that between 70 and 75% of people with schizophrenia do not meet public health targets for physical activity [ 8 ]. Yet, physical activity interventions have been shown to improve cardiometabolic health outcomes in people with mental illnesses and improve symptoms of depression, cognitive function, feelings of isolation, and quality of life [ 9 – 11 ].

Insufficient physical activity and excessive sedentary behaviour in people receiving care for SMI have been observed in both community and inpatient settings [ 12 , 13 ]. However, the majority of intervention studies have recruited people receiving care in community and outpatient settings, and less research has been done in inpatient settings [ 14 ]. While some of the reasons for insufficient physical activity and excessive sedentary behaviour are common across both inpatient and community settings, such as the sedative effects of psychotropic medicine [ 15 ] and mental health symptoms (lack of motivation, anhedonia, fatigue and negative body image) [ 13 ], there are some unique barriers presented by inpatient settings. For example, lack of appropriate facilities, lack of suitably trained staff to support physical activity, and restrictions on leave for people detained under mental health legislation all contribute to decreased opportunities for physical activity in inpatient settings [ 16 – 19 ]. However, inpatient physical activity programmes provide an opportunity to improve patients’ physical and mental health. For this reason, it is important to have an up-to-date understanding of the literature on this topic.

The scope of inpatient physical activity research is broad, including quantitative or qualitative research such as randomised controlled trials (RCTs) of physical activity interventions or interviews with service users exploring their perceptions of physical activity. Studies have also explored correlates of physical activity or been more intervention focused. Qualitative studies have examined the views of patients, carers or healthcare professionals, or a particular subpopulation of patients. Recent reviews regarding inpatient physical activity have focused on tightly defined inclusion criteria leading to the inclusion of specific sets of studies, such as RCTs. One systematic review and meta-analysis [ 14 ] explored the benefits of, adherence to, and safety of physical activity interventions delivered in inpatient mental health settings. This review and meta-analysis also investigated trials that supported sustaining physical activity after patient discharge and discussed patient feedback on physical activity interventions [ 14 ]. In addition, two reviews focused on physical activity interventions for inpatients in secure forensic settings. The first of these reviews investigated the effectiveness of physical activity programmes for inpatients in secure forensic settings on various health outcomes [ 20 ]. The second paper used the scoping review methodology to explore and synthesise the literature on physical activity interventions for inpatients in secure mental health settings [ 21 ]. [ 14 , 20 , 21 ] A broader review of inpatient physical activity research, that considers all inpatient settings and quantitative and qualitative evidence would be advantageous to understand the current state of the literature and inform future research. A scoping review is a suitable way of achieving this [ 22 ]. Understanding and mapping the available evidence on physical activity in inpatient settings, including qualitative and quantitative research, is important due to their complementary nature. They answer different questions about physical activity. For example, quantitative research can shed light on cause-and-effect relationships between various factors associated with physical activity, while qualitative research can tell us why this is the case. A scoping review also provides a means to determine whether there is scope and a need for a systematic review of a particular type or in a specific area of literature, and to identify gaps in the existing research base that could be filled by future primary research [ 22 ]. The overall aim of this scoping review was therefore to understand the extent and type of evidence regarding physical activity in adult users of inpatient mental health services. This included study designs used, primary conditions of participants, types of outcomes assessed, correlates of physical activity explored, intervention characteristics, outcomes, and research recommendations.

This scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews [ 23 ] and reported in accordance with the PRISMA Extension for Scoping Reviews (PRISMAScR) [ 24 ]. A protocol was prepared in advance and published in the Open Science Framework [ 25 ].

Participants/Context

We included studies pertaining to adult (≥18 years) users of inpatient mental health services. This included studies where psychiatric inpatients were the participants and studies where other stakeholders were involved (e.g., healthcare professionals giving their views regarding services for psychiatric inpatients). Studies focusing on learning disability populations were included whereas those focusing on eating disorder populations were excluded because of the unique requirement to carefully manage energy input/output in these populations. “Inpatient Setting” was defined as mental health care facilities which provide continuous care for a period of over 24 hours. This included psychiatric hospitals, separate inpatient units of a general hospital, residential treatment centres, and the prison service. Outpatient and community living participant-based studies were not included. There were no limits on the country of origin.

The phenomenon of interest was physical activity. Physical activity has been defined as any bodily movement produced by skeletal muscles and requiring energy expenditure [ 26 ]. Exercise is a subset of physical activity that has been defined as any structured and repetitive physical activity that has an objective of improving or maintaining physical fitness [ 26 ]. To address the aims of the review we took a broad view of physical activity and included studies that had focused on supervised exercise or promotion of self-managed physical activity.

Types of sources

This scoping review included experimental and quasi-experimental study designs such as RCTs, non-randomised controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies were included. This review also considered descriptive observational study designs including case series, individual case reports and descriptive cross-sectional studies for inclusion. Qualitative studies that utilised various methodologies (e.g., phenomenology, grounded theory, ethnography, action research) were also considered. Literature reviews and meta-analyses were used to identify primary studies, but were excluded from data analysis. Conference abstracts and opinion papers were also excluded.

Search strategy

The search strategy targeted peer-reviewed publications. A pilot search of the MEDLINE database was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe them were employed to develop a full search strategy for the MEDLINE, CINAHL, PsycINFO, ASSIA and Web of Science databases ( S1 File ). The search strategy, including all identified keywords and index terms, was adapted for each included database and/or information source. The database searches were conducted on October 31, 2022 and updated on October 24, 2023. The reference list of all included sources of evidence, and those of any review articles or meta-analyses, were screened for additional studies. We also conducted forward citation tracking of included studies using Google Scholar. We only included studies that were published in English language from 2007 onwards. The latter relates to amendments in the 1983 Mental Health Act that were made in 2007; prior studies may have employed different clinical practices and patient populations.

Study selection

Following the search, all identified citations were collated and uploaded into Covidence [ 27 ], and duplicates were removed. After a pilot test, the titles and abstracts were screened by pairs of independent reviewers against the eligibility criteria for the review. Potentially relevant sources were retrieved in full and assessed in detail against the eligibility criteria by pairs of independent reviewers. The reasons for excluding sources of evidence in full text that did not meet the eligibility criteria were documented. Any disagreements that arose between the reviewers at each stage of the selection process were resolved through discussion or with the aid of additional reviewers.

Data extraction

Data were extracted from papers included in the scoping review by pairs of independent reviewers using a data extraction form ( S2 File ) developed by the reviewers in Covidence [ 27 ], which was based on the JBI template extraction tool [ 28 ]. The form was piloted on twenty papers to ensure it was fit for purpose.

The extracted data encompassed specific details about the participants, concept, context, study methods, key findings relevant to the review questions, and research recommendations. Any disagreements between the reviewers were resolved through discussion or with the aid of an additional reviewer. Due to limited timescales and resources, we did not contact any authors to request missing or additional data.

Data analysis and presentation

A descriptive analytical approach was used to summarise the included studies’ contextual, process and outcome-related data [ 29 , 30 ]. This approach was undertaken to map the key concepts and available evidence, synthesise existing research findings, and identify research gaps. Extracted data were organised in Microsoft Excel. Physical activity correlates were categorised based on the Socio-Ecological Model [ 31 – 33 ]. This model was chosen as it considers the multifaceted and interactive effects of various factors (e.g., interpersonal, organisational and community), which characterise the delivery of physical activity interventions for people with SMI. Themes for research recommendations were derived inductively following review of original quotes by two independent reviewers. The analysis was reported in accordance with the synthesis without meta-analysis (SWiM) guideline [ 34 ], with data presented in tables and figures where appropriate.

Fig 1 shows the PRISMA flow diagram. The database searches yielded 35,278 records. After removing duplicates, we screened 27,040 records, from which we reviewed 280 full-text reports, and finally included 132 reports. Later, we reviewed a further 246 full-text reports that were identified from review articles or the forward and backward citations of included reports. This resulted in a further 78 reports being included. Together, 210 reports from 182 studies were included in the review. The complete reference list of included reports can be found in S3 File .

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https://doi.org/10.1371/journal.pone.0301857.g001

Descriptive characteristics and methodological information of included articles

Sixty-one (34%) studies reported on correlates of physical activity, 139 (76%) studies reported on physical activity interventions, and 19 (10%) studies reported on both physical activity correlates and interventions.

Of the 61 studies on correlates of physical activity, 43 (70%) studies reported on quantitative data (28 observational studies, 15 interventional studies) and 22 (36%) studies reported on qualitative data (14 observational studies, 8 interventional studies) ( Table 1 ). Sample sizes varied by study type, with observational quantitative studies including the largest samples. The majority of studies were conducted in Europe (62%), with most of the remainder originating from Australasia (16%) and Asia (11%). The three most common settings were psychiatric hospitals (39%), forensic/secure settings (23%), and ‘mixed’ settings (16%).

https://doi.org/10.1371/journal.pone.0301857.t001

Of the 139 studies on interventions ( Table 2 ), 57 (41%) studies used a single-group, pre-post design and 57 (41%) studies were RCTs. The majority of studies included fewer than 100 participants (86%) and were conducted in Europe (47%) and within a psychiatric hospital (45%). The most common study populations included people with schizophrenia or related psychotic disorders (35%) and a mixture of diagnoses (20%). Mental health was the most commonly reported outcome (64%), whereas physical activity (13%) and quality of life (16%) were rarely reported outcomes ( Table 2 ).

https://doi.org/10.1371/journal.pone.0301857.t002

Fourteen (10%) of the intervention studies were qualitative studies. All 14 studies collected qualitative data from service users who had participated in the intervention; seven studies (50%) also collected data from healthcare staff, and one study (7%) also collected data from family members. Most studies (71%) used one-to-one interviews to collect data. Other methods included observations (n = 2), evaluation forms (n = 2), document analysis (n = 1) and focus groups (n = 1).

Correlates of physical activity

Tables 3 and 4 summarise the physical activity correlates examined or highlighted in quantitative and qualitative studies, respectively. A broad range of individual, interpersonal, environmental and organisational correlates was reported regarding inpatient physical activity, whereas no wider societal factors were highlighted. ‘Health status’ and ‘medication side effects’ were the most commonly reported demographic and biological factors in both quantitative (23% and 21%, respectively) and qualitative (55% and 23%, respectively) studies. ‘Self-motivation’ was the most common factor in the ‘psychological, cognitive and emotional’ category (37% quantitative, 45% qualitative). Factors were less frequently reported in the ‘behavioural’ and ‘social and cultural’ categories, but ‘physical activity enjoyment’ (7% quantitative, 5% qualitative) and ‘social support’ (26% quantitative, 41% qualitative) were the most common factors, respectively. ‘Access to equipment and facilities’ (28% quantitative) and ‘environment restrictions’ (23% quantitative, 32% qualitative) were commonly cited physical environment factors. ‘Staff capacity’ (33% quantitative, 82% qualitative) and ‘staff capability’ (51% quantitative, 59% qualitative) were among the top-ranking organisational factors.

https://doi.org/10.1371/journal.pone.0301857.t003

https://doi.org/10.1371/journal.pone.0301857.t004

Table 5 summarises the themes of research recommendations from the studies of physical activity correlates. Twenty-two (36%) of the 61 studies included research recommendations, which we grouped according to whether they were related to the research topic, research methods, or patient involvement.

https://doi.org/10.1371/journal.pone.0301857.t005

Physical activity interventions

The components of physical activity interventions are summarised in Table 2 . Most interventions delivered physical activity directly to participants (90%) and in group-based sessions (50%). Most physical activity interventions included structured exercise (34.5%) such as aerobic and/or resistance training, or a variety of physical activities (24%). Fewer studies considered sport- or dance-based interventions (7% and 6%, respectively). The duration, frequency and intensity of sessions varied (see Table 2 ). Most interventions were delivered by health and/or exercise professionals, but few studies assessed interventions for staff. There was also very little evidence on environmental interventions with only one study exploring an environmental intervention.

Table 6 summarises the themes of the findings from the 14 qualitative studies, which we grouped under the headings of ‘perceptions of the intervention’ and ‘factors influencing intervention delivery and participation’. Beneficial psychosocial effects of interventions were reported in most studies (79%), such as participants feeling more relaxed, happier and calmer. Several studies reported on a range of personal and environmental factors that might influence participation in physical activity. Examples of personal factors included perceived health benefits, social support, medication side effects, confinement in a locked facility, and the availability of trained staff. Environmental factors included physical space and facilities.

https://doi.org/10.1371/journal.pone.0301857.t006

Table 7 summarises the themes of research recommendations from the studies of physical activity interventions. Forty-nine (35%) of the 139 studies included research recommendations, which we grouped according to whether they were related to the research topic or research methods. The most commonly reported research topic-related recommendation was to investigate other physical activity interventions (11.5%), such as different modes of exercise or different behaviour change strategies. The most commonly reported research methods-related recommendations were longer follow-up periods (12%), investigating other outcomes (11.5%), and larger sample sizes (11%).

https://doi.org/10.1371/journal.pone.0301857.t007

Summary of evidence

This scoping review shows that a wide range of research has been published regarding physical activity and adult users of inpatient mental health services since 2007.

Forty-three quantitative studies explored correlates of physical activity. Organisational factors and psychological, cognitive and emotional factors were the top two domains cited ( Table 3 ). Within these, four out of the top five factors were organisational factors: staff capability, staff capacity, staff attitudes to physical activity, and access to equipment, while self-motivation was the second most highly cited correlate of physical activity overall. Similar findings were observed among the 22 qualitative studies that reported on correlates, with the addition of social support. There was also more emphasis on stigma, health, value of health and funding for physical activity programmes in the qualitative studies. Overall, a broad range of correlates have been reported.

One hundred and thirty-nine interventional studies were identified; only eight of these were larger-scale RCTs with 100 or more participants, and long-term follow-up was rare with only six out of the 57 RCTs (11%) having a follow up of 6 months or more. We did not identify any studies that included an economic evaluation, and there were few replications, suggesting that it would be challenging to evaluate the clinical and cost-effectiveness of physical activity interventions within the current evidence.

In terms of intervention design, the majority of studies explored an intervention that involved delivering physical activity (81%) rather than promoting physical activity (8%); 9% used a mixed model of both delivering and promoting physical activity. Interventions were mainly limited to the period of inpatient stay. The type of physical activity delivered was generally some form of structured exercise or physical recreation targeting individuals. However, descriptions of the interventions were often incomplete, and interventions appeared to lack systematic development. For example, within the 57 RCTs, only two interventions were described as being based on a specific theory [ 70 , 71 ], and only one [ 72 ]made reference to the Medical Research Council’s guidance on developing and evaluating complex interventions [ 73 ]. There was a notable lack of research on environmental interventions and interventions targeting healthcare professionals. In the current review, and elsewhere [ 74 ], we have observed that the reporting of interventions is often inadequate. Since adequate reporting of interventions is central to interpreting study findings and translating effective interventions into practice, we recommend that researchers use relevant reporting guidelines, such as TIDieR [ 75 ], when writing study reports.

Research has been conducted in a wide range of countries, including both high-income and low- and middle-income countries. However, the majority of studies were conducted in European psychiatric inpatient settings. Given the fact that forensic settings are likely to have a more stable population, in terms of patients’ length of stay, than some other inpatient settings, where patients may stay only a few days, surprisingly few RCTs have been conducted in forensic settings (n = 1).

Outcomes collected were mainly mental or physical health-related and the primary outcome was often not clearly stated. In many studies more than one mental or physical health outcome was examined, with some of the outcomes being positive and others neutral or negative, leading to difficulty interpreting the study results. It is important that studies, especially RCTs, clearly state their primary outcome from the outset to avoid cherry-picking results. Physical activity and health-related quality of life were rarely included as outcomes; the lack of physical activity outcomes suggests that increasing levels of physical activity was not the primary objective of many of the studies.

This current review differed in scope from the earlier papers [ 14 , 20 , 21 ] in that it encompassed varied settings (all adult inpatient mental health settings) and clinical populations (not only patients with serious mental illness but also those who receive care on inpatient mental health wards, e.g., those with dementia). In this way, it offered a systematically developed map of research available on physical activity interventions in adult users of inpatient mental health services. It also differed in its purpose and methods from previous studies [ 14 , 20 ]. For example, it included qualitative studies, which facilitated the identification of contextual factors that may influence the implementation and delivery of physical activity interventions in adult inpatient mental health settings.

Strengths and limitations

This review encompasses a wide range of articles and was conducted rigorously and systematically following a predefined protocol and existing guidance for scoping reviews. It provides a comprehensive overview of the extent and type of research on physical activity in inpatient mental health services and identifies important gaps in the literature.

Although a systematic search was conducted, some eligible articles might have been missed. The review is also limited to English language articles and does not include grey literature. Although a scoping review was appropriate to meet the objectives of this study, it is subject to limitations that are typical of this approach. For example, it did not permit a quality assessment of the included studies. It was also limited in its capacity to conclude what factors affect participation in physical activity among adult users of inpatient mental health services, what interventions are effective, and what themes recur in the qualitative literature.

Recommendations for future research

A 2018 meta-review of the evidence on physical activity as a treatment for SMI made several research recommendations [ 9 ], the following of which are relevant for research in relation to the inpatient context:

• More research is needed to establish pragmatic, scalable methods for delivering physical activity with the ultimate goal of optimising treatment ‘reach’.
• More research is required to ascertain the optimal frequency, intensity, time and type of physical activity interventions in each inpatient sub-population, acknowledging that these might vary according to individual needs, preferences and characteristics.
• More research is needed to explore how specific individual, interpersonal, environmental, and organisational factors influence the uptake and maintenance of physical activity interventions when they are implemented in clinical practice.
• More research is needed to investigate whether sedentary behaviours can be reduced in inpatients and tease out the importance of reducing sedentary behaviours in structured exercise interventions.
• Economic evaluations are required to establish the cost-effectiveness of specific physical activity interventions.

In addition, we believe that more research is needed to develop and test interventions that span the transition from inpatient to community settings. For example, it would be useful to study longer-term outcomes, such as the impact of physical activity programmes on rates of readmission to inpatient mental health facilities. Finally, this scoping review has identified sets of articles that could be collated for quantitative or qualitative systematic reviews of physical activity in inpatient mental health services. Researchers conducting such reviews should consider the quality of the studies, which was beyond the scope of this review, and to consider the variety of populations represented in these studies.

Conclusions

In conclusion, this scoping review summarised the extent and type of research on physical activity in adult users of inpatient mental health services. We identified a modest volume of evidence regarding correlates of physical activity. A broad range of individual, interpersonal, environmental and organisational correlates have been reported, but more studies with a longitudinal design are needed to determine how these and other factors are associated. We also found a large number of studies reporting on the outcomes of specific physical activity interventions. Most interventions targeted service users and involved the delivery of physical activity sessions rather than self-management interventions. There were very few large-scale RCTs and most studies did not include physical activity or quality of life outcomes. The findings of this review will help guide further primary research that is needed to guide clinical practice and policy.

Supporting information

S1 file. search strategy..

https://doi.org/10.1371/journal.pone.0301857.s001

S2 File. Data extraction form.

https://doi.org/10.1371/journal.pone.0301857.s002

S3 File. Reference list of included reports.

https://doi.org/10.1371/journal.pone.0301857.s003

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• 27. Veritas Health Innovation. Covidence systematic review software. Melbourne, Australia; 2022.
• 28. JBI template source of evidence details, characteristics and results extraction instrument. In: https://jbi-global-wiki.refined.site/space/MANUAL/4687579 . 20 Sep 2022.

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207 Mental Health Research Topics For Top Students

College and university students pursuing psychology studies must write research papers on mental health in their studies. It is not always an exciting moment for the students since getting quality mental health topics is tedious. However, this article presents expert ideas and writing tips for students in this field. Enjoy!

What Is Mental Health?

It is an integral component of health that deals with the feeling of well-being when one realizes his or her abilities, cope with the pressures of life, and productively work. Mental health also incorporates how humans interact with each other, emote, or think. It is a vital concern of any human life that cannot be neglected.

How To Write Mental Health Research Topics

One should approach the subject of mental health with utmost preciseness. If handled carelessly, cases such as depression, suicide or low self-esteem may occur. That is why students are advised to carefully choose mental health research paper topics for their paper with the mind reader.

To get mental health topics for research paper, you can use the following sources:

• The WHO website
• Websites of renowned psychology clinics
• News reports and headlines.

However, we have a list of writing ideas that you can use for your inspiration. Check them out!

Top Mental Disorders Research Topics

• Is the psychological treatment of mental disorders working for all?
• How do substance-use disorders impede the healing process?
• Discuss the effectiveness of the mental health Gap Action Programme (mhGAP)
• Are non-specialists in mental health able to manage severe mental disorders?
• The role of the WHO in curbing and treating mental disorders globally
• The contribution of coronavirus pandemic to mental disorders
• How does television contribute to mental disorders among teens?
• Does religion play a part in propagating mental disorders?
• How does peer pressure contribute to mental disorders among teens?
• The role of the guidance and counselling departments in helping victims of mental disorders
• How to develop integrated and responsive mental health to such disorders
• Discuss various strategies for promotion and prevention in mental health
• The role of information systems in mental disorders

Mental Illness Research Questions

• The role of antidepressant medicines in treating mental illnesses
• How taxation of alcoholic beverages and their restriction can help in curbing mental illnesses
• The impact of mental illnesses on the economic development of a country
• Efficient and cost-effective ways of treating mental illnesses
• Early childhood interventions to prevent future mental illnesses
• Why children from single-parent families are prone to mental illnesses
• Do opportunities for early learning have a role in curbing mental diseases?
• Life skills programmes that everyone should embrace to fight mental illnesses
• The role of nutrition and diet in causing mental illness
• How socio-economic empowerment of women can help promote mental health
• Practical social support for elderly populations to prevent mental illnesses
• How to help vulnerable groups against mental illnesses
• Evaluate the effectiveness of mental health promotional activities in schools

Hot Mental Health Topics For Research

• Do stress prevention programmes on TV work?
• The role of anti-discrimination laws and campaigns in promoting mental health
• Discuss specific psychological and personality factors leading to mental disorders
• How can biological factors lead to mental problems?
• How stressful work conditions can stir up mental health disorders
• Is physical ill-health a pivotal contributor to mental disorders today?
• Why sexual violence has led many to depression and suicide
• The role of life experiences in mental illnesses: A case of trauma
• How family history can lead to mental health problems
• Can people with mental health problems recover entirely?
• Why sleeping too much or minor can be an indicator of mental disorders.
• Why do people with mental health problems pull away from others?
• Discuss confusion as a sign of mental disorders

Research Topics For Mental Health Counseling

• Counselling strategies that help victims cope with the stresses of life
• Is getting professional counselling help becoming too expensive?
• Mental health counselling for bipolar disorders
• How psychological counselling affects victims of mental health disorders
• What issues are students free to share with their guiding and counselling masters?
• Why are relationship issues the most prevalent among teenagers?
• Does counselling help in the case of obsessive-compulsive disorders?
• Is counselling a cure to mental health problems?
• Why talking therapies are the most effective in dealing with mental disorders
• How does talking about your experiences help in dealing with the problem?
• Why most victims approach their counsellors feeling apprehensive and nervous
• How to make a patient feel comfortable during a counselling session
• Why counsellors should not push patients to talk about stuff they aren’t ready to share

Mental Health Law Research Topics

• Discuss the effectiveness of the Americans with Disabilities Act
• Does the Capacity to Consent to Treatment law push patients to the wall?
• Evaluate the effectiveness of mental health courts
• Does forcible medication lead to severe mental health problems?
• Discuss the institutionalization of mental health facilities
• Analyze the Consent to Clinical Research using mentally ill patients
• What rights do mentally sick patients have? Are they effective?
• Critically analyze proxy decision making for mental disorders
• Why some Psychiatric Advance directives are punitive
• Discuss the therapeutic jurisprudence of mental disorders
• How effective is legal guardianship in the case of mental disorders?
• Discuss psychology laws & licensing boards in the United States
• Evaluate state insanity defence laws

Controversial Research Paper Topics About Mental Health

• Do mentally ill patients have a right to choose whether to go to psychiatric centres or not?
• Should families take the elderly to mental health institutions?
• Does the doctor have the right to end the life of a terminally ill mental patient?
• The use of euthanasia among extreme cases of mental health
• Are mental disorders a result of curses and witchcraft?
• Do violent video games make children aggressive and uncontrollable?
• Should mental institutions be located outside the cities?
• How often should families visit their relatives who are mentally ill?
• Why the government should fully support the mentally ill
• Should mental health clinics use pictures of patients without their consent?
• Should families pay for the care of mentally ill relatives?
• Do mentally ill patients have the right to marry or get married?
• Who determines when to send a patient to a mental health facility?

Mental Health Topics For Discussion

• The role of drama and music in treating mental health problems
• Explore new ways of coping with mental health problems in the 21 st century
• How social media is contributing to various mental health problems
• Does Yoga and meditation help to treat mental health complications?
• Is the mental health curriculum for psychology students inclusive enough?
• Why solving problems as a family can help alleviate mental health disorders
• Why teachers can either maintain or disrupt the mental state of their students
• Should patients with mental health issues learn to live with their problems?
• Why socializing is difficult for patients with mental disorders
• Are our online psychology clinics effective in handling mental health issues?
• Discuss why people aged 18-25 are more prone to mental health problems
• Analyze the growing trend of social stigma in the United States
• Are all people with mental health disorders violent and dangerous?

Mental Health Of New Mothers Research Topics

• The role of mental disorders in mother-infant bonding
• How mental health issues could lead to delays in the emotional development of the infant
• The impact of COVID-19 physical distancing measures on postpartum women
• Why anxiety and depression are associated with preterm delivery
• The role of husbands in attending to wives’ postpartum care needs
• What is the effectiveness of screening for postpartum depression?
• The role of resilience in dealing with mental issues after delivery
• Why marginalized women are more prone to postpartum depression
• Why failure to bond leads to mental disorders among new mothers
• Discuss how low and middle-income countries contribute to perinatal depression
• How to prevent the recurrence of postpartum mental disorders in future
• The role of anti-depression drugs in dealing with depression among new mothers
• A case study of the various healthcare interventions for perinatal anxiety and mood disorders

What Are The Hot Topics For Mental Health Research Today

• Discuss why mental health problems may be a result of a character flaw
• The impact of damaging stereotypes in mental health
• Why are many people reluctant to speak about their mental health issues?
• Why the society tends to judge people with mental issues
• Does alcohol and wasting health help one deal with a mental problem?
• Discuss the role of bullying in causing mental health disorders among students
• Why open forums in school and communities can help in curbing mental disorders
• How to build healthy relationships that can help in solving mental health issues
• Discuss frustration and lack of understanding in relationships
• The role of a stable and supportive family in preventing mental disorders
• How parents can start mental health conversations with their children
• Analyze the responsibilities of the National Institute for Health and Care Excellence (NICE)
• The role of a positive mind in dealing with psychological problems

Good Research Topics On Refugees Mental Health

• Why do refugees find themselves under high levels of stress?
• Discuss the modalities of looking after the mental health of refugees
• Evaluate the importance of a cultural framework in helping refugees with mental illnesses
• How refugee camp administrators can help identify mental health disorders among refugees
• Discuss the implications of dangerous traditional practices
• The role of the UNHCR in assisting refugees with mental problems
• Post-traumatic Stress Disorder among refugees
• Dealing with hopelessness among refugees
• The prevalence of traumatic experiences in refugee camps
• Does cognitive-behavioural therapy work for refugees?
• Discuss the role of policy planning in dealing with refugee-mental health problems
• Are psychiatry and psychosomatic medicine effective in refugee camps?
• Practical groups and in‐group therapeutic settings for refugee camps

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• Discuss why suicide is among the leading causes of death among adolescents
• The role of acting-out behaviour or substance use in mental issues among adolescents
• Mental effects of unsafe sexual behaviour among adolescents
• Psychopharmacologic agents and menstrual dysfunction in adolescents
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• Mental health disorders and impairment among adolescents
• Why adolescents not in school risk developing mental disorders
• Does a clinical model work for adolescents with mental illnesses?
• The role of self-worth and esteem in dealing with adolescent mental disorders
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• Evaluate mental health leadership and governance in the United States
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• What is the essence of a mental health commission?
• Benefits of mental well-being to the prosperity of a country
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• Legal frameworks for dealing with substance use disorders
• How mental health can impede the development of a country
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• What does it mean to display strange behaviour?
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• Role of culture and social norms
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• Coercive interrogations and psychology

Behavioural Health Issues In Mental Health

• Detachment from reality
• Inability to withstand daily problems
• Conduct disorder among children
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• Eating and drinking habits and mental health
• Addictive behaviour patterns for teenagers in high school
• Discuss mental implications of gambling and sex addiction
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• Role of friends in behavioural complications
• Spiritual leaders in helping deal with behavioural issues
• Suicidal thoughts

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• A distorted perception of reality
• Rights of mental caregivers
• Dealing with a loss
• Handling a break-up

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School Milestones Impact Child Mental Health in Taiwan

This study uses administrative health insurance records in Taiwan to examine changes in child mental health treatment around four school milestones including: Primary and middle school entry, high stakes testing for high school, and high stakes testing for college entry. Leveraging age cutoffs for school entry in Taiwan, we compare August-born children to children born in September of the same year. The former hit all the milestones one year earlier than the latter, enabling us to identify each milestone’s effect. We find that entry into both primary school and middle schools is associated with increases in mental health prescribing, not only for ADHD but also for depression. Middle school entry is also associated with increases in the prescribing of anti-anxiety and antipsychotic medications. Perhaps surprisingly, there is no run-up in the use of psychiatric medications prior to high-stakes tests. But the use of psychiatric medications falls sharply following the tests. These effects are stronger in counties where both parents and children have higher educational aspirations. Hence, the use of psychiatric drugs increases at junctures when educational stresses increase and falls when these stresses are relieved.

We thank the Health and Welfare Data Science Center and the Ministry of Health and Welfare in Taiwan for access to data and we thank Ming-Jen Lin and seminar participants at Princeton and Fudan Universities for helpful comments. Gustav Chung Yang and NTU C2L2 lab provided excellent research assistance. Chen acknowledges the support from the National Science and Technology Council grant NSTC 111-2628-H-002-019 and the Yushan Fellow Program by the Ministry of Education, Taiwan (MOE-112-YSFSL-0003-001-P1). Currie thanks the NOMIS Foundation for their support. Any errors are our own. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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If You Journal for Mental Health, Here Are Some Effective Prompts

Use these therapist-approved suggestions and tips to jot down your thoughts and feelings.

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Gratitude journal prompts

Intention journal prompts, review journal prompts, values journal prompts, random mental health journal prompts, how to start a mental health journal, when to get help.

“We’ve recommended journaling to our clients for years, because it provides both a general mental outlet as well as a way to gain insight and perspective,” adds Janna Koretz, Psy.D. , a psychologist and the founder of the therapy practice Azimuth .

The good news is, you don’t need any special talents or supplies to create a mental health journal. Whether you opt to put pen to paper, type away in the Notes app on your iPhone or record your thoughts in password-protected voice memos, there’s no one right way to create a mental health journal. Use the expert-approved prompts and advice below to see how a journal can transform the way you feel.

Self-reflection journal prompts

A journal that you use for self-reflection can help you recognize your behavior patterns. “It helps to ground people with the body-mind connection,” says Tarry. “So you can become more insightful as to what are your feelings and what do your feelings motivate you to do?”

These prompts should help you identify strong feelings, notice how they can result in physical sensations, and then bring awareness to your responsive behaviors:

• What are you feeling? Take a moment to really think about what emotions you’re experiencing right now. Maybe you didn’t realize how exhausted you were until you paused, or maybe something happened that made you feel really content.
• Where are you feeling your emotions? Slowly scan your body from the top of your head all the way to your toes and see if you can locate the origin of your feelings. If you're worried about a meeting, you may feel flutters in your gut. If you're angry from a fight you had with your partner, you might have a sensation in your lower spine or heat behind your knees.
• How did your feelings change during the day? If you’re journaling at night, describe how your feelings shifted over the course of the day. Did feelings of nervousness always appear around the same people? Did you forget about your anger when you got to work?
• What did you do with your feelings? Think back and note the actions you took when you had strong emotions. Did you send impulsive texts? Did you eat junk food? Did you shut down in bed under the covers?
• How would you like to respond in the future? Maybe, after carefully thinking about it, you’re happy with how you’ve been handling your emotions. If not, this is your chance to consider small steps you can take to change your behaviors.

Keeping a gratitude journal allows us to see the bright side of things even when we’re feeling down. “Our culture is so focused on identifying problems and fixing them that we forget to see the parts of life that are worth being deeply grateful for,” says Koretz. “When we allow ourselves to feel gratitude, we gain the perspective and mental space needed to feel joy despite any life difficulties we are experiencing, making our day to day easier and more enjoyable.”

She recommends starting with these prompts:

• Describe a small, everyday moment from today that you're grateful for and why it brightened your day.
• Reflect on a challenge you've faced recently. What unexpected positive outcomes or lessons emerged from this difficulty?
• Think of someone who has positively impacted your life. What specific qualities or actions of theirs are you most thankful for?

Often when we set goals, they’re too big and overwhelming to put into reality, but an intention journal trains us to focus on what we want. “Many people will set daily or weekly intentions, and use the journal to guide their actions during these time periods to ensure they reach their goals,” says Koretz. “It helps decrease distractibility and outside influences, so you don’t get sidetracked and lose sight of what is really important.”

Here are some prompts she’s found useful for an intention journal:

• What is one goal you'd like to accomplish this week? Break it down into three actionable steps you can take each day.
• Visualize your ideal day tomorrow. What intentions can you set now to help make that vision a reality?
• Identify a habit you'd like to build or break. What is one small, specific intention you can set to move towards this change?

This type of journal is the closest thing to a traditional diary. “ Review journaling is essentially summarizing the day, noting how you felt, and considering what you might do differently next time ,” says Koretz. “It tends to be a bit of a ‘stream of consciousness,’ but it can be a helpful tool for remembering important events that happened, as well as giving you a space to release pent-up emotion.”

If you’d rather not just think back on the day you just finished, she suggests these prompts for a review journal:

• Reflect on your past week. What were your top three accomplishments, and what factors contributed to your success?
• Describe a situation where things didn't go as planned. What lessons did you learn, and how might you approach a similar scenario differently in the future?
• Looking at your goals from the start of the month, how have you progressed? What adjustments, if any, do you need to make to stay on track?

Sometimes it’s easy to be swept away, go with the flow and lose sight of what matters most to you, but a values journal may help you get back on track. “ Values journaling lets you take the time to really consider the ‘why’ behind what really matters to you ,” says Koretz. “For example, ‘family’ may be very important to you, but are you driven by the value of being a caretaker, a provider, building a legacy or something else? As you journal about your day, you can reflect on which parts were and were not in line with your value system. Then, you can make changes to your behavior to get more aligned with your values, which are associated with a greater sense of well-being.”

To see what she means, try the prompts below:

• Think of a recent decision you made. How did this choice align with or diverge from your core values?
• Imagine you're at your own retirement party. What would you want people to say about how you lived your life? How does this relate to your values?
• Identify a value that's important to you (e.g., creativity, honesty, kindness). Describe three specific ways you could express this value in your daily life over the next week.

Your journal doesn’t need to follow a strict format to be beneficial to your mental health. Maybe one day you want to reflect on what you’re grateful for, and the next you’d rather do a body scan and get in tune with your feelings. Here are three random prompts that Tarry recommends to her clients:

• What are you thinking? When you’re overwhelmed , it can help to do a “brain dump” and pour out all of your thoughts, even if they don’t form proper sentences or cohesive paragraphs. Your journal is a safe container to place restless thinkings in.
• Do I have a safe person? It’s great to have someone that you trust and can open up to and who can help you process things that happen. As you write, consider how available the person is, how supportive they are, and times in the past when they gave you good advice.
• What did I dream about when I was sleeping? Keep your journal next to your bed and if you wake up in the middle of the night and can’t get back to sleep, write them down. This can be especially helpful for people struggling with past traumas.

Starting any new activity can be intimidating, even if it’s something no one else will see (like a journal). “Remember, it’s just important to start,” says Koretz. “There is no right or wrong way to journal, but the more you can stick to it, the better. With practice, you’ll find the approach that is most helpful to you.” Use these tips to begin:

.css-13m1f6i{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;font-weight:inherit;font-style:inherit;-webkit-box-pack:start;-ms-flex-pack:start;-webkit-justify-content:flex-start;justify-content:flex-start;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;cursor:pointer;scroll-margin-top:0rem;background-color:#ffffff;color:#000;width:100%;border:0;border-top:thin solid #D4D4D4;text-align:left;padding-top:0.3125rem;border-bottom:none;padding-bottom:0.3125rem;}@media(min-width: 64rem){.css-13m1f6i{scroll-margin-top:3.375rem;}} .css-b4ahb2{border-radius:50%;width:1.875rem;border:thin solid #737373;height:1.875rem;padding:0.4rem;margin-right:0.625rem;} .css-jlx6sx{display:-webkit-inline-box;display:-webkit-inline-flex;display:-ms-inline-flexbox;display:inline-flex;width:0.9375rem;height:0.9375rem;margin-right:0.625rem;-webkit-transform:rotate(90deg);-moz-transform:rotate(90deg);-ms-transform:rotate(90deg);transform:rotate(90deg);-webkit-transition:-webkit-transform 250ms ease-in-out;transition:transform 250ms ease-in-out;} Pick your tools.

Are you someone who likes to write, type or talk? Choose the method you feel most comfortable with. If you like to write, buy a pretty journal with a cover that you’ll enjoy looking at and nice, soft paper.

Start slowly.  

" Give yourself a few minutes when you wake up instead of reaching for your phone, pull out your journal — which I ask people to leave by their bedside — and write what you’re feeling,” says Tarry. “That’s where people can start the process of just reminded themselves to check in with their body, check in with their thoughts, then put it aside and start their day.”

Add a nightly entry.  

After a week or two of journaling for a few minutes every morning, try doing it again at the end of each night. How did your day progress from your earlier journal entry? Did you do and say everything you wanted to? How did you feel about events that occurred, and how did you respond to them?

Revisit your journal entries.

“At the end of each week, go back and review your journal prompts and see out of those things, is there something that you can release?” asks Tarry. “Are you as angry now as you were when you first wrote that journal entry? Is there something that is continuously pressing on your mind that you want to discuss in therapy?”

Sometimes journaling isn’t going to cut it. “If you’re having really strong, negative self-harming thoughts or thoughts of harming someone else, you don’t want to leave that in a journal or put that in a note in your app or in a voice note,” says Tarry. “People can have thoughts and not have plans or intentions, but that’s not something I think that if you’re having, you should deal with on your own. Those are risk factors for other things that you want to make sure you talk to a professional about.” Call your provider and share those sensations or thoughts, especially if they continue to grow, so that your provider can intervene. If you’re having an urgent crisis, call or text 988 to reach a crisis counselor serving the Suicide & Crisis Lifeline.

Kaitlyn Phoenix is a deputy editor in the Hearst Health Newsroom, where she reports, writes and edits research-backed health content for Good Housekeeping , Prevention and Woman's Day . She has more than 10 years of experience talking to top medical professionals and poring over studies to figure out the science of how our bodies work. Beyond that, Kaitlyn turns what she learns into engaging and easy-to-read stories about medical conditions, nutrition, exercise, sleep and mental health. She also holds a B.S. in magazine journalism from Syracuse University.

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• Diagnostic error in mental health: a review
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• http://orcid.org/0000-0002-8390-8844 Andrea Bradford 1 , 2 ,
• http://orcid.org/0000-0001-7993-8584 Ashley N D Meyer 1 , 2 ,
• Sundas Khan 2 ,
• http://orcid.org/0000-0002-9184-6524 Traber D Giardina 1 , 2 ,
• http://orcid.org/0000-0002-4419-8974 Hardeep Singh 1 , 2
• 1 Department of Medicine , Baylor College of Medicine , Houston , TX , USA
• 2 Center for Innovations in Quality, Effectiveness and Safety , Michael E. DeBakey VA Medical Center and Baylor College of Medicine , Houston , Texas , USA
• Correspondence to Dr Andrea Bradford, Baylor College of Medicine, Houston, Texas, USA; Andrea.Bradford{at}bcm.edu

Diagnostic errors are associated with patient harm and suboptimal outcomes. Despite national scientific efforts to advance definition, measurement and interventions for diagnostic error, diagnosis in mental health is not well represented in this ongoing work. We aimed to summarise the current state of research on diagnostic errors in mental health and identify opportunities to align future research with the emerging science of diagnostic safety. We review conceptual considerations for defining and measuring diagnostic error, the application of these concepts to mental health settings, and the methods and subject matter focus of recent studies of diagnostic error in mental health. We found that diagnostic error is well understood to be a problem in mental healthcare. Although few studies used clear definitions or frameworks for understanding diagnostic error in mental health, several studies of missed, wrong, delayed and disparate diagnosis of common mental disorders have identified various avenues for future research and development. Nevertheless, a lack of clear consensus on how to conceptualise, define and measure errors in diagnosis will pose a barrier to advancement. Further research should focus on identifying preventable missed opportunities in the diagnosis of mental disorders, which may uncover generalisable opportunities for improvement.

• Diagnostic errors
• Mental health
• Medical error, measurement/epidemiology

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjqs-2023-016996

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Introduction

Timely and appropriate diagnosis in mental health is an essential first step towards effective treatment. Missed, delayed or wrong diagnosis of mental disorders can lead to poorer patient outcomes and can waste time and resources. For example, delayed diagnosis of bipolar disorder has been linked to more frequent relapse and hospitalisations. 1 2 In a large registry study of over 1000 patients with narcolepsy, over one-quarter of the sample reported having consulted five or more clinicians before receiving the diagnosis. 3 Missed and delayed diagnosis can also result in a lack of functional improvement, delayed remission, and delayed or unnecessary treatments. 4

Mental disorders are largely clinical diagnoses that seldom have specific objective findings that can be detected through laboratory testing, physical examination or imaging. As such, history taking, behavioural observation and data gathering from collateral sources (eg, family members, teachers) are essential to the diagnosis. Despite the importance of effective data gathering and synthesis, time pressures, competing priorities and various cognitive biases can interfere with this process. 4–6 Validated psychological tests and symptom reporting scales can help with the data gathering process, but these can lead to inaccurate diagnostic impressions if they are interpreted without sufficient context or not followed with an appropriate diagnostic interview. 7 8 Finally, evolving (and in some cases, expanding) diagnostic criteria for mental disorders have prompted concerns that clinicians could inadvertently pathologise normal experiences. 9 10

Despite these and other concerns about the quality of psychiatric diagnosis, most discussion of diagnostic error in mental health has been disconnected from the broader national conversation on diagnostic error and diagnostic excellence. As a stark example, while the National Academies of Science, Engineering, and Medicine’s (NASEM) landmark report Improving Diagnosis in Health Care 4 describes mental health diagnosis as ‘particularly challenging’ (p. 52), there is otherwise little explicit mention of mental health in this 472-page report. In turn, the NASEM report is only sparsely cited in the mental health literature. 11 12 The NASEM report and contemporary research on diagnostic errors has stimulated major private (eg, Moore Foundation) and public (eg, Agency for Healthcare Research and Quality) funding initiatives to study and improve diagnostic safety. Again, however, mental health has been scarcely represented in the various projects funded under these initiatives. This is a significant gap given the high prevalence of mental disorders in the USA and worldwide.

As definitions and methods for studying diagnostic safety advance, it is important that these concepts can be applied to mental health. In this narrative review, we aim to summarise the current state of research on diagnostic error in mental health and identify opportunities to align future research with the emerging science of diagnostic safety. Specifically, we review (1) how diagnostic error in mental health has been conceptualised and measured; (2) evidence for diagnosis-specific pitfalls in common mental disorders; and (3) evidence to inform interventions to reduce diagnostic errors. Although diagnostic overshadowing (the attribution of symptoms to an existing diagnosis rather than a potential comorbid condition 13 ) in people with mental disorders is an important problem, 13–16 this is reviewed elsewhere 17 18 and is outside the scope of this review. We also do not cover the topic of overdiagnosis (when a condition is diagnosed that would not otherwise be consequential to the patient’s health or well-being 4 19 ), as the term is used inconsistently in this literature and is usually conflated with related concepts such as false positives, overtreatment and misdiagnosis. 20

Conceptualising and measuring diagnostic errors

Explicit definitions of diagnostic error seldom appear in the mental health literature, making it difficult to compare findings across studies. A definition in a major psychiatry textbook, acknowledging the work of Cullen et al , 21 focuses on diagnostic accuracy: ‘Diagnostic errors are not only inappropriate psychiatric diagnosis, but also mistaking a physical illness for a psychiatric condition or vice versa.’ 22 Similarly, studies of diagnostic error in mental health have implicitly or explicitly conceptualised diagnostic error as a discrepancy between a previously assigned clinical diagnosis (or lack thereof) and subsequent reappraisal. For example, in a youth community mental health sample, Jensen-Doss and colleagues compared clinician-generated diagnoses with the diagnoses generated by team consensus based on a structured diagnostic interview, medical record review and diagnostic impressions from team members. In this study, most discrepancies between clinician and team consensus diagnoses were attributable to missed diagnoses (ie, diagnoses not noted by the original clinician but subsequently assigned by team consensus). 23

Studies use similar approaches to reappraising prior mental disorder diagnoses with the aid of structured diagnostic interviews such as the Composite International Diagnostic Interview (CIDI), 24–26 Mini Neuropsychiatric Inventory (MINI), 2 , 7–32 Structured Clinical Interview for DSM Disorders (SCID), 33–36 or population-specific 37 or disorder-specific 38 interviews. Others report re-review of medical records to confirm diagnostic criteria. 39–41 However, there are several potential pitfalls of using diagnostic reappraisal to identify errors, including hindsight bias, failure to consider the disorder’s timing of onset, natural history or circumstances that might have complicated a previous diagnostic evaluation. 42 Moreover, methodological inconsistencies prevent comparisons across studies. For instance, whereas some studies of diagnostic discrepancies use structured interviews and other standardised methods for diagnostic assessment, others have inferred a previously ‘missed’ diagnosis solely based on a positive screening test without a more thorough assessment of diagnostic criteria. 43–47 Table 1 summarises recent approaches to identifying diagnostic error and recommendations for future studies.

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Empirical approaches for studying diagnostic error in mental health

More detailed conceptual and operational definitions for diagnostic errors are needed to measure and learn from these events. The NASEM report defines diagnostic error in terms of not only accuracy but also timeliness and communication: ‘the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.’ 4 Other recent definitions emphasise similar concepts and also introduce a component of preventability (‘missed opportunities’). 48 49 An acceptable or normative diagnostic interval is difficult to specify and must be balanced against unrealistic expectations that could invite hasty or overaggressive pursuit of diagnosis. 42 However, factors that are systematically associated with diagnostic accuracy or delays may point to missed opportunities. Such variation can also be examined in the context of health disparities ( table 1 ).

Importantly, conceptual models for understanding diagnostic error emphasise diagnosis as a process that unfolds within a complex system, sometimes across providers and locations. For example, the diagnostic process model in the NASEM report 4 ( figure 1 ), as well as the related Safer Dx framework, 50 describe five data gathering and interpretation processes: clinical history and interview, physical examination (including observation of appearance and behaviour), referral and consultation, diagnostic testing, and (in the latter) patient-related factors. Identifying process failures 51 (eg, did the clinician gather sufficient information to rule out an alternative diagnosis?), rather than focusing solely on the end result (eg, was the clinician’s original diagnosis correct?) enables more precise measurement of errors even when the ‘correct’ or final diagnosis cannot be confirmed, and allows for targeted improvements in the diagnostic process. Clinic-based studies are needed to better understand clinical reasoning and other diagnostic processes in practice. However, complementary evidence about clinical reasoning comes from vignette-based studies that experimentally manipulate patient characteristics, symptom presentation and specific instructions for diagnostic reasoning. 52–58 In a separate section below, we discuss further details of potential interventions to enhance the diagnostic process.

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The diagnostic process model from the National Academies of Science, Medicine and Engineering report Improving Diagnosis in Health Care 4 (reprinted with permission) emphasises data gathering and synthesis, as depicted in the circular portion of the diagram. To better describe the context of missed and delayed diagnosis in mental health, we suggest an elaboration of this model (depicted in the upper portion) that describes the steps and potential delays involved in seeking and accessing mental health services (adapted from Andersen et al 64 ).

Applying diagnostic process models to mental health

While formal concepts and definitions have potential to advance understanding of diagnostic error, it is important to ensure that they reflect the context of mental disorder diagnosis. For instance, while the NASEM model includes the initial steps of experiencing a health problem and engaging with the healthcare system, the model places less emphasis on these initial steps as compared with data gathering. This is an important limitation because patient knowledge and attitudes, stigma and structural barriers play a considerable role in mental healthcare delays. 59–61 A few studies of delayed diagnosis in mental health have defined the diagnostic process in terms of key clinical milestones (eg, first symptoms, first time seeking professional help and time of final, accurate diagnosis), altogether constituting the duration of untreated illness. For example, two studies depicted the evolution of a bipolar disorder diagnosis 62 63 in the form of a graph showing the total diagnostic timeline and the time elapsed between milestones. Other process-oriented models cited in this literature emphasise potential barriers and facilitators to care seeking (eg, Andersen’s behavioural model of health services 64 65 and the cascade of care model 66 ). To better account for the total delay in diagnosing mental disorders, elaboration of the NASEM model may be appropriate. The extension of the NASEM model shown in figure 1 is similar to depictions of the diagnostic pathway for other diseases such as cancer. 67 68

Evidence of diagnosis-specific pitfalls and process breakdowns

Studies have brought to light several pitfalls in the diagnosis of common mental disorders, which may inform further studies to identify and mitigate diagnostic errors. While not an exhaustive list, below is a summary of the some of the most frequently studied conditions in this literature. The degrees of both prevalence and interest in these conditions make them strong candidates for further research and development of improvement strategies:

Anxiety disorders. Despite the high prevalence of anxiety disorders (eg, generalised anxiety disorder, panic disorder, phobias), few studies focus on this category of disorders. The available data point to underdetection and misdiagnosis as common problems. In a study of children and adolescents, 18% of anxiety disorder diagnoses were missed by clinicians compared with 1% that were false positives. 23 A clinic-based study of adults found that 29% of major depressive disorder (MDD) diagnoses were not supported by findings on structured interview, and in about half of these cases, an anxiety disorder was a more appropriate diagnosis. 28 In a sample of 61 US veterans with a diagnosis of ‘anxiety disorder not otherwise specified,’ a more specific diagnosis was justified in 77% of cases, a meaningful finding given that patients with non-specific diagnoses were less likely to receive treatment. 35

Attention deficit hyperactivity disorder (ADHD). A systematic literature review on diagnostic error in children and adolescents did not identify a clear pattern or underdetection versus overdetection of ADHD. 69 However, US-based research has identified evidence of racial and ethnic disparities in ADHD diagnosis. For instance, even after adjusting for demographic and behavioural risk factors, white children are consistently more likely to be diagnosed with ADHD than their Black, Hispanic/Latino and Asian peers. 70–73 There is some evidence that diagnostic disparities between white and Black children has narrowed over time, but disparities in treatment have not narrowed in turn. 74 Additionally, a study of 685 children found evidence that ADHD was underdetected in children with neurological disorders, suggestive of diagnostic overshadowing. 75

Autism spectrum disorder (ASD). Older age at diagnosis is considered a marker of delayed identification, which may indicate missed opportunities in diagnosis. Children who are higher functioning and have less severe or atypical symptoms are at risk for later diagnosis. 65 76 77 Later diagnosis of ASD has also been associated with female gender, 78 79 lower family education and socioeconomic status, 76 77 79 80 less reliable access to healthcare, 65 66 history of adverse childhood experiences 81 and prior diagnosis of ADHD. 82 Racial and ethnic disparities in the diagnosis of ASD have been documented, 83 84 although findings are inconsistent across studies. 85 86

Mood disorders. Research suggests a variety of potential problems in the diagnosis of MDD. A self-reported clinical diagnosis of ‘depression’ had a 62% false-positive rate in a study of over 5000 US adults. 24 In a UK study of 441 people with a recent (past 5 years) diagnosis of MDD, 15% did not meet criteria for MDD or any mood disorder and 30% had undetected bipolar disorder (type I or II). 25 Studies performed outside of the USA and UK document care delays in MDD, 87 88 and a study from Israel found that underdetection occurred more frequently than false-positive diagnosis. 89 Missed and delayed diagnoses are consistently documented in bipolar disorder. 90 Patients with bipolar disorder often experience depressive episodes before (hypo)manic mood symptoms emerge, and thus a diagnostic journey from MDD to bipolar disorder can be expected in many cases. However, failure to assess previous episodes of elevated mood in a depressed patient is a source of diagnostic error. For example, in the aforementioned UK study, among patients with bipolar disorder who were first diagnosed with MDD, about half reported elevated mood symptoms even before their first MDD diagnosis. 25 Additional studies suggest possible missed opportunities to assess manic symptoms at the time of a mood disorder diagnosis, with a significant proportion of major depressive disorder diagnoses converted to bipolar disorder on re-evaluation. 29 91–94 Other studies suggest that bipolar disorder is often misdiagnosed initially as a psychotic disorder. 95 96

Schizophrenia is a challenging diagnosis, especially in the early stage of the disorder. Several studies suggest that an initial diagnosis of schizophrenia changes after further assessment within a short-term interval in 36–51% of patients. 40 97 98 However, it is unclear to what extent these initial incorrect diagnoses reflect ‘missed opportunities’ versus other diagnostic challenges. Another concerning signal for missed opportunities comes from studies of racial disparities, which show that Black patients are more likely than white patients to be diagnosed with schizophrenia even when adjusting for clinical and demographic risk factors. 99–101

To better understand these diagnostic pitfalls and translate them into preventive strategies, it will be important to clarify common diagnostic process breakdowns. Research on diagnostic error in other fields of medicine has identified both general and disease-specific pitfalls that can inform improvements to clinical training and practice. 102 Adaptation of existing frameworks to classify diagnostic process breakdown frameworks 51 103 for use in mental health settings may help facilitate future efforts. For instance, Fletcher et al ’s adaptation of a checklist to assess missed opportunities in diagnosis yielded good reviewer agreement on presence/absence of diagnostic errors in a review of 103 records of US veterans with anxiety disorder diagnoses. 11

Potential interventions to reduce diagnostic error in mental health

Although existing studies of diagnostic error have highlighted potential intervention targets, few studies have tested specific strategies to improve diagnostic decision-making and reduce error in psychiatric diagnosis. We are aware of only two publications that evaluated individual-level interventions to facilitate clinician cognition in ‘real time.’ In a randomised study of 475 clinicians who assigned diagnoses based on vignettes, use of checklists to facilitate assessment (vs no checklists) resulted in fewer false-positive diagnoses of MDD, generalised anxiety disorder and borderline personality disorder. However, checklist use also led to underdetection of MDD. 57 Another study randomised 137 mental health professionals to receive brief education about paediatric bipolar disorder, versus education about cognitive biases and corrective strategies, prior to evaluating four vignettes. Participants in the ‘de-biasing’ condition gave more accurate diagnostic impressions and made fewer errors. 54 Although both studies were conducted within low-fidelity simulations, they join a larger body of work suggesting that cognitive interventions may improve clinicians’ diagnostic performance. 104

Distributing the work of diagnosis among team members is another potential avenue for intervention that emerges from the literature. In a randomised trial, 296 new psychiatric outpatients were randomised to receive usual care vs the addition of a structured clinical interview (SCID) conducted by a psychiatric nurse within 2 weeks of the patient’s intake visit. Results of the interview were provided to the psychiatrist. Within 90 days, the diagnosis changed in 73% of the interview group vs 16% of patients assigned to usual care. 105 In primary care settings, where a large proportion of mental disorder diagnoses are identified, the integration of behavioural health professionals as team members may facilitate screening and diagnosis of mental disorders. 106 107 Integration of mental health services is supported by position statements from the American College of Physicians 108 and the American Academy of Family Physicians. 109 Further studies should evaluate how error in the diagnosis of mental disorders is conceptualised in primary care versus specialty mental health settings.

Interventions to reduce diagnostic errors in mental health need further development. Batstra et al advocated for a conservative ‘stepped diagnosis’ approach that allows for diagnostic evolution within an episode of care without delaying treatment. 110 Suggested interventions that have appeared in the diagnostic error literature, including second opinions, decision support tools and patient engagement strategies, are promising avenues for further investigation in mental health settings. 111 112

We aimed to summarise the state of current research on diagnostic error in mental disorders. The volume of literature on this topic indicates that diagnostic error is well understood to be a problem. However, an obstacle to progress is a lack of clear consensus on how to conceptualise, define and measure errors in mental health diagnosis. Formal definitions for diagnostic errors, if they are cited at all, are used inconsistently in the mental health literature and are not always consistent with definitions used elsewhere in the literature on diagnostic quality and safety. Without a useful way to conceptualise diagnostic errors, it will be difficult to gain insight into how best to prevent them.

Another limitation of much of the literature is that it is difficult to distinguish preventable diagnostic error from other possible causes of diagnostic delays or discrepancies. Very few studies use methods to assess whether sufficient information was available to make an earlier, correct diagnosis. Because variation in diagnosis is subject to many influences, some outside of the clinician’s control, future research should focus on identifying preventable missed opportunities. Fortunately, recent evidence suggests that strategies to identify missed diagnostic opportunities in record review can be adapted to mental health settings. 11 Framing diagnostic errors as learning opportunities is consistent with a culture of safety and improvement and can help break down barriers to open acknowledgement and discussion of this important issue. 113–115

Advancing concepts and measurement strategies will yield better estimates of diagnostic errors and help identify ways to prevent them. However, it is not necessary to quantify these with precision before working towards tools and interventions to reduce errors. Development of measurement methods and interventions can and should occur in parallel. Bridging the gap between the mental health field and the emerging field of diagnostic safety promises to enhance both fields and advance the science of improving patient care. Given the increasingly large share of the population who seek care for mental health problems, 116 117 even modest improvements in diagnostic quality have potential to translate to meaningful gains in patients’ health and quality of life.

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Not applicable.

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X @abradfordphd, @TDGiardina, @HardeepSinghMD

Correction notice This aritcle has been corrected since it was first published online. The funding statement has been updated. In addition, the author Ashley N D Meyer was incorrectly listed as Ashley Mayer. This has now been updated.

Contributors AB and HS contributed to the conception and design of the study. AB, AM, SK and TDG participated in data collection, data analysis and data interpretation. AB wrote the initial draft of the manuscript and revised the manuscript after peer review. AM, SK, TDG and HS critically reviewed the manuscript. All authors have read and approved the final version.

Funding This project was funded under contract number HHSP233201500022I/75P00119F37006 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. Drs. Bradford, Giardina, Meyer, and Singh are partially supported by the Houston VA Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness, and Safety (CIN13-413). Dr. Meyer is additionally supported by a U.S. Veterans Administration (VA) HSR&D Career Development Award (CDA-17-167); Dr. Giardina is additionally supported by AHRQ (K01-HS025474); and Dr. Singh is additionally supported by AHRQ (R01HS028595 and R18HS029347).

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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What are the mental health benefits of exercise?

Other mental health benefits of exercise, reaping the mental health benefits of exercise is easier than you think, overcoming obstacles to exercise, getting started with exercise when you have a mental health issue.

• Easy ways to move more that don't involve the gym

The Mental Health Benefits of Exercise

You already know that exercise is good for your body. But did you know it can also boost your mood, improve your sleep, and help you deal with depression, anxiety, stress, and more?

Exercise is not just about aerobic capacity and muscle size. Sure, exercise can improve your physical health and your physique, trim your waistline, improve your sex life, and even add years to your life. But that’s not what motivates most people to stay active.

People who exercise regularly tend to do so because it gives them an enormous sense of well-being. They feel more energetic throughout the day, sleep better at night, have sharper memories, and feel more relaxed and positive about themselves and their lives. And it’s also a powerful medicine for many common mental health challenges.

Regular exercise can have a profoundly positive impact on depression, anxiety, and ADHD. It also relieves stress, improves memory, helps you sleep better, and boosts your overall mood. And you don’t have to be a fitness fanatic to reap the benefits. Research indicates that modest amounts of exercise can make a real difference. No matter your age or fitness level, you can learn to use exercise as a powerful tool to deal with mental health problems, improve your energy and outlook, and get more out of life.

Exercise and depression

Studies show that exercise can treat mild to moderate depression as effectively as antidepressant medication—but without the side-effects, of course. As one example, a recent study done by the Harvard T.H. Chan School of Public Health found that running for 15 minutes a day or walking for an hour reduces the risk of major depression by 26%. In addition to relieving depression symptoms , research also shows that maintaining an exercise schedule can prevent you from relapsing.

Exercise is a powerful depression fighter for several reasons. Most importantly, it promotes all kinds of changes in the brain, including neural growth, reduced inflammation, and new activity patterns that promote feelings of calm and well-being. It also releases endorphins, powerful chemicals in your brain that energize your spirits and make you feel good. Finally, exercise can also serve as a distraction, allowing you to find some quiet time to break out of the cycle of negative thoughts that feed depression.

Exercise and anxiety

Exercise is a natural and effective anti-anxiety treatment . It relieves tension and stress, boosts physical and mental energy, and enhances well-being through the release of endorphins. Anything that gets you moving can help, but you’ll get a bigger benefit if you pay attention instead of zoning out.

Try to notice the sensation of your feet hitting the ground, for example, or the rhythm of your breathing, or the feeling of the wind on your skin. By adding this mindfulness element—really focusing on your body and how it feels as you exercise—you’ll not only improve your physical condition faster, but you may also be able to interrupt the flow of constant worries running through your head.

Exercise and stress

Ever noticed how your body feels when you’re under stress ? Your muscles may be tense, especially in your face, neck, and shoulders, leaving you with back or neck pain, or painful headaches. You may feel a tightness in your chest, a pounding pulse, or muscle cramps. You may also experience problems such as insomnia, heartburn, stomachache, diarrhea, or frequent urination. The worry and discomfort of all these physical symptoms can in turn lead to even more stress, creating a vicious cycle between your mind and body.

Exercising is an effective way to break this cycle. As well as releasing endorphins in the brain, physical activity helps to relax the muscles and relieve tension in the body. Since the body and mind are so closely linked, when your body feels better so, too, will your mind.

Exercise and ADHD

Exercising regularly is one of the easiest and most effective ways to reduce the symptoms of ADHD and improve concentration, motivation, memory, and mood. Physical activity immediately boosts the brain’s dopamine, norepinephrine, and serotonin levels—all of which affect focus and attention. In this way, exercise works in much the same way as ADHD medications such as Ritalin and Adderall.

Exercise and PTSD and trauma

Evidence suggests that by really focusing on your body and how it feels as you exercise, you can actually help your nervous system become “unstuck” and begin to move out of the immobilization stress response that characterizes PTSD or trauma. Instead of allowing your mind to wander, pay close attention to the physical sensations in your joints and muscles, even your insides as your body moves. Exercises that involve cross movement and that engage both arms and legs—such as walking (especially in sand), running, swimming, weight training, or dancing—are some of your best choices.

Outdoor activities like hiking, sailing, mountain biking, rock climbing, whitewater rafting, and skiing (downhill and cross-country) have also been shown to reduce the symptoms of PTSD.

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Even if you’re not suffering from a mental health problem, regular physical activity can still offer a welcome boost to your mood, outlook, and mental well-being.

Exercise can help provide:

Sharper memory and thinking. The same endorphins that make you feel better also help you concentrate and feel mentally sharp for tasks at hand. Exercise also stimulates the growth of new brain cells and helps prevent age-related decline .

Higher self-esteem. Regular activity is an investment in your mind, body, and soul. When it becomes habit, it can foster your sense of self-worth and make you feel strong and powerful. You’ll feel better about your appearance and, by meeting even small exercise goals, you’ll feel a sense of achievement.

Better sleep. Even short bursts of exercise in the morning or afternoon can help regulate your sleep patterns . If you prefer to exercise at night, relaxing exercises such as yoga or gentle stretching can help promote sleep.

More energy. Increasing your heart rate several times a week will give you more get-up-and-go. Start off with just a few minutes of exercise per day, and increase your workout as you feel more energized.

Stronger resilience. When faced with mental or emotional challenges in life, exercise can help you build resilience and cope in a healthy way, instead of resorting to alcohol, drugs, or other negative behaviors that ultimately only make your symptoms worse. Regular exercise can also help boost your immune system and reduce the impact of stress.

You don’t need to devote hours out of your busy day to train at the gym, sweat buckets, or run mile after monotonous mile to reap all the physical and mental health benefits of exercise. Just 30-minutes of moderate exercise five times a week is enough. And even that can be broken down into two 15-minute or even three 10-minute exercise sessions if that’s easier.

Even a little bit of activity is better than nothing

If you don’t have time for 15 or 30 minutes of exercise, or if your body tells you to take a break after 5 or 10 minutes, for example, that’s okay, too. Start with 5- or 10-minute sessions and slowly increase your time. The more you exercise, the more energy you’ll have, so eventually you’ll feel ready for a little more. The key is to commit to some moderate physical activity—however little—on most days. As exercising becomes a habit, you can slowly add extra minutes or try different types of activities. If you keep at it, the benefits of exercise will begin to pay off.

You don’t have to suffer to get results

Research shows that moderate levels of exercise are best for most people . Moderate means:

• That you breathe a little heavier than normal, but are not out of breath. For example, you should be able to chat with your walking partner, but not easily sing a song.
• That your body feels warmer as you move, but not overheated or very sweaty.

Can’t find time to exercise during the week? Be a weekend warrior

A recent study in the United Kingdom found that people who squeeze their exercise routines into one or two sessions during the weekend experience almost as many health benefits as those who work out more often. So don’t let a busy schedule at work, home, or school be an excuse to avoid activity. Get moving whenever you can find the time—your mind and body will thank you!

Even when you know that exercise will help you feel better, taking that first step is still easier said than done. Obstacles to exercising are very real—particularly when you’re also struggling with a mental health issue.

Here are some common barriers and how you can get past them.

Feeling exhausted. When you’re tired, depressed, or stressed, it seems that working out will just make you feel worse. But the truth is that physical activity is a powerful energizer. Studies show that regular exercise can dramatically reduce fatigue and increase your energy levels. If you are really feeling tired, promise yourself a quick, 5-minute walk. Chances are, once you get moving you’ll have more energy and be able to walk for longer.

Feeling overwhelmed. When you’re stressed or depressed, the thought of adding another obligation to your busy daily schedule can seem overwhelming. Working out just doesn’t seem practical. If you have children, finding childcare while you exercise can also be a big hurdle. However, if you begin thinking of physical activity as a priority (a necessity for your mental well-being), you’ll soon find ways to fit small amounts of exercise into even the busiest schedule.

Feeling hopeless. Even if you’ve never exercised before, you can still find ways to comfortably get active. Start slow with easy, low-impact activities a few minutes each day, such as walking or dancing.

Feeling bad about yourself. Are you your own worst critic? It’s time to try a new way of thinking about your body. No matter your weight, age or fitness level, there are plenty of others in the same boat. Ask a friend to exercise with you. Accomplishing even the smallest fitness goals will help you gain body confidence and improve how you think about yourself.

Feeling pain. If you have a disability, severe weight problem, arthritis, or any injury or illness that limits your mobility, talk to your doctor about ways to safely exercise . You shouldn’t ignore pain, but rather do what you can, when you can. Divide your exercise into shorter, more frequent chunks of time if that helps, or try exercising in water to reduce joint or muscle discomfort.

Many of us find it hard enough to motivate ourselves to exercise at the best of times. But when you feel depressed, anxious, stressed or have another mental health problem, it can seem doubly difficult. This is especially true of depression and anxiety, which can leave you feeling trapped in a catch-22 situation. You know exercise will make you feel better, but depression has robbed you of the energy and motivation you need to work out, or your social anxiety means you can’t bear the thought of being seen at an exercise class or running through the park.

Start small. When you’re under the cloud of anxiety or depression and haven’t exercised for a long time, setting extravagant goals like completing a marathon or working out for an hour every morning will only leave you more despondent if you fall short. Better to set achievable goals and build up from there.

Schedule workouts when your energy is highest. Perhaps you have most energy first thing in the morning before work or school or at lunchtime before the mid-afternoon lull hits? Or maybe you do better exercising for longer at the weekends. If depression or anxiety has you feeling tired and unmotivated all day long, try dancing to some music or simply going for a walk. Even a short, 15-minute walk can help clear your mind, improve your mood, and boost your energy level. As you move and start to feel a little better, you’ll often boost your energy enough to exercise more vigorously—by walking further, breaking into a run, or adding a bike ride, for example.

Focus on activities you enjoy. Any activity that gets you moving counts. That could include throwing a Frisbee with a dog or friend, walking laps of a mall window shopping, or cycling to the grocery store. If you’ve never exercised before or don’t know what you might enjoy, try a few different things. Activities such as gardening or tackling a home improvement project can be great ways to start moving more when you have a mood disorder—as well as helping you become more active, they can also leave you with a sense of purpose and accomplishment.

Be comfortable. Wear clothing that’s comfortable and choose a setting that you find calming or energizing. That may be a quiet corner of your home, a scenic path, or your favorite city park.

Reward yourself. Part of the reward of completing an activity is how much better you’ll feel afterwards, but it always helps your motivation to promise yourself an extra treat for exercising. Reward yourself with a hot bubble bath after a workout, a delicious smoothie, or with an extra episode of your favorite TV show, for example.

Make exercise a social activity. Exercising with a friend or loved one, or even your kids, will not only make exercising more fun and enjoyable, it can also help motivate you to stick to a workout routine. You’ll also feel better than if you were exercising alone. In fact, when you’re suffering from a mood disorder such as depression, the companionship can be just as important as the exercise.

Easy ways to move more that don’t involve the gym

Don’t have a 30-minute block of time to dedicate to yoga or a bike ride? Don’t worry. Think about physical activity as a lifestyle rather than just a single task to check off your to-do list. Look at your daily routine and consider ways to sneak in activity here, there, and everywhere.

Move in and around your home. Clean the house, wash the car, tend to the yard and garden, mow the lawn with a push mower, sweep the sidewalk or patio with a broom.

Sneak activity in at work or on the go. Bike or walk to an appointment rather than drive, use stairs instead of elevators, briskly walk to the bus stop then get off one stop early, park at the back of the lot and walk into the store or office, or take a vigorous walk during your coffee break.

Get active with the family. Jog around the soccer field during your kid’s practice, make a neighborhood bike ride part of your weekend routine, play tag with your children in the yard, go canoeing at a lake, walk the dog in a new place.

Get creative with exercise ideas. Pick fruit at an orchard, boogie to music, go to the beach or take a hike, gently stretch while watching television, organize an office bowling team, take a class in martial arts, dance, or yoga.

Make exercise a fun part of your everyday life

You don’t have to spend hours in a gym or force yourself into long, monotonous workouts to experience the many benefits of exercise. These tips can help you find activities you enjoy and start to feel better, look better, and get more out of life.

More Information

• Greer, T. L., Trombello, J. M., Rethorst, C. D., Carmody, T. J., Jha, M. K., Liao, A., Grannemann, B. D., Chambliss, H. O., Church, T. S., & Trivedi, M. H. (2016). Improvements in psychosocial functioning and health-related quality of life following exercise augmentation in patients with treatment response but non-remitted major depressive disorder: Results from the TREAD study. Depression and Anxiety, 33(9), 870–881. Link
• Kandola, A., Vancampfort, D., Herring, M., Rebar, A., Hallgren, M., Firth, J., & Stubbs, B. (2018). Moving to Beat Anxiety: Epidemiology and Therapeutic Issues with Physical Activity for Anxiety. Current Psychiatry Reports, 20(8), 63. Link
• Aylett, E., Small, N., & Bower, P. (2018). Exercise in the treatment of clinical anxiety in general practice – a systematic review and meta-analysis. BMC Health Services Research, 18(1), 559. Link
• Stubbs, B., Vancampfort, D., Rosenbaum, S., Firth, J., Cosco, T., Veronese, N., Salum, G. A., & Schuch, F. B. (2017). An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis. Psychiatry Research, 249, 102–108. Link
• Kandola, A. A., Osborn, D. P. J., Stubbs, B., Choi, K. W., & Hayes, J. F. (2020). Individual and combined associations between cardiorespiratory fitness and grip strength with common mental disorders: A prospective cohort study in the UK Biobank. BMC Medicine, 18(1), 303. Link

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Mental Health Research During the COVID-19 Pandemic: Focuses and Trends

Yaodong liang.

1 Law School, Changsha University, Changsha, China

2 Department of Psychology, University of Toronto St. George, Toronto, ON, Canada

3 Centre for Mental Health and Education, Central South University, Changsha, China

Associated Data

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The COVID-19 pandemic has profoundly influenced the world. In wave after wave, many countries suffered from the pandemic, which caused social instability, hindered global growth, and harmed mental health. Although research has been published on various mental health issues during the pandemic, some profound effects on mental health are difficult to observe and study thoroughly in the short term. The impact of the pandemic on mental health is still at a nascent stage of research. Based on the existing literature, we used bibliometric tools to conduct an overall analysis of mental health research during the COVID-19 pandemic.

Researchers from universities, hospitals, communities, and medical institutions around the world used questionnaire surveys, telephone-based surveys, online surveys, cross-sectional surveys, systematic reviews and meta-analyses, and systematic umbrella reviews as their research methods. Papers from the three academic databases, Web of Science (WOS), ProQuest Academic Database (ProQuest), and China National Knowledge Infrastructure (CNKI), were included. Their previous research results were systematically collected, sorted, and translated and CiteSpace 5.1 and VOSviewers 1.6.13 were used to conduct a bibliometric analysis of them.

Authors with papers in this field are generally from the USA, the People's Republic of China, the UK, South Korea, Singapore, and Australia. Huazhong University of Science and Technology, Hong Kong Polytechnic University, and Shanghai Jiao Tong University are the top three institutions in terms of the production of research papers on the subject. The University of Toronto, Columbia University, and the University of Melbourne played an important role in the research of mental health problems during the COVID-19 pandemic. The numbers of related research papers in the USA and China are significantly larger than those in the other countries, while co-occurrence centrality indexes in Germany, Italy, England, and Canada may be higher.

We found that the most mentioned keywords in the study of mental health research during the COVID-19 pandemic can be divided into three categories: keywords that represent specific groups of people, that describe influences and symptoms, and that are related to public health policies. The most-cited issues were about medical staff, isolation, psychological symptoms, telehealth, social media, and loneliness. Protection of the youth and health workers and telemedicine research are expected to gain importance in the future.

Introduction

Although the impacts of the COVID-19 pandemic will be recorded in human medical history and in socio-economic history, various psychological consequences regarding mental health among populations cannot be ignored, including stress, anxiety, depression, frustration, insomnia, and so on. Researchers from universities, hospitals, communities, and medical institutions worldwide have been focusing on mental health problems during the pandemic. They have used questionnaire surveys, telephone-based surveys, online surveys, cross-sectional surveys, systematic reviews and meta-analysis, and systematic umbrella reviews to investigate mental health problems during the pandemic. Two years after the outbreak of the COVID-19, the pandemic has gradually subsided in some countries, while others have adopted a strategy of coexisting with the virus. If more deadly mutant strains do not appear in the future, it is very likely that the pandemic will not climax again. It is pertinent to summarize and study mental health research during the pandemic, because many psychological problems have arisen as a result, and there has been significant interest in research on such issues in the previous two years.

As an effective quantitative analysis method, bibliometrics can be used not only to assess the quality and quantity of published papers, but also to explore research focuses and trends, the distribution of authors and institutions, the impact of publications, journals, and different countries regarding research contributions to the theme. Due to the rapid growth in research in this area, there are now over 1,000 academic papers, and accordingly, it would appear necessary to investigate important, valid, and meaningful information from large databases to guide scientific research. The authors used CiteSpace and VOSviewers to determine the focuses and trends in this regard.

Data Analysis and Visualization

The authors searched the Web of Science (WOS), ProQuest Academic Database (ProQuest), and China National Knowledge Infrastructure (CNKI) to extract publications related to mental health and COVID-19. Their previous research results were systematically collected, sorted, and translated, and CiteSpace 5.1 and VOSviewers 1.6.13 were used to conduct a bibliometric analysis of them.

Data Source and Search Strategy

Our team selected 1,226 papers from 2019 to 2022 using three combinations of keywords, mental health and COVID-19, mental health and new coronavirus, and mental health and novel coronavirus, from the three academic paper databases, WOS, ProQuest, and CNKI. Two explanations are necessary here, the first is about the keywords and the second is about the databases. (1) The reason we used new or novel coronavirus as keywords was that the name COVID-19 has not been determined about 2 years ago. In order not to miss relevant research results, we also included these synonyms as keywords for the search. (2) Among the three databases, WOS and ProQuest, in which most of the English-language papers were published, are well-known to scholars all around the world. However, the CNKI database is not as popular as WOS or ProQuest given that most of the papers in CNKI were published in Chinese. We chose to use the CNKI data for the following three reasons: first, China was the most affected country during the COVID-19 outbreak and Chinese academic journals published significant research on mental health. Second, CNKI is the largest Chinese academic database. Third, after the outbreak, the Chinese government's virus clearance policy has been implemented and continues to date. Strict control has helped suppress the spread of the virus, but has also likely had mental health implications, given the severe reduction in social interactions. Therefore, we think that the Chinese database is appropriate and useful in this study.

About 50% of the articles were from the WOS, about 10% of the articles from ProQuest, and about 40% from CNKI. Basic information such as title, author, institution, country, abstract, keywords, methods, results, and conclusions of all articles, if not in English, are translated into English and analyzed using SiteSpaceII and VOSviewers. Since the keywords include COVID-19 and mental health, synonyms such as novel coronavirus and psychological distress spontaneously appeared while searching. Words that are closely related to the subject, such as public health, quarantine, and insomnia, were most frequently mentioned.

Most articles were published during the period from February 2020 to July 2022, including those pre-published online from April to July, and only one article that had been published in 2019 was included. Judging from the line chart above, since the volume of COVID-19 and mental health-related articles had already risen two times in June 2020 and June 2021 and then remained low until now, it is high time to conclude a previous study on COVID-19 and mental health, to sort out the foci of those studies, and to analyze and predict future trends ( Figure 1 ).

The volume of COVID-19 and mental health-related articles in 2020–2022.

Scholars from around the world have contributed to the study of mental health issues during the COVID-19 pandemic. The top 10 countries with the largest quantum of publications related to mental health during COVID-19 are the USA, People's Republic of China, England, Canada, Australia, India, Italy, Japan, Iran, and Germany. Wide and active participation of several countries has laid a solid foundation for its future development. Universities, hospitals, communities, and medical institutions around the world have conducted sample surveys of patients, students, community residents, medical workers, and other sample populations of considerable sample sizes since the outbreak. Survey and research methods include questionnaire survey, telephone-based survey, online survey, cross-sectional survey, systematic review and meta-analyses, and systematic umbrella review ( Table 1 ).

Top 20 countries.

Most papers are from the USA, the People's Republic of China, England, Australia, Canada, India, Italy, Iran, Japan, and Germany. Judging from the country or region co-occurrence graph, England and Canada are in the center of this graph, with India, Poland, Denmark, Spain, South Korea, Portugal, Italy, and Canada around them. England, Australia, Canada, Japan, Brazil, India, Iran, and Germany have done significant research work in this field. In addition, the number of related research papers in the USA and China is significantly larger than that in all other countries ( Figure 2 ).

Country or region co-occurrence.

In Table 2 , we can see that most names of the top 20 authors are Asian names, and they are mainly from China. Six of them published more than 10 articles by the end of 2021. In the extended ranking, we find that the authors who have published a large number of papers are generally from the USA, China, the UK, South Korea, Singapore, and Australia. The authors Griffiths MD, Cheung T, Xiang Y, Lin C, Wang Y, and Zhang L were very active in this field of study.

Top 20 authors.

In the abovementioned graphs, we can see six groups of related authors. The VOSviewer was used to describe the partnership between them. Though six colors were used to separate these groups, there were still lines connecting the groups to represent the partnership between them. We can take Cheung T and Xiang Y as the center of the largest group. Another group with Griffiths MD and Lin C as its center was also significant ( Figures 3 , ​ ,4 4 ).

Author co-occurrence.

Author co-occurrence groups.

The top five institutions are Huazhong University of Science and Technology, Hong Kong Polytechnic University, Shanghai Jiao Tong University, Columbia University, and the University of Toronto. Meanwhile, the top five institutions in centrality are the University of Macau, the University of Melbourne, Columbia University, Wuhan University, and the University of Toronto. It is worth mentioning that Huazhong University of Science and Technology and Wuhan University are located in the city of Wuhan, one of the areas most affected by the virus through the outbreak. The society and economy of the city temporarily stagnated at the time, and its medical system was once paralyzed. Eventually, Wuhan City's medical system was fully recovered. The University of Toronto, Columbia University, and the University of Melbourne have played an important role in the research of mental health problems during the COVID-19 pandemic ( Table 3 and Figure 5 ).

Top 20 institutions.

Institutions' co-occurrence.

As can be seen in Figure 6 , Huazhong University of Science and Technology has led Chinese universities and research institutions, such as Shanghai Jiao Tong University and Peking University, in conducting research on COVID-19 and mental health. Hong Kong Polytechnic University, Fudan University, and the University of Melbourne acted as bridges, connecting famous universities and research institutions in Europe, America, and other countries in the world, such as Kings College London and Harvard Medical School, to jointly study issues in this field. In particular, they conduct joint research, directly or indirectly, through Hong Kong Polytechnic University, which display the important communication and joint role of Hong Kong Polytechnic University.

Keyword clustering.

Judging from Table 4 , the most mentioned keywords, in addition to COVID-19 and mental health, can be roughly divided into three categories: (1) keywords representing specific groups of people, such as adolescents, young adults, doctors, nurses, medical staff, and healthcare workers; (2) keywords describing influences and symptoms, such as isolation, loneliness, anxiety, depression, stress, and insomnia; and (3) keywords related to public health policies, such as lockdown, social distancing, telehealth, telemedicine, and quarantine.

Keyword clustering I.

In Graph 7, we can judge that COVID-19, mental health, pandemic, and coronavirus are represented by larger red dots as their centrality indexes are naturally higher. In this bibliometric network map, other keywords emerged next to them and together formed this visualization bibliometric network. Occupational and sociodemographic characteristics are clustered together, while symptoms of mental health problems are clustered next to them. Specific groups of people and their typical symptoms and causes occupy certain areas on the map. For example, typical symptoms of university students and the possible causes of these symptoms are grouped together on the map. Similarly, quarantine policy and its influence are also classified in certain areas. In addition, research methods and solutions appeared sporadically on this map.

Table 5 shows eight groups of core keywords separated from keyword clustering I. Each of these groups contains three keywords, which proves that these keywords appear at the same time in a considerable part of the research, and are more closely related. Keyword ClusteringII cannot only present the outline of existing mental health research in academia, but also highlights the focus of research. In addition, SiteSpaceII and VOSviewers also gave us some clues about the research trends and further development.

Keyword clustering II.

Research Focuses

Medical staff.

The COVID-19 pandemic has exacerbated mental health problems among populations, especially medical staff, patients with COVID-19, chronic disease patients, and isolated people. Doctors, nurses, and other medical staff have significantly higher rates of insomnia than other populations ( 1 ). The researchers obtained the relevant demographic data through the WeChat questionnaire survey. Questions in the questionnaire are related to insomnia, depression, anxiety, and stress-related symptoms during the pandemic. Their research found that, since the outbreak, more than one-third of the medical staff suffered from symptoms of insomnia. Psychological intervention measures were necessary for those people ( 2 ). Research within medical institutions shows that the psychological pressure of medical staff in isolation wards was greater, but had also attracted greater attention from hospital administrators. The concern of hospital managers alleviated the pressure of medical staff to a certain extent. Further, concern for the public also reduced their psychological burden. In terms of anxiety about infection and fatigue factors, the research results showed that the psychological burden of nurses was heavier than that of doctors. Healthcare workers who lived with their own children showed more obvious fatigue and anxiety, which might be due to the fear of their children becoming infected. In terms of workload and work motivation, medical staff who have been working for more than 20 years have a heavier workload, but they can still maintain their enthusiasm to fight against the pandemic ( 3 ). Another survey showed that 73.4% of healthcare workers, mainly physicians, nurses, and auxiliary staff, reported post-traumatic stress symptoms during outbreaks, with symptoms persisting for up to 3 years in 10–40% of the cases. Depressive symptoms were reported in 27.5–50.7%, insomnia symptoms in 34–36.1%, and severe anxiety symptoms in 45% ( 4 ). A subgroup analysis revealed gender and occupational differences, with female health care practitioners and nurses exhibiting higher rates of affective symptoms compared to men and medical staff, respectively ( 5 ).

As a result, depressive symptoms (21%) and anxiety symptoms (19%) are higher during the COVID-19 pandemic compared to previous epidemiological data. About 16% of the subjects suffered from severe clinical insomnia during the lockdown. The pandemic and lockdown seemed to be particularly stressful for younger adults who were under 35 years old, women, people out of work, or those with low incomes ( 6 ). In the fight against the pandemic, China adopted measures to restrict population aggregation, such as the blockade of pandemic areas, individual patient isolation, and restrictions on the movement of people in non-pandemic areas. These measures effectively prevented the spread of the pandemic. At the same time, the use of health codes, grid-like community management, and the operational efficiency of infectious disease information networks have greatly improved. However, quarantine has also brought with it a number of problems, such as increasing psychological pressure on the population, affecting the daily lives of families, and hindering social and economic development ( 7 ). A large sample size study with wide coverage published in 2021 showed that young people quarantined at home in different provinces had different rates of anxiety and depression due to different severity of pandemic situations in different regions. The risk of anxiety and depression was statistically significantly higher in girls than in boys. The rate of anxiety and depression was affected by factors, such as gender, age, and area, as well as the existence of COVID-19 cases in the surrounding area ( 8 ).

Psychological Symptoms

The impact of the aforementioned isolation measures on mental health is only part of the impact of the COVID-19 on mental health. Psychological symptoms brought about by the pandemic have also been systematically sorted out by scholars. These studies show two clues. First, certain people have special psychological symptoms; second, psychological symptoms in different countries of the world are roughly the same. Several factors were associated with a higher risk of psychiatric symptoms or low psychological wellbeing, including female gender and poor self-related health ( 9 ). Relatively, severe symptoms of anxiety, depression, post-traumatic stress disorder, psychological distress, and stress were reported in the general population during the COVID-19 pandemic in China, Spain, Italy, Iran, the USA, Turkey, Nepal, and Denmark. Risk factors associated with measures of distress include female gender, younger age group, the presence of chronic or psychiatric illnesses, unemployment, student status, and frequent exposure to social media or news concerning COVID-19. The pandemic is associated with significant levels of psychological distress that, in many cases, will meet the threshold for clinical relevance. Mitigating the hazardous effects of COVID-19 on mental health is an international public health priority ( 1 ). Infectious disease pandemics often cause some people to act irrationally. The results of a survey based on psychological symptoms and irrational behaviors have drawn some conclusions. First, the vast majority of people remain in good physical and mental health, but some exhibit irrational behaviors. Second, women, elderly people, and those with confirmed cases showed more physical and mental symptoms and irrational behaviors. Finally, paradoxically, people with high education levels showed more mental symptoms, but fewer irrational behaviors ( 10 ).

Telemedicine

Just as the pandemic has enabled the rapid development of online education, the prospects of telemedicine are also favored by experts, observers, and investors. However, there are two restrictive aspects, namely, telemedicine equipment and telemedicine human resources. The application of 5G communication technology, telemedicine equipment, remote monitoring equipment, remote physical sign monitoring equipment, and medical artificial intelligence triage equipment all need to be urgently developed and improved. Jiangsu, a province in China, is a model province of the national project called “Internet + Medical and Health.” During the pandemic, the telemedicine by public hospitals in Jiangsu Province helped improve the efficiency of diagnosis and treatment, alleviating the pressure of offline diagnosis and treatment, and reducing the risk of cross-infection. Subsequently, medical staff were fully supportive of telemedicine. However, there was a shortage of medical staff in fever clinics, obstetrics and gynecology, pediatrics, and psychiatrists that provided telemedicine services, and they lacked corresponding incentive mechanisms ( 11 ). Effective mitigation strategies to improve mental health were developed by public health management experts. To control the rapid spread of COVID-19 and manage the crisis better, both developed and developing countries have been improving the efficiency of their health system by replacing a proportion of face-to-face clinical encounters with telemedicine solutions ( 12 ).

Social Media

There were rumors in various kinds of media during the COVID-19 pandemic. Although we can regard rumors as a disturbing error for psychological measurement, if they are not strictly controlled, their impact on people's mental health and behavior cannot be ignored. A study focusing on the spread of WeChat rumors has explored the psychological perception mechanism of audiences affected by rumor spreading in emergency situations. The study has significant results in the following terms: the form characteristics of the rumors in COVID-19, the ranking of susceptible age groups, the degree of dependence of the test subject on certain media and its psychological impact, and the follow-up behavior of the test subjects related to psychological variables ( 2 ). In 2021, another interesting study based on the data of TikTok videos released by three mainstream media in China showed that they inevitably caused some psychological trauma to the public. However, from the perspective of overall emotional orientation, short-format videos with positive reporting emotional tendencies had an advantage in attracting likes from TikTok users. Positive government responses to pandemic information were very important, and those responses could be recognized and praised by most social media users. Some of the TikTok videos, such as The Plasma of a Recovered Patient Cured 11 Other ICU Patients, The First COVID-19 Test Kit Passed Inspection, and A Frenchman Named Fred gave up Returning to Home to Join China's Anti-COVID-19 Battle, are extremely popular among social media users. Most social media users have been providing spiritual sustenance for people in the pandemic ( 13 ). When a public health crisis occurs, social media plays an important role in increasing public vigilance, helping the public identify rumors, and boosting public morale.

University Students and Loneliness

A study that assessed the adverse impact on the mental health of university students has drawn some conclusions. First, the severity of the outbreak has an indirect effect on negative emotions by affecting sleep quality. Second, a possible mitigation strategy to improve mental health includes ensuring suitable amounts of daily physical activity and deep sleep. Third, the pandemic has reduced people's aggressiveness, probably by making people realize the fragility and preciousness of life ( 14 ). Another research focused on social networks and mental health compared two cohorts of Swiss undergraduate students who were experiencing the crisis, and made an additional comparison with an earlier cohort who did not experience the pandemic. The researchers found that interaction and co-study networks had become sparser, and more students were studying alone. Stressors shifted from fear of missing out on social life to concern about health, family, friends, and their future ( 15 ). Young adults, women, people with lower education or lower income, the economically inactive, people living alone, and urban residents were at greater risk of being lonely during the pandemic. Being a student emerged as a higher than usual risk factor for loneliness during the lockdown ( 16 ). A study to explore the relationship between loneliness and stress among undergraduates in North America showed that the loneliness and stress among college students increased. On one hand, stress plays a key role in the deterioration of college students' mental health; on the other hand, reducing the loneliness of college students is expected to reduce the negative impact of stress on college students' mental health ( 17 ).

Research Trends

Due to the limited training sample of academic papers at present, it is difficult to predict the outcomes accurately. Though we cannot exactly predict the hot issues in the future, we can sort out some possible research trends in this field by analyzing existing research approaches. Psychological symptoms that affected people's mental health during the COVID-19 pandemic will be discovered further, especially those that probably continued to affect people's mental health even after the pandemic is controlled.

Studies on mild psychological symptoms, such as mild insomnia and anxiety, tend to decrease slowly, and in the case of severe problems caused by the pandemic, or severe psychological symptoms, such as clinical insomnia, depression, bipolar disorder, the corresponding in-depth research will continue. The impact of a global pandemic on the mental health of the global population must be profound and worthy of study. Due to the rapid development of COVID-19, many famous universities and research institutions have not had enough time to collect sufficient data and relevant research materials. The different effects on populations in different countries with different pandemic prevention policies are not yet fully displayed.

Regardless of how research on mental health develops, the COVID-19 pandemic has indeed brought us some new insights. As mentioned in many articles on mental health interventions for adolescents and college students, the mental health of specific populations and the development of telemedicine all deserve continued academic attention. Mental health intervention for adolescents and college students is a means to consider and prepare for the future. To ensure responsible and accountable behavior for future generations, we should all pay attention to the research and application of this method. Caring for specific groups of people, such as doctors, nurses, and other healthcare workers, and studying how to protect them in a global pandemic is a topic that global academia must study in the future, or we will lose protection the next time the virus sweeps the world. In addition, telemedicine is the trend in the future, and face-to-face diagnosis and treatment will undoubtedly increase the risk of cross-infection during the pandemic. Therefore, the development of telemedicine is an important way to avoid contact between the patients. The COVID-19 pandemic has accelerated the research and development of telemedicine.

Limitations

(1) Though we have selected three databases for analysis, there are still some databases that may be related to this field that are not covered in this study. (2) Since COVID-19-related research was started just 2 years ago, the results of the bibliometric analysis may vary after adding new data. (3) The citation frequency of articles is influenced by the time of publication, thus previously published articles should be cited more frequently than new ones. (4) Bibliometric data change over time, and different conclusions may be drawn over time. Therefore, this study should be updated in the future.

Conclusions

The most mentioned keywords, in addition to COVID-19 and mental health, can be roughly divided into three categories: keywords representing specific groups of people, keywords describing influences and symptoms, and keywords related to public health policies. The most mentioned issues were about medical staff, quarantine, psychological symptoms, telemedicine, social media, and loneliness. Mild psychological symptoms, such as insomnia, depression, and anxiety, tend to decrease slowly, while severe ones, such as severe clinical insomnia, depression, and bipolar disorder, are yet to be discovered. The importance of studies on the protection of youth medical staff and telemedicine studies will become even more significant in the future. While physical health is threatened by the pandemic, human mental health also suffers. Judging from the current situation of pandemic prevention and control, if severe prevention and control measures are taken, the impact of COVID-19 on the health of the social population is controllable; if a strategy of coexistence with the virus is adopted, as long as a new deadly mutation of COVID-19 does not emerge, the outcomes can be controllable. However, the impact of the pandemic on human mental health is not easy to predict. In addition to the abovementioned papers on mental health, the author also noted that some papers focused on neuromedicine pointed out that the virus might have some damage to the normal working mechanism of the human nervous system, but these studies are outside the scope of mental health research, at least for now. This study aims to summarize the observations, analysis, and research of scholars on mental health during the pandemic from 2020 to early 2022, with a view to provide more clues for future researchers. We hope that more researchers will build on our research to discover new research areas and new questions to help more countries, groups, and individuals affected by the COVID-19 pandemic.

Data Availability Statement

Author contributions.

YL was responsible for the concept and design, drafting this article, and bibliometric analysis. YL, LS, and XT were responsible for the revision and data collection. All authors contributed to this article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The authors thank the study participants for their time and effort.

Trajectories of disability and influence of contextual factors among adults aging with HIV: insights from a community-based longitudinal study in Toronto, Canada

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Background: Individuals aging with HIV may experience disability that is multidimensional and evolving over time. Our aims were to characterize the longitudinal trajectories of disability and to investigate how intrinsic and extrinsic contextual factors influence dimensions of disability over an 8-month period among adults aging with HIV. Methods: We analyzed longitudinal observational data from a community-based study in Toronto, Canada, where adults aging with HIV completed self-reported questionnaires over 8 months (5 time points). We measured disability using the Short-Form HIV Disability Questionnaire (SF-HDQ), which included six dimensions: physical, cognitive, mental-emotional health challenges, uncertainty, difficulties with day-to-day activities, and challenges to social inclusion. Higher SF-HDQ scores (range: 0-100) indicate greater severity of disability. We assessed intrinsic (age, gender, education, living status, number of comorbidities, mastery) and extrinsic (stigma, social support) contextual factors using baseline self-reported questionnaires. Latent class growth analysis was performed to identify distinct disability trajectories within each of the six dimensions. Multinomial logistic regression models were used to assess the influence of contextual factors on the disability trajectories. Results: Of 108 participants, 89% identified as men with a mean age of 50.6 years (standard deviation ±10.9). We identified three disability trajectories: low, medium, and high disability severity in the physical, mental-emotional, and day-to-day activities dimensions. Four trajectories: low, medium-low, medium-high, and high (or high-declining) disability severity were in the cognitive, uncertainty, and social inclusion dimensions. Factors such as higher self-mastery and social support were associated with lower disability trajectories, whereas greater number of comorbidities and stigma were associated with more severe disability trajectories over time. Conclusion: Disability experiences among adults aging with HIV included three or four distinct trajectories with considerable heterogeneity over time. Information on contextual factors may be helpful for informing interventions and supports that mitigate disability among adults aging with HIV.

Competing Interest Statement

The authors have declared no competing interest.

Clinical Protocols

https://bmjopen.bmj.com/content/6/10/e013618

Funding Statement

This study was funded by the Canadian Institutes of Health Research (CIHR) HIV/AIDS Community-Based Research (CBR) Program (Funding Reference Number #CBR-139685; 160 Elgin Street, Ottawa, Ontario, Canada, K1A 0W9). https://cihrirsc. gc.ca/e/193.html. Tai-Te Su was supported by the Ontario HIV Treatment Network Endgame Research Program Breaking New Ground Award (EFP-1121-BNG) (https://www.ohtn.on.ca/). KKO is supported by a Canada Research Chair in Episodic Disability and Rehabilitation from the Canada Research Chairs Program (https://www.chairschaires.gc.ca/home-accueil-eng.aspx). AT was supported by a Clinician-Scientist Award (Phase II) from the Ontario Heart & Stroke Foundation (P-19-TA-1192). AMB was supported by the Fondation Alma and Baxter Ricard Chair in Inner City Health at St. Michaels Hospital and the University of Toronto.

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I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The research was approved by the HIV/AIDS Research Ethics Board at the University of Toronto (Protocol #32910).

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

This revised version of the manuscript includes ORCID IDs for authors and supplemental files.

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All relevant data are within the paper and its Supporting information files.

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Mental Health and Physical Health Research Paper

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Introduction

According to the World Health Report 2001, over the past 20 years a fundamental and inseparable connection between mental and physical health has been convincingly established (WHO, 2001). Both mental and physical health are influenced by a combination of biological, psychological, and social factors. Thoughts, feelings, and behavior have a major impact on physical health. Conversely, physical health has an important influence on mental health and well-being. The report notes two critical pathways through which this occurs: Physiological systems such as neuroendocrine and immune functioning and health behavior. These pathways are not independent: Behavior may affect physiology, while physiological functioning may in turn affect health behavior. In this research paper, we examine the historical shift that has occurred from a dualistic conception of health and illness to the biopsychosocial model that emphasizes an integration of mind and body. We explore this interrelationship using the examples of somatoform disorder, chronic pain, HIV/AIDS, cardiovascular disease, cancer, and diabetes. Finally, we focus on some of the somatic manifestations of mental illness.

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Get 10% off with 24start discount code, historical development of an integrated model, the biomedical model.

In the seventeenth century, the mind and body were considered to be two separate entities, largely unrelated to each other and influenced by discrete sets of factors. Rene´ Descartes, a major proponent of a dualistic conceptualization of mind and body, considered it appropriate that the functioning of the body should fall in the realm of science, while the workings of the mind and soul should be the concern of philosophy and, subsequently psychology. In the strongly religious atmosphere of this era, Cartesian dualism provided an important restraint on the influential Christian church from interfering in scientific activities that were considered previously taboo, such as the dissection of corpses, which was considered sinful and was forbidden by the European church. However, if it could be agreed that scientists would be concerned with the body and nothing else, it would no longer be the prerogative of the church to interfere in scientific affairs. In return, the soul and mind would remain the domain of the clergy and outside of the realm of science. In this context, mind and body were separate and the boundary between the two was seen as impermeable.

Dualism became highly influential in informing the biomedical model of health care. The medical model, whose hegemony went largely unchallenged for more than two centuries, embraces the view that illness is caused by internal or external agents that arrest or alter the normal functioning of the body. Such agents include bacteria, viruses, toxins, carcinogens, or genes. In the medical model, the objective is to identify the etiological factors associated with poor health and rectify these so as to restore the body to optimal functioning. Accordingly, humans are chiefly biological organisms who can be understood by examining their constituent parts. In its extreme form, the only conceptual apparatuses required by the biomedical model to understand human functioning are physical and chemical in nature. This emphasis has led to the ascendance of disciplines such as anatomy, physiology, and biochemistry in traditional biomedicine. Disease in the biomedical paradigm occurs when there is disruption in normal biological functioning, usually caused by an identifiable event of a physical or chemical nature. Medical treatment from this perspective involves physical or chemical agents to correct the disruption and restore the body to health.

The Biopsychosocial Model

With further discoveries in the health sciences in the nineteenth and twentieth centuries, it became apparent that a dualistic conceptualization of health and illness was an inadequate explanatory model. It was instead recognized that the physiological regulation of the body’s various systems (e.g., the digestive and respiratory systems) entailed a series of complex interactions and feedback loops involving a variety of variables. The utility of linear and mechanistic causal models of illness thus diminished and a greater emphasis was placed on a systemic understanding of human functioning. Thus, viruses and bacteria remained necessary conditions for the occurrence of illness but were no longer considered sufficient. Instead, disease is thought to occur as a result of the interaction between host systems and disease agents. This interaction is characterized by complexity and nonlinearity, with an emphasis on systemic rather than mechanistic functioning. It has become accepted that human health and wellbeing are shaped by a multitude of factors that include behavior, personality, cognitive style, and social, economic and political relationships.

The biopsychosocial model emphasizes the interaction of psychological, social, economic, behavioral, biological, and physical factors in influencing the functioning of human beings. As such, it invokes a systemic understanding in which elements are arranged hierarchically so that change in one element of a system affects other parts. Human beings are highly complex systems that consist of organ systems, organs, tissue, cells, and chemical elements located in a historical, social, and economic context. Yet, while this context influences individuals, the environment is similarly affected by human interpretation, action, interaction, and social change. Thus, environment influences human behavior and is also simultaneously influenced by it. Similarly, behavior may influence biological processes but may also be influenced by such processes. The biopsychosocial model considers the boundary between the psychological and physical dimensions of human functioning to be a highly permeable mediator of reciprocal influences. The emphasis on multiple elements and their dynamic interplay provides a complex and nuanced understanding of the factors that influence health.

The biopsychosocial model defines health and illness as ‘the product of a combination of factors that include biological characteristics (e.g. genetic predisposition), behavioral factors (e.g. lifestyle, stress, health beliefs), and social conditions (e.g. cultural influences, family relationships, and social support)’ (American Psychological Association, 2001). Political and economic structures and systems as well as (their associated) health systems and approaches to financing of health care have also been found to directly affect health.

Mental and physical health intersect in various ways. While in reality it is often not possible to separate out these relationships, the following are important identifiable junctures between mental and physical health.

• Mental health status may impact on health risk behaviors;
• Mental problems may manifest as or impact on physical health problems;
• Diseases may attack both the brain and other organs or functions of the body;
• Physical ailments may affect mental functioning;
• A mental disorder may influence the course of physical disease;
• Medication given for the treatment of both mental and physical health problems may affect the other.

Having addressed some of the paradigmatic and theoretical considerations regarding mental and physical health, we now focus on specific conditions such as somatization, chronic pain, HIV and AIDS, cardiovascular disease, cancer, and diabetes. Our analysis is in keeping with the biopsychosocial model to the extent that we de-emphasize rigid divisions between the two dimensions of health.

Health Conditions

Somatoform disorders.

When physical symptoms occur in patients that are not fully explained by a general medical condition, these are usually referred to as somatoform disorders. In the category of somatoform disorders, the DSM-IV-TR includes somatization disorder (characterized by pain, gastrointestinal, and sexual problems), conversion disorder (involving unexplained symptoms that affect motor or sensory function), and hypochondriasis (characterized by the idea that one may have a serious disease, based on misinterpretation of bodily symptoms). Complaints about pain, nausea, erectile dysfunction, paralysis, and excessive concerns about illness in the absence of objective evidence to support such concerns may fall into the category of somatization disorder. The features of this condition that differentiate it from a general medical condition are the involvement of more than one unrelated organ system, chronicity of complaints without the development of structural abnormalities, and the absence of laboratory evidence that suggests a medical condition. Somatization has been shown to pose serious medical, social, and economic problems and may be difficult to manage clinically.

Various theories have been postulated to explain somatoform disorders. We review the psychoanalytic and the communicative perspectives. The idea that physical symptoms could be removed by influencing the mind rose to prominence in the nineteenth century and formed the foundation of the work of psychologists such as Jean Charcot, Pierre Janet, Josef Breuer, and Sigmund Freud. The psychoanalytic perspective advanced by Freud suggests that an unexplained physical symptom is a defense in response to anxiety from unacceptable unconscious conflict. The theory holds that the individual experiences anxiety because of an unacceptable idea or experience, against which the conversion is a defense. Psychic energy is then converted into a somatic symptom, which debilitates the physical organ. By this process, the somatic loss symbolizes the underlying psychic conflict.

The communicative perspective holds that somatizing patients may be defending against a variety of feelings such as depression, guilt, or anger. The patient then uses the problem of somatization to cope with these emotions and negotiate personal interactions that may be considered stressful. In the communicative perspective, the condition of alexithymia has been associated with somatization. This term has been used to refer to persons who have difficulty in expressing their feelings. Thus when asked to express feelings in response to loss, a typical response may be a report about physical symptoms such as headaches. There appears to be some evidence suggesting a relationship between somatization and alexithymia. Alexithymic persons have been shown to be particularly susceptible to somatoform disorders and psychosomatic problems. Somatization has often been viewed as a defense against awareness of emotional distress or as a masked version of depression. In a population-based epidemiologic survey, among respondents with five or more somatic symptoms, 63% reported psychological problems and 50% met criteria for a psychiatric diagnosis. Among persons without somatic symptoms on the other hand, these figures were 7% and 6%, respectively (Simon and VonKorf, 1991).

Common diagnostic conditions associated with somatization include chronic fatigue syndrome (CFS) and fibromyalgia. CFS is considered a revision of a condition that first occurred in the nineteenth century named neurasthenia, which referred to undue exhaustion in the context of minimal physical effort. It has been demonstrated that CFS is often comorbid with psychiatric illness. Fibromyalgia is related to chronic fatigue and is characterized by muscle pain and tenderness. This condition is also often accompanied by depression and sleep disturbance.

In keeping with the biopsychosocial paradigm, it is postulated that if the mind and brain transact, then, being regulated by the brain, organ systems are subject to influence by the mind and, in turn, anything that affects the mind (e.g., society and culture). As an example of the nonlinearity of the mind–body interaction, we examine the question of chronic pain and its association with psychological disturbance.

Chronic Pain

The traditional biomedical model of chronic pain is that it is caused by an identifiable disease state or tissue damage. Medical interventions are aimed at correcting the physical pathology with the intention of removing the experience of pain. While there have been considerable advances in fields such as anatomy and neurophysiology, much of patients’ reported experiences of pain cannot be accounted for only by physical factors. For example, there are many instances when patients have reported dissimilar subjective experiences of pain despite identical physical stimuli to produce them; the association between the extent of injury and the intensity of reported pain has been shown to be modest; it has been suggested that between 30% and 50% of patients seeking medical treatment may not have a specific diagnosable condition (Dworkin and Massoth, 1994); and the majority of patients who present with chronic back pain do not have a physical basis for their condition.

Many chronic pain researchers place a strong emphasis on the distinction between disease and illness. Disease refers to the objective biological event such as trauma or physiological changes to body tissue. Illness, on the other hand, refers to the patient’s subjective appraisal of the biological event and is associated with the experience of physical discomfort, emotional distress, behavioral limitations, and psychosocial disruption. While the biomedical model has traditionally focused on disease, the emphasis of the biopsychosocial model is primarily on illness.

Chronic pain in terms of the biopsychosocial model is best understood as the result of ongoing and multifactorial processes in which there is a dynamic and reciprocal relationship between the biological, psychological, and social factors shaping patients’ experiences. The dynamics of these reciprocal relationships may occur in at least three ways. First, biological factors initiate and maintain physical sensations, psychological factors may influence the manner in which a person appraises and perceives physiological signs and social factors may influence how patients respond behaviorally to these perceptions. Second, psychological and mood-related factors affect biological processes by having an effect on hormone production and the autonomic nervous system. Behavioral responses may also have an effect on biological factors, as in the case of a patient who refrains from strenuous activities in order to reduce symptoms of pain. Third, biological factors and pharmaceutical treatment can cause fatigue, influence a patient’s ability to concentrate, and affect their ability to engage in certain activities. Various examples demonstrate the interrelationship between these factors. For example, soldiers who sustain injuries on a battlefield report feeling considerably less pain than they would if the same injury had occurred elsewhere; athletes typically report feeling pain after a sports injury only once they are off the sports field; and patients who have the same degree of physical deterioration as measured by objective tests may have very different subjective perceptions of pain. Patients may also report pain in the absence of any objective evidence of tissue damage. These examples provide an indication of the complexity of the pain experience.

Gate Control Theory

Probably the most successful attempt at understanding perception of pain is gate control theory (Melzack and Wall, 1982). In his original work, Melzack noted that pain is an adaptive response to ensure the survival of the species as it ensures that a person avoids a stimulus in order to avoid injury, for example a hot plate that causes tissue damage. Gate control theory suggests that there are three systems that converge to affect the way in which pain is perceived, namely, sensory-discriminative, motivational-affective, and cognitive-evaluative. The model thus rejects the dichotomous view that pain is either physiological or psychological and suggests an integration of peripheral stimuli with psychological variables such as mood and anxiety in the experience of pain. The pain experience involves an ongoing set of activities that is reflexive at the beginning and may be modified by excitatory and inhibitory influences and the level of activity in the CNS. GCT proposes that there is a series of neurophysiological mechanisms located in the dorsal horn of each segment of the spinal cord. The activity of these mechanisms mediates the experience of pain and depends in part on both sensory information from the external environment (e.g., temperature and touch) and brain processes related to emotional state, past learning, and expectations. The meaning attributed to the stimulation is then transmitted back to the gate via nerve fibres that go from the brain to the spinal cord. In this way, the experience of pain is related to a combination of sensory input (tissue damage) and the psychological and behavioral state of the person.

Chronic Pain And Psychopathology

Emotional distress is common among persons experiencing chronic pain (Gatchel, 1996). Gatchel proposes a three-stage model to account for the relationship between chronic pain and distress. In Stage 1, the individual experiences emotional distress as a consequence of experiencing pain when it is acute, as pain is most commonly associated with physical harm. In Stage 2 when the pain does not remit and becomes chronic, psychological reactions may include learned helplessness, depression, emotional distress, anger, and somatization. While the model does not suppose a personality type that predisposes an individual to experiencing pain, it presumes that the nature and extent of these problems depend on the preexisting psychological characteristics and social context of the person. There appears to be mixed evidence concerning whether depression is a consequence of chronic pain or whether chronic pain is part of a symptom cluster of depression. In Stage 3 of the model, as the behavioral or psychological problems persist, the person may adopt a sick role, which permits him or her to be excused from responsibilities and obligations. Physical deconditioning may also occur alongside the progression of patients along the trajectory of this model, as a lack of physical activity may result in muscular atrophy and in turn in a decrease in physical capacity. Physical deconditioning may have a deleterious effect on emotional wellbeing and self-esteem, which may lead to additional psychological difficulties. Those chronic pain patients who experience depression may, as part of the symptom picture of this condition, experience a decrease in their level of motivation to engage in work, social, or recreational activities, which may in turn further contribute to physical deconditioning.

Chronic Pain And Depression

There is considerable evidence of a close relationship between chronic pain and symptoms of depression. However, this relationship is complex and possibly overlapping as the diagnostic criteria for mild depressive disorder also include some physical problems that could be attributed to chronic pain, such as sleep disturbance, energy loss, change in appetite, and weight gain or loss. Criterion contamination of this nature makes the process of accurate diagnosis of depression difficult. The various efforts to determine the causal direction between pain and depression may be organized in the following manner (Dersh et al., 2002):

• the antecedent hypothesis, which holds that depression precedes the onset of chronic pain;
• the consequence hypothesis, which states that depression follows the onset of pain;
• the scar hypothesis, which speculates that prior episodes of depression predispose pain patients to further episodes of depression;
• the cognitive behavioral mediation hypothesis, which states that cognitions mediate the relationship between chronic pain and the development of depression;
• the common pathogenic mechanisms hypothesis, which states that both pain and depression have a common etiological factor.

In a review of several studies addressing these various hypotheses, little support was found for the antecedent hypothesis, but robust support was found for the consequence hypothesis and the cognitive behavioral mediation hypothesis, which are in many ways compatible with each other (Fishbain et al., 1997). Some support was also found for the scar and common mechanisms hypotheses. The scar hypothesis assumes a genetic predisposition to depression and is supported by findings that suggest that a higher proportion of patients with chronic pain have family members with depression than those in the general population. There is also evidence that common processes are involved in the mechanisms of pain and mood disturbance. For example, nociceptive (pain-related) and affective pathways are thought to coincide anatomically; the neurotransmitters associated with mood disorders, namely norepinephrine and serotonin, have some involvement in the gate control mechanism described above; and antidepressant medication has been shown to relieve chronic pain (Dersh et al., 2002). It is apparent therefore that the relationship between chronic pain and depression is complex and dynamic, rather than linear and mechanistic.

Chronic Pain And Other Mental Disorders

Depression is by far the most common psychological association with chronic pain. Yet, it is evident that conditions such as substance abuse, anxiety, somatoform disorders, and personality disorders may be common among patients suffering chronic pain. The association between these disorders and chronic pain have received much less empirical scrutiny than mood disorders and the trajectory of their causal pathways awaits investigation.

HIV/AIDS And Mental Health

The complex interrelationship between mental and physical health is starkly exemplified with respect to HIV/ AIDS. Five key mechanisms through which this occurs are presented.

Mental Health Status As A Precursor To HIV/AIDS

In the United States, people with severe mental illness are nearly 20 times more likely to be infected with HIV than the general population. Lack of appreciation of risk, impaired social interactions, low levels of assertiveness, low use of condoms, injecting drug use, multiple partners, and homelessness appear to be some of the reasons for the higher infection rates.

Higher rates of infection have not been reported in the few studies that have been conducted in developing countries, where the prevalence of HIV in people with mental illness has usually mirrored population prevalence. It is possible that because studies have primarily been done in closed systems of in-patient psychiatric institutions that people have been somewhat protected from the infection. However, once infection does take root within a closed system, the chances of widespread infection are increased. Given high-risk sexual behaviors in people with mental illness globally, higher rates in this grouping should be anticipated.

HIV Infection Affects The Central Nervous System

Infiltration of HIV into the CNS is common, often resulting in HIV dementia and minor cognitive disorder. HIV can be detected in the cerebrospinal fluid of over 90% of asymptomatic patients while 75% of AIDS patients have been found to have brain pathology at autopsy. Between 30% and 50% of HIV-seropositive individuals are estimated to experience some cognitive–motor problems (Grant et al., 1999). HIV invades the brain early in the infection process and in a certain proportion of people psychotic symptoms manifest, especially in late-stage AIDS. Manic episodes are above the population norm in people with HIV (around 5%), especially at more advanced stages of the disease, and are the most common reason for psychiatric hospitalization in the HIV seropositive population in the United Kingdom.

Mental Disorders And HIV/AIDS

Studies of the mental health status of people infected with HIV have consistently found a higher prevalence of mental health problems than is found in community or clinical samples, ranging from relatively mild distress to a full mental disorder.

Mood disorder is the most frequent psychiatric complication associated with people with HIV/AIDS. High levels of major depression, mild depressive disorder and dysthymia have been found in seropositive individuals. Bing et al. (2001) found a 36% 1-year prevalence of depression among a large national sample of HIV-positive men and women in the US. In a meta-analysis of studies comparing HIV-positive and HIV-negative samples, Ciesla and Roberts (2001) showed that major depressive disorder occurred nearly twice as often among HIVpositive than HIV-negative patients. In a review of studies of mental health problems of HIV-infected people in developing countries, Collins et al. (2006) also found a significantly higher prevalence of depressive symptoms among HIV-positive people compared with controls.

Feelings of anxiety and distress are a normal and arguably even a healthy response to a diagnosis of HIV. However anxiety may reach clinical levels and impair overall functioning and people’s capacity for adequate self-care. The prevalence of anxiety disorders in studies in the US range from negligible to around 40%. Anxiety can be provoked by the unpredictability of the virus and by certain milestones such as initial diagnosis, first opportunistic infection, declining CD4 count, or the onset or progression of an AIDS-defining illness.

Since the introduction of antiretroviral therapy (ART) in developed countries, the mental health and quality of life of people living with HIV/AIDS has improved considerably. Firstly, the progressive neuropsychiatric progression of HIV is diminished. Secondly people’s psychological responses to living with HIV/AIDS are deeply affected by treatment. A number of cross-sectional as well as longitudinal studies have shown decreased depression for people on ART. However, there is other evidence that suggests that ART does not itself alleviate depression and that a diagnosis of HIV remains profoundly distressing for most people. In London, even though there was a significant decrease in the number of referrals for adjustment disorder and organic brain syndromes from pre-ART to post-ART eras, there was an increase in the proportion of people experiencing depressive disorders. People tended to have new problems and anxieties around forming relationships, disclosure, and demoralization around the side effects of medication.

Mental Disorder May Influence Health Behaviors

An HIV-positive person needs to engage in a number of behaviors to maintain good health. For example, he or she must engage in protected sex to avoid reinfection, eat nutritious food, refrain from excessive use of alcohol, seek treatment for opportunistic infections when needed and, if antiretroviral treatment is required, adhere to the medication regimen (95% adherence is needed). The person’s psychological state is likely to affect his or her ability to engage in these behaviors.

As part of the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study Group, Uldall et al. (2004) reviewed over 50 studies that examined mental illness and substance abuse and the impacts on adherence. Mental health problems were found to be barriers to adherence in a number of community samples, for example in a population-based cohort and in a national probability sample of people living with HIV/AIDS engaged in primary care. This association has been found to be particularly significant in women. While the introduction of HAART in the US has reduced HIV-associated dementia, two studies have shown that mental flexibility was strongly associated with poor adherence. The effect of depression on HIV medication has also been extensively studied. At least eight studies have shown that adherence to antiretroviral medication is adversely affected by mood disturbance. A number of studies have reported associations between adherence and generalized anxiety disorder, panic disorder, PTSD, recent trauma, and social phobia.

Initial studies in Africa have pointed to high levels of ART adherence. However, in a recent analysis of African adherence research Gill et al. (2005) caution against complacency and conclude that adherence rates in Africa are in fact quite variable and often poor. They suggest that additional research is urgently needed to determine patient-level barriers. They also suggest that ways of increasing adherence levels need to be found. In some pilot treatment sites, people with mental health and substance-abuse problems have been excluded from programs in order not to compromise the program. While it is not clear to what extent such exclusion corresponds with program success rates, given that mental health and substance abuse have been regularly found to be barriers to adherence in developed countries, this relationship seems possible and needs further exploration.

Does Treatment Of Mental Disorder Improve Adherence?

The evidence that mental health problems impair HIV treatment is far more comprehensive than the evidence available on treating mental health problems and thereby improving ART adherence. Nonetheless, there is some research that indicates efficacy resulting from mental health and psychosocial interventions.

According to Uldall et al. (2004), most of the interventions that have been designed to improve adherence have focused on cognitive-behavioral skills, such as helping individuals with remembering to take their medication and improving medication-taking self-efficacy, rather than treating mental health problems in order to improve adherence and overall health. However, a retrospective study based on pharmaceutical records found that antiretroviral adherence was higher for depressed patients who received antidepressant medication than those who did not. It was also higher for those who adhered to their psychiatric medication.

In a study on the impacts of self-efficacy on HIV viral load and distress in women living with AIDS, Ironson et al. (2005) showed an improved course of illness linked to their SMART/EST intervention. They suggest that this may be the effect of improved adherence linked to their intervention. One US study on severely nonadherent patients showed that continuous and personalized counseling improved adherence and virologic outcomes. Motivational interviewing has also been utilized to improve adherence, although with mixed results.

Side Effects Of Medication

In a minority of patients, mania and psychosis can occur due to the AIDS medication they receive such as AZT, 3TC, efavirenz, abacavir, and nevirapine. People taking efavirenz may experience nightmares and have other paranoid symptoms. These usually resolve within 2–3 weeks but may persist. Patients who have had multiple episodes of depression are at particular risk of having negative reactions to efavirenz.

Cardiovascular Disease

The most common psychological attributes associated with persons with cardiac disease are type A behavior pattern (TABP). TABP is a predisposition to think, feel, and act in a time-urgent, aggressive, and impatient manner. This constellation of behaviors first reached the attention of researchers in the 1950s when two cardiologists, Friedman and Rosenman, observed that their heart patients behaved similarly to one another during clinic visits. Patients sat on the edge of their seats while waiting for appointments, as if they were ready to bolt at any instant. In fact, the waiting room seats became worn in a rather unusual way: only in the front. The original work on TABP was conducted in the 1970s (Friedman and Rosenman, 1974), and it was consistently found that the combination of cognitive, emotional, and behavioral predispositions was predictive of coronary heart disease. These predispositions included time urgency, impatience, aggression toward others, and a propensity toward hostility. In accounting for the relationship between TABP and CHD, it is thought that appraising the world in a time urgent and hostile manner can lead to chronic psychosocial stress via a mechanism involving excessive sympathetic nervous system activation, which in turn leads to an exacerbation of coronary artery atherosclerosis.

While TABP is a well-documented antecedent of CHD, there have also been psychological effects of heart disease. Clinical depression is a prominent psychological feature of CHD patients and may be a strong predictor of death. In a large-scale national community survey, 52.1% of heart patients displayed symptoms of depression, and of these 30.1% met the criteria for clinical depression (Purebl et al., 2006). However, other estimates have been somewhat lower. CHD patients who experience depression are considered to be at greater risk of dying of a subsequent heart attack than nondepressed patients. Various pathways between depression and CAD have been considered, including behavioral mechanisms that involve poor adherence to medical and behavioral recommendations, diminished heart rate variability, stress induced ischemia, platelet activation, and immunological dysregulation (Faller, 2005). Studies of efficacy and effectiveness for depression have generally been conducted with non-CHD patients and have provided support for psychological treatments such as cognitive behavioral therapy and interpersonal therapy. In addition, aerobic exercise as a means to elevate mood may have additional benefits of addressing the cardiovascular condition from which patients suffer.

While many of the psychosocial concerns of cancer are unique to the specific type of cancer, there are several common psychological and behavioral factors that define most oncology patients. Nezu and colleagues (1999) have systematically identified the psychological issues that patients may face when confronting cancer. When first detecting symptoms, the patient may experience anxiety and fear, which in some cases may lead to a delay in seeking a diagnosis. The task at hand in this early stage of illness is to seek the most appropriate and available medical attention. Upon diagnosis, many patients experience emotional distress, anxiety, anticipatory grief, and anger, have to engage with the stress of treatment decision making, and have to adjust to a new role and related responsibilities. The process of undergoing treatment may also in many cases present its own challenges.

Treatment requires the marshalling of effort, energy, and support in combating cancer, accompanied by anxiety and grief with the loss of well-being. Common treatments for cancer include chemotherapy, radiation therapy, and surgery. Chemotherapy is a systemic therapy that involves introducing medication into the body with the intention of destroying cancer cells. The side effects of chemotherapy occur because of the medication’s inability to differentiate between cancerous cells and normal cells. Common side effects of chemotherapy include hair loss, mouth sores, diarrhea, nausea and emesis, loss of appetite, and fatigue. Radiation therapy is considered a local therapy in that it is directed at a specific area of the body that is affected by cancer. Similar to chemotherapy, radiation that destroys cancer cells may also harm noncancerous ones; thus side effects are usually related to the area of the body being treated. For example, radiation targeted at the abdomen may lead to diarrhea, while radiation directed at the mouth may lead to changes in taste and sensitivity. Surgery is a local treatment that usually involves the loss of body tissue that is affected by cancer, such as the breast, prostate, lung, or larynx. Many patients may experience anxiety prior to surgery and some may experience emotional difficulties related to their altered body image.

At post treatment, many patients may be concerned with the fear of recurrence and anxiety as the healthcare team may be less available to provide support. Many patients who have been through treatment report re-evaluating their life priorities. Among patients who experience a recurrence of cancer, common emotional responses include disappointment, guilt, anxiety, anger, and grief. Treatment decision-making is accompanied by psychological adaptation to treatment and follow-up evaluation. When facing death from cancer that has metastasized to other parts of the body, common experiences among patients include fear of abandonment, suffering, and anxiety and sadness related to loss of control over their lives. Patients may engage in a re-evaluation of their lives and try to find meaning to their experience with cancer.

In general, emotional distress is commonly experienced by many cancer patients, especially when their diagnosis is unexpected. Specifically, symptoms of depression and anxiety are common, while psychiatric disorders such as major depression and posttraumatic stress disorder occur in a minority of patients. It has been argued that cancer patients are no more likely to experience major depression than general medical patients. In a study of psychiatric morbidity of breast cancer patients, the prevalence estimates of emotional distress, major depression, and generalized anxiety disorder were 29%, 9%, and 6%, respectively (Coyne et al., 2004). Distress among cancer patients may be most appropriately ameliorated with social and family support, information about treatment options, and psychological counseling. For the minority of patients who meet the criteria for a psychiatric disorder, psychotropic medication is likely to be appropriate.

Personality And Cancer

The question of whether personality factors play a role in precipitating the onset of cancer is controversial. The major proponent of the view that certain personality characteristics are associated with cancer is Hans Eysenck, who has conducted several studies on the so-called type C, or cancer-prone personality (Eysenck, 2000). According to Eysenck, persons at increased risk of developing cancer tend to be unassertive, harmony-seeking, unable to express emotions, and have difficulties in coping that may lead to helplessness and depression. There appear to be some data to support this contention. For example, in a prospective study in which a sample of 1353 healthy persons were followed for 10 years until death, personality traits that involved blocking of feelings and needs in important relationships appeared to be associated with certain cancers, most notably breast cancer (Grossarth-Maticek et al., 1997). Eysenck even went so far as to propose autonomy training to move personality characteristics away from type C tendencies (Eysenck, 2000).

On the other hand, results of other investigations have yielded null findings on the relationship of personality factors and carcinogenesis. In a prospective study of 5133 adults, the incidence of cardiovascular disease was significantly predicted by emotional lability, behavioral control, and TABP, but the incidence of cancer was unrelated to these variables. In an examination of the relationship between personality factors and cancer, Amelang and Schmidt-Rathiens (2003) conclude that personality factors are of little importance and explain less than 2% of the health–disease variance. These authors have shown that the significance of these variables has decreased over the past several years, while the biomedical predictors of carcinogenesis have remained robust. The conclusion of this review is that ‘hypotheses addressing the causal relationships between personality and disease are of little value’ (Amelang and Schmidt-Rathiens, 2003: 22).

It may well be the case that certain personality factors predispose certain people to engaging in behaviors that place them at greater risk for developing certain kinds of cancer. For example, the relationship between smoking and lung cancer has been well documented. However, the case for personality characteristics as a carcinogenic or even constituting a risk factor for cancer remains unconvincing.

Psychological difficulties common among endocrine patients include poor adherence to medication and lifestyle regimens, poor adjustment to the illness, an exacerbation of medical symptoms by stress, and psychiatric problems such as depression and anxiety. Aikens and Wagner (2003) classified 65 consecutive referrals seen in a behavioral endocrinology service in terms of the primary presenting problem or the corresponding DSM-IV diagnosis: major depression (15%), adjustment disorder (8%), dysthymic disorder (8%), specific phobia (8%), regimen nonadherence (13%), and stress affecting diabetes mellitus (21%).

In most of the literature on the psychological and behavioral aspects of diabetes, treatment adherence is a salient theme. Medications that are prescribed following consultation with a medical professional are usually dispensed with an expectation of close to perfect adherence. Such expectations pertain to the dosage, timing, ingestion with specific foods, contraindications regarding ingestion with other medicines, and consistent adherence to the treatment regimen over time (World Health Organization, 2003). These details are of crucial importance in maximizing the health benefits from medical treatment. Patient nonadherence may therefore have severe implications for the control of symptoms, recovery time, quality of life, and mortality. Among the factors associated with adherence in diabetes patients are health literacy, social support, and emotional problems.

Health literacy implies an awareness of the importance of adherence even when actual symptoms are absent. Behavioral regimens such as restricted fat and sugar intake, exercise, and adherence to specific medications in many cases serve an important preventive function by controlling blood sugar and insulin levels. In the absence of overt symptoms, for many patients adherence may appear to be unimportant. Yet, the longer-term health consequences of nonadherence may be severe, as symptoms will inevitably develop.

Considerable research has demonstrated consistently that social support is a strong predictor of medical adherence. Social support for adherence is defined as encouragement from family and friends for the patient to cooperate with the recommendations and prescriptions of a health professional. The expression of concern and encouragement from others to engage in health-promoting behaviors, including medication adherence, combine with social desirability needs on the part of the patient to yield higher rates of medical cooperation. An issue related to social support, namely the relationship between the health-care worker and patient, has also been shown to be strongly associated with adherence. Data obtained by Roberts (2002) further suggest that medical providers viewed communicating with patients about adherence issues as an essential component of the health-care service. While the provider–patient relationship may ostensibly constitute an example of social support, it also extends beyond this. The health professional is often seen as a person of authority, in the possession of specific expertise that is unobtainable elsewhere, and as someone in whom the patient solely invests hope for assistance in the recovery process.

Emotional problems such as depression appear to be common among patients with diabetes. Depressive symptoms such as loss of interest in activities, decreased energy, fatigue, difficulties in concentrating, remembering and making decisions, and appetite disturbance may seriously affect the extent to which patients are adherent to their dietary and lifestyle regimens. Anxiety may be related to diabetes in at least three ways: Symptoms of anxiety may be produced by sympathetic nervous system responses to hyperglycemia; endocrine abnormalities may be exacerbated by normal physiological stress responses, and the psychological stress of living with a chronic illness and managing the challenging self-care tasks may have a general negative effect on mood. Hypoglycemic fear is also a concern for insulin-dependent diabetes patients as hypoglycemia is a highly distressing experience that can cause serious physical consequences that include unconsciousness, coma, and in extreme cases, death.

Somatic Symptoms Associated With Mental Illness

Somatic symptoms form part of the symptom picture of a number of psychiatric illnesses, most notably major depressive disorder. The symptoms of depression, for example, include weight loss or gain, sleep disturbance, and fatigue or loss of energy. When criterion contamination of this nature occurs, it may be suggested that physical symptoms are ‘caused’ by a mental condition. Such an appraisal may tend toward dualism and a distortion of a complex condition, which has both mental and physical features. Yet, from a treatment perspective it is essential to understand the etiological features of a disease.

In assessing patients for depression, the DSMIV-TR criteria stipulate that these symptoms should not be due to the direct effects of a medical condition, such as hypothyroidism. Hypothyroidism, a condition in which the body lacks sufficient thyroid hormone and is caused by the inflammation of the thyroid gland, is said to mimic the symptoms of major depressive disorder. The symptoms of hypothyroidism thus similarly include fatigue, weakness, weight gain or difficulty losing weight, depressed mood, irritability, memory impairment, and a decreased libido, which can cause difficulties for mental health professionals in distinguishing between the two conditions. There are clear implications for treatment if patients are misdiagnosed: Hypothyroidism is effectively treated with hormone therapy, while the most efficacious treatment for depression is a combination of antidepressant medication and psychological counseling. Among cancer patients as well, common somatic symptoms include pain, fatigue, weakness, and reduced energy. Symptoms such as these make the process of diagnosing depression and anxiety in cancer patients a complex process, again with important treatment implications.

On the other hand, there are somatic symptoms that are associated with a mental illness as well. In general, somatic symptoms of depression create diagnostic dilemmas in the assessment of patients with medical comorbidities because symptoms may be due to either the medical condition or depressive illness. In an effort to determine whether the etiology of somatic symptoms was due to an illness condition or mood disturbance among older patients, Drayer and colleagues (2005) showed that scores on measures of somatization, namely the Asberg Side Effects Rating Scale and the Utvalg for Kliniske Undersogelser (UKU), were significantly correlated with psychological symptoms of depression but not with medical comorbidities (Drayer et al., 2005). These authors recommended that when assessing medical disorders with multiple somatic complaints, clinicians should consider the possibility that such symptoms may be due to depressive illness rather than solely due to the medical disorder. Further, it may be necessary to assess the effects of antidepressant medication on somatic symptoms. For example, in a 32-week trial testing the effects of citalopram, a selective serotonin reuptake inhibitor, on somatic symptoms among patients with anxiety and anxious depression, it was concluded that somatic symptoms often improve with successful antidepressant medication management (Lenze et al., 2005).

Health And Behavior Change

Health behavior is a key determinant of overall health, and a person’s health behavior is in turn highly dependent on that person’s mental health and psychological state. Many noncommunicable diseases such as cardiovascular disease and diabetes are linked to unhealthy behavior such as alcohol and tobacco use, poor diet, and a sedentary lifestyle. Health behavior is also an important determinant of communicable diseases through, for example, unsafe sex practices. Health-care-seeking behavior is similarly influenced by mental health. Three exemplars of theoretical models on health behavior change need mention.

Theory Of Planned Behavior

The Theory of Planned Behavior (TPB) postulates that the likelihood of an individual engaging in a health behavior (for example, regular exercise) is correlated with the strength of his or her intention to engage in the behavior. A behavioral intention represents an individual’s commitment to act and is itself the outcome of a combination of several variables. According to the TPB, the factors that directly influence intentions to engage in a health behavior include the person’s attitudes toward the behavior, the person’s perception of subjective group norms concerning the behavior, and the extent to which the person perceives himor herself to have control concerning the behavior (Fishbein, 2002).

Health Belief Model

The Health Belief Model (HBM) hypothesizes that health-related behavior depends on the combination of several factors, namely, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. Perceived susceptibility refers to an individual’s opinion of the chances of contracting the illness condition. Perceived severity refers to an individual’s opinion of how serious a condition and its consequences are. Perceived benefits refer to one’s belief in the efficacy of the recommended health behavior in reducing the risk or seriousness of the condition. Perceived barriers refer to the perception of cost associated with adhering to a recommended health behavior if it is likely to be beneficial in reducing or eliminating the perceived threat. Self-efficacy refers to the level of confidence in one’s ability to perform the health behavior in question. Those persons who have low self-efficacy will have low confidence in their ability, which will have an effect on the likelihood of the behavior being performed. The HBM has been applied with considerable success to a range of health behaviors and populations, particularly preventive behaviors, such as diet, exercise, smoking cessation, vaccination, and contraception and sick role behaviors such as adherence to recommended medical treatments.

The Transtheoretical Model

This theory proposes that individuals progress through five interlocking stages in their effort to engage in health behaviors. Precontemplation is the time during which people are not seriously thinking about changing the behavior that will permit the attainment of better health. In this stage, individuals are either unaware or underaware of their health problems and the need to alter their behavior. During the stage of contemplation, people are aware that a health problem exists and have earnestly begun thinking about behavior change but have not yet committed themselves to taking action. The third stage of the model is preparation, in which the individual is preparing to enact the health behavior in question. The next stage is the action stage, when individuals are making unambiguous changes in their behavior, experiences, or environment in order to address health problems. The beginning of the maintenance stage is sometimes defined as 6 months following taking overt action to engage in the desired health behavior. Progression through the stages defined by the model is not necessarily linear since in many instances relapses occur and individuals return to either the precontemplation or contemplation stages before finally succeeding in maintenance.

Conclusion And Implications

In defining health as a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity, the countries involved in developing this World Health Organization definition of health in 1948 portrayed great insight and understanding of the components of health. It is unlikely, however, that at the time they realized just how interdependent all the elements in the definition in fact are to health and illness. These relationships are now becoming clearer. While much research is still needed to fully understand these relationships and mechanisms, conceptualizing the components as useful products of language that help explain different influences on health and well-being is an important step forward. Despite the evidence that the distinction between mental and physical health is permeable, in reality this distinction remains in the minds of many and in the health services of most countries. A number of shifts are needed to change this.

• Health worker education. The education of health workers rarely conceptualizes health as being a product of physical, mental, and social influences. Where this does happen, it is often in a linear manner. Even within many public health approaches where there is a growing emphasis on the social aspects of health, there is only minimal emphasis on the psychological or behavioral aspects. A comprehensive and integrated understanding of health needs to become the norm in order to change the way health workers think about and engage with their patients. Such an understanding should also result in health workers becoming more involved in prevention of health problems.
• Integration of mental and physical health care. The integration of mental health into general health care, where this has occurred, has been an important step forward in health-care treatment. However, this approach is still in its infancy, especially in developing countries. Separating physical and mental health services reinforces difference and mitigates against treating a whole person. Moreover, separation often leads to poorer accessibility of mental health services when, for example, only physical health care is provided at local clinics or hospitals.
• Stigma and discrimination. Mental health problems as well as some physical health problems, such as HIV/ AIDS, are highly stigmatized in most countries and people are often discriminated against both by members of the public and health workers. Redressing stigma and discrimination is essential for good health within a population, as health seeking behavior and health service provision may be adversely affected. Stigmatization also negatively influences the course of illness.
• Promoting health-related behavior. The relationships between lifestyle and treatment behaviors and health are being increasingly recognized as fundamental. Integrating more of the behavioral sciences with the health sciences is a crucial step that needs to be taken boldly.

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