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  • 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.

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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.

figure 1

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 ).

figure 2

Number of sources by characteristics of included literature

figure 3

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 ].

figure 4

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

Ahmed N, Devitt KS, Keshet I, Spicer J, Imrie K, Feldman L, et al. A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg. 2014;259(6):1041–53.

Article   Google Scholar  

Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.

Atallah F, McCalla S, Karakash S, Minkoff H. Please put on your own oxygen mask before assisting others: a call to arms to battle burnout. Am J Obstet Gynecol. 2016;215(6):731.e1.

Baer TE, Feraco AM, Tuysuzoglu Sagalowsky S, Williams D, Litman HJ, Vinci RJ. Pediatric resident burnout and attitudes toward patients. Pediatrics. 2017;139(3):e20162163. https://doi.org/10.1542/peds.2016-2163 .

Article   PubMed   Google Scholar  

Blais R, Safianyk C, Magnan A, Lapierre A. Physician, heal thyself: survey of users of the Quebec physicians health program. Can Fam Physician. 2010;56(10):e383–9.

PubMed   PubMed Central   Google Scholar  

Brennan J, McGrady A. Designing and implementing a resiliency program for family medicine residents. Int J Psychiatry Med. 2015;50(1):104–14.

Cass I, Duska LR, Blank SV, Cheng G, NC dP, Frederick PJ, et al. Stress and burnout among gynecologic oncologists: a Society of Gynecologic Oncology Evidence-based Review and Recommendations. Gynecol Oncol. 2016;143(2):421–7.

Chan AM, Cuevas ST, Jenkins J 2nd. Burnout among osteopathic residents: a cross-sectional analysis. J Am Osteopath Assoc. 2016;116(2):100–5.

Chaukos D, Chad-Friedman E, Mehta DH, Byerly L, Celik A, McCoy TH Jr, et al. Risk and resilience factors associated with resident burnout. Acad Psychiatry. 2017;41(2):189–94.

Compton MT, Frank E. Mental health concerns among Canadian physicians: results from the 2007-2008 Canadian physician health study. Compr Psychiatry. 2011;52(5):542–7.

Cunningham C, Preventing MD. Burnout. Trustee. 2016;69(2):6–7 1.

PubMed   Google Scholar  

Daskivich TJ, Jardine DA, Tseng J, Correa R, Stagg BC, Jacob KM, et al. Promotion of wellness and mental health awareness among physicians in training: perspective of a national, multispecialty panel of residents and fellows. J Grad Med Educ. 2015;7(1):143–7.

Dyrbye LN, Shanafelt TD. Physician burnout: a potential threat to successful health care reform. JAMA. 2011;305(19):2009–10.

Article   CAS   Google Scholar  

Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med. 2013;88(3):301–3.

Evans RW, Ghosh K. A survey of headache medicine specialists on career satisfaction and burnout. Headache. 2015;55(10):1448–57.

Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 2008;336(7642):488–91.

Fargen KM, Spiotta AM, Turner RD, Patel S. The importance of exercise in the well-rounded physician: dialogue for the inclusion of a physical fitness program in neurosurgery resident training. World Neurosurg. 2016;90:380–4.

Gabel S. Demoralization in Health Professional Practice: Development, Amelioration, and Implications for Continuing Education. J Contin Educ Health Prof 2013 Spring. 2013;33(2):118–26.

Google Scholar  

Govardhan LM, Pinelli V, Schnatz PF. Burnout, depression and job satisfaction in obstetrics and gynecology residents. Conn Med. 2012;76(7):389–95.

Jennings ML, Slavin SJ. Resident wellness matters: optimizing resident education and wellness through the learning environment. Acad Med. 2015;90(9):1246–50.

Keller EJ. Philosophy in medical education: a means of protecting mental health. Acad Psychiatry. 2014;38(4):409–13.

Krall EJ, Niazi SK, Miller MM. The status of physician health programs in Wisconsin and north central states: a look at statewide and health systems programs. WMJ. 2012;111(5):220–7.

Lemaire JB, Wallace JE. Burnout among doctors. BMJ. 2017;358:j3360.

Linzer M, Bitton A, Tu SP, Plews-Ogan M, Horowitz KR, Schwartz MD, et al. The end of the 15-20 minute primary care visit. J Gen Intern Med. 2015;30(11):1584–6.

Lu DW, Dresden S, McCloskey C, Branzetti J, Gisondi MA. Impact of burnout on self-reported patient care among emergency physicians. West J Emerg Med. 2015;16(7):996–1001.

Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397–422.

McClafferty H, Brown OW. Section on integrative medicine, committee on practice and ambulatory medicine, section on integrative medicine. Physician health and wellness. Pediatrics. 2014;134(4):830–5.

Miyasaki JM, Rheaume C, Gulya L, Ellenstein A, Schwarz HB, Vidic TR, et al. Qualitative study of burnout, career satisfaction, and well-being among US neurologists in 2016. Neurology. 2017;89(16):1730–8.

Peterson J, Pearce P, Ferguson LA, Langford C. Understanding scoping reviews: definition, purpose, and process. JAANP. 2016;29:12–6.

Przedworski JM, Dovidio JF, Hardeman RR, Phelan SM, Burke SE, Ruben MA, et al. A comparison of the mental health and well-being of sexual minority and heterosexual first-year medical students: a report from the medical student CHANGE study. Acad Med. 2015;90(5):652–9.

Ripp JA, Privitera MR, West CP, Leiter R, Logio L, Shapiro J, et al. Well-being in graduate medical education: a call for action. Acad Med. 2017;92(7):914–7.

Salles A, Mueller CM, Cohen GL. Exploring the relationship between stereotype perception and Residents’ well-being. J Am Coll Surg. 2016;222(1):52–8.

Shiralkar MT, Harris TB, Eddins-Folensbee FF, Coverdale JH. A systematic review of stress-management programs for medical students. Acad Psychiatry. 2013;37(3):158–64.

Sikka R, Morath J, Leape L. The quadruple aim: care, health, cost and meaning in work. BMJ Qual Saf. 2015;24(10):608–10. https://doi.org/10.1136/bmjqs-2015-004160 .

Tawfik DS, Phibbs CS, Sexton JB, Kan P, Sharek PJ, Nisbet CC, et al. Factors Associated With Provider Burnout in the NICU. Pediatrics. 2017;139(5):608. https://doi.org/10.1542/peds.2016-4134 Epub 2017 Apr 18.

Turner TB, Dilley SE, Smith HJ, Huh WK, Modesitt SC, Rose SL, et al. The impact of physician burnout on clinical and academic productivity of gynecologic oncologists: a decision analysis. Gynecol Oncol. 2017;146(3):642–6.

West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272.

Williams D, Tricomi G, Gupta J, Janise A. Efficacy of burnout interventions in the medical education pipeline. Acad Psychiatry. 2015;39(1):47–54.

Woodside JR, Miller MN, Floyd MR, McGowen KR, Pfortmiller DT. Observations on burnout in family medicine and psychiatry residents. Acad Psychiatry. 2008;32(1):13–9.

World Health Organization. (2001). Mental disorders affect one in four people.

World Health Organization. Promoting mental health: concepts, emerging evidence, practice (Summary Report). Geneva: World Health Organization; 2004.

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M.M. and E.N. were involved in identifying the relevant research question and developing the combinations of keywords used in consultation with a professional librarian. M.M. performed the literature selection and screening of references for eligibility. Both authors were involved in the creation of the literature extraction tool in Excel. Both authors coded the data inductively, first independently reading five articles and generating themes from the data, then discussing their coding and developing a coding scheme that was subsequently applied to ten more papers. Both authors then refined and finalized the coding scheme and M.M. used it to code the rest of the data. M.M. conceptualized and wrote the first copy of the manuscript, followed by extensive drafting by both authors. E.N. was a contributor to writing the final manuscript. All authors read and approved the final manuscript.

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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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Children and youth’s perceptions of mental health—a scoping review of qualitative studies

  • Linda Beckman 1 , 2 ,
  • Sven Hassler 1 &
  • Lisa Hellström 3  

BMC Psychiatry volume  23 , Article number:  669 ( 2023 ) Cite this article

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Recent research indicates that understanding how children and youth perceive mental health, how it is manifests, and where the line between mental health issues and everyday challenges should be drawn, is complex and varied. Consequently, it is important to investigate how children and youth perceive and communicate about mental health. With this in mind, our goal is to synthesize the literature on how children and youth (ages 10—25) perceive and conceptualize mental health.

We conducted a preliminary search to identify the keywords, employing a search strategy across electronic databases including Medline, Scopus, CINAHL, PsychInfo, Sociological abstracts and Google Scholar. The search encompassed the period from September 20, 2021, to September 30, 2021. This effort yielded 11 eligible studies. Our scoping review was conducted in accordance with the PRISMA-ScR Checklist.

As various aspects of uncertainty in understanding of mental health have emerged, the results indicate the importance of establishing a shared language concerning mental health. This is essential for clarifying the distinctions between everyday challenges and issues that require treatment.

We require a language that can direct children, parents, school personnel and professionals toward appropriate support and aid in formulating health interventions. Additionally, it holds significance to promote an understanding of the positive aspects of mental health. This emphasis should extend to the competence development of school personnel, enabling them to integrate insights about mental well-being into routine interactions with young individuals. This approach could empower children and youth to acquire the understanding that mental health is not a static condition but rather something that can be enhanced or, at the very least, maintained.

Peer Review reports

Introduction

In Western society, the prevalence of mental health issues, such as depression and anxiety [ 1 ], as well as recurring psychosomatic health complaints [ 2 ], has increased from the 1980s and 2000s. However, whether these changes in adolescent mental health are actual trends or influenced by alterations in how adolescents perceive, talk about, and report their mental well-being remains ambiguous [ 1 ]. Despite an increase in self-reported mental health problems, levels of mental well-being have remained stable, and severe psychiatric diagnoses have not significantly risen [ 3 , 4 ]. Recent research indicates that understanding how children and youth grasp mental health, its manifestations, and the demarcation between mental health issues and everyday challenges is intricate and diverse. Wickström and Kvist Lindholm [ 5 ] show that problems such as feeling low and nervous are considered deep-seated issues among some adolescents, while others refer to them as everyday challenges. Meanwhile, adolescents in Hellström and Beckman [ 6 ] describe mental health problems as something mainstream, experienced by everyone at some point. Furthermore, Hermann et al. [ 7 ] point out that adolescents can distinguish between positive health and mental health problems. This indicates their understanding of the complexity and holistic nature of mental health and mental health issues. It is plausible that misunderstandings and devaluations of mental health and illness concepts may increase self-reported mental health problems and provide contradictory results when the understanding of mental health is studied. In a previous review on how children and young people perceive the concept of “health,” four major themes have been suggested: health practices, not being sick, feeling good, and being able to do the desired and required activities [ 8 ]. In a study involving 8–11 year olds, children framed both biomedical and holistic perspectives of health [ 9 ]. Regarding the concept of “illness,” themes such as somatic feeling states, functional and affective states [ 10 , 11 ], as well as processes of contagion and contamination, have emerged [ 9 ]. Older age strongly predicts nuances in conceptualizations of health and illness [ 10 , 11 , 12 ].

As the current definitions of mental health and mental illness do not seem to have been successful in guiding how these concepts are perceived, literature has emphasized the importance of understanding individuals’ ideas of health and illness [ 9 , 13 ]. The World Health Organization (WHO) broadly defines mental health as a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, work productively and fruitfully and make a contribution to his or her community [ 14 ] capturing only positive aspects. According to The American Psychology Association [ 15 ], mental illness includes several conditions with varying severity and duration, from milder and transient disorders to long-term conditions affecting daily function. The term can thus cover everything from mild anxiety or depression to severe psychiatric conditions that should be treated by healthcare professionals. As a guide for individual experience, such a definition becomes insufficient in distinguishing mental illness from ordinary emotional expressions. According to the Swedish National Board of Health and Welfare et al. [ 16 ], mental health works as an umbrella term for both mental well-being and mental illness : Mental well-being is about being able to handle life's difficulties, feeling satisfied with life, having good social relationships, as well as being able to feel pleasure, desire, and happiness. Mental illness includes both mild to moderate mental health problems and psychiatric conditions . Mild to moderate mental health problems are common and are often reactions to events or situations in life, e.g., worry, feeling low, and sleep difficulties.

It has been argued that increased knowledge of the nature of mental illness can help individuals to cope with the situation and improve their well-being. Increased knowledge about mental illness, how to prevent mental illness and help-seeking behavior has been conceptualized as “mental health literacy” (MHL) [ 17 ], a construct that has emerged from “health literacy” [ 18 ]. Previous literature supports the idea that positive MHL is associated with mental well-being among adolescents [ 19 ]. Conversely, studies point out that low levels of MHL are associated with depression [ 20 ]. Some gender differences have been acknowledged in adolescents, with boys scoring lower than girls on MHL measures [ 20 ] and a social gradient including a positive relationship between MHL and perceived good financial position [ 19 ] or a higher socio-economic status [ 21 ].

While MHL stresses knowledge about signs and treatment of mental illness [ 22 ], the concern from a social constructivist approach would be the conceptualization of mental illness and how it is shaped by society and the thoughts, feelings, and actions of its members [ 23 ]. Studies on the social construction of anxiety and depression through media discourses have shown that language is at the heart of these processes, and that language both constructs the world as people perceive it but also forms the conditions under which an experience is likely to be construed [ 24 , 25 ]. Considering experience as linguistically inflected, the constructionist approach offers an analytical tool to understand the conceptualization of mental illness and to distinguish mental illness from everyday challenges. The essence of mental health is therefore suggested to be psychological constructions identified through how adolescents and society at large perceive, talk about, and report mental health and how that, in turn, feeds a continuous process of conceptual re-construction or adaptation [ 26 ]. Considering experience as linguistically inflected, the constructionist approach could then offer an analytical tool to understand the potential influence of everyday challenges in the conceptualization of mental health.

Research investigating how children and youth perceive and communicate mental health is essential to understand the current rise of reported mental health problems [ 5 ]. Health promotion initiatives are more likely to be successful if they take people’s understanding, beliefs, and concerns into account [ 27 , 28 ]. As far as we know, no review has mapped the literature to explore children’s and youths’ perceptions of mental health and mental illness. Based on previous literature, age, gender, and socioeconomic status seem to influence children's and youths’ knowledge and experiences of mental health [ 10 , 11 , 12 ]; therefore, we aim to analyze these perspectives too. From a social constructivist perspective, experience is linguistically inflected [ 26 ]; hence illuminating the conditions under which a perception of health is formed is of interest.

Therefore, we aim to study the literature on how children and youth (ages 10—25) perceive and conceptualize mental health, and the specific research questions are:

What aspects are most salient in children’s and youths’ perceptions of mental health?

What concepts do children and youth associate with mental health?

In what way are children's and youth’s perceptions of mental health dependent on gender, age, and socioeconomic factors?

Literature search

A scoping review is a review that aims to provide a snapshot of the research that is published within a specific subject area. The purpose is to offer an overview and, on a more comprehensive level, to distinguish central themes compared to a systematic review. We chose to conduct a scoping review since our aim was to clarify the key concepts of mental health in the literature and to identify specific characteristics and concepts surrounding mental health [ 29 , 30 ]. Our scoping review was conducted following the PRISMA-ScR Checklist [ 31 ]. Two authors (L.B and L.H) searched and screened the eligible articles. In the first step, titles and abstracts were screened. If the study included relevant data, the full article was read to determine if it met the eligibility criteria. Articles were excluded if they did not fulfill all the eligibility criteria. Any uncertainties were discussed among L.B. and L.H., and the third author, S.H., and were carefully assessed before making an inclusion or exclusion decision. The software Picoportal was employed for data management. Figure  1 illustrates a flowchart of data inclusion.

figure 1

PRISMA flow diagram outlining the search process

Eligibility criteria

We incorporated studies involving children and youth aged 10 to 25 years. This age range was chosen to encompass early puberty through young adulthood, a significant developmental period for young individuals in terms of comprehending mental health. Participants were required not to have undergone interviews due to chronic illness, learning disabilities (e.g., mental health linked to a cancer diagnosis), or immigrant status.

Studies conducted in clinical settings were excluded. For the purpose of comparing results under similar conditions, we specifically opted for studies carried out in Western countries .

Given that this review adopts a moderately constructionist approach, intentionally allowing for the exploration of how both young participants and society in general perceive and discuss mental health and how this process contributes to ongoing conceptual re-construction, the emphasis was placed on identifying articles in which participants themselves defined or attributed meaning to mental health and related concepts like mental illness. The criterion of selecting studies adopting an inductive approach to capture the perspectives of the young participants resulted in the exclusion of numerous studies that more overtly applied established concepts to young respondents [ 32 ].

Information sources

We utilized electronic databases and reached out to study authors if the article was not accessible online. Peer-reviewed articles were exclusively included, thereby excluding conference abstracts due to their perceived lack of relevance in addressing the review questions. Only research in English was taken into account. Publication years across all periods were encompassed in the search.

Search strategy

Studies concerning children’s and youths’ perceptions of mental health were published across a range of scientific journals, such as those within psychiatry, psychology, social work, education, and mental health. Therefore, several databases were taken into account, including Medline, Scopus, CINAHL, PsychInfo, Sociological abstracts, and Google Scholar, spanning from inception on September 20, 2021 to September 30, 2021. We involved a university librarian from the start in the search process. The combinations of search terms are displayed in Table 1 .

Quality assessment

We employed the Quality methods for the development of National Institute for Health Care Excellence (NICE) public health guidance [ 33 ] to evaluate the quality of the studies included. The checklist is based on checklists from Spencer et al. [ 34 ], Public Health Resource Unit (PHRU) [ 26 , 35 ], and the North Thames Research Appraisal Group (NTRAG) [ 36 ] (Refer to S2 for checklist). Eight studies were assigned two plusses, and three studies received one plus. The studies with lower grades generally lacked sufficient descriptions of the researcher’s role, context reporting, and ethical reporting. No study was excluded in this stage.

Data extraction and analysis

We employed a data extraction form that encompassed several key characteristics, including author(s), year, journal, country, details about method/design, participants and socioeconomics, aim, and main results (Table 2 ). The collected data were analyzed and synthesized using the thematic synthesis approach of Thomas and Harden [ 37 ]. This approach encompassed all text categorized as 'results' or 'findings' in study reports – which sometimes included abstracts, although the presentation wasn’t always consistent throughout the text. The size of the study reports ranged from a few sentences to a single page. The synthesis occurred through three interrelated stages that partially overlapped: coding of the findings from primary studies on a line-by-line basis, organization of these 'free codes' into interconnected areas to construct 'descriptive' themes, and the formation of 'analytical' themes.

The objective of this scoping review has been to investigate the literature concerning how children and youth (ages 10—25) conceptualize and perceive mental health. Based on the established inclusion- and exclusion criteria, a total of 11 articles were included representing the United Kingdom ( n  = 6), Australia ( n  = 3), and Sweden ( n  = 2) and were published between 2002 and 2020. Among these, two studies involved university students, while nine incorporated students from compulsory schools.

Salient aspects of children and youth’ perceptions of mental health

Based on the results of the included articles, salient aspects of children’s and youths’ understandings revealed uncertainties about mental health in various ways. This uncertainty emerged as conflicting perceptions, uncertainty about the concept of mental health, and uncertainty regarding where to distinguish between mild to moderate mental health problems and everyday stressors or challenges.

One uncertainty was associated with conflicting perceptions that mental health might be interpreted differently among children and youths, depending on whether it relates to their own mental health or someone else's mental health status. Chisholm et al. [ 42 ] presented this as distinctions being made between ‘them and us’ and between ‘being born with it’. Mental health and mental illness were perceived as a continuum that rather developed’, and distinctions were drawn between ‘crazy’ and ‘diagnosed.’ Participants established strong associations between the term mental illness and derogatory terms like ‘crazy,’ linking extreme symptoms of mental illness with others. However, their attitude was less stigmatizing when it came to individual diagnoses, reflecting a more insightful and empathetic understanding of the adverse impacts of stress based on their personal realities and experiences. Despite the initial reactions reflecting negative stereotypes, further discussion revealed that this did not accurately represent a deeper comprehension of mental health and mental illness.

There was also uncertainty about the concept of mental health , as it was not always clearly understood among the participating youth. Some participants were unable to define mental health, often confusing it with mental illness [ 28 ]. Others simply stated that they did not understand the term, as in O’Reilly [ 44 ]. Additionally, uncertainty was expressed regarding whether mental health was a positive or negative concept [ 27 , 28 , 40 , 44 ], and participants associated mental health with mental illness despite being asked about mental health [ 28 ]. One quote from a grade 9 student illustrates this: “ Interviewer: Can mental health be positive as well? Informant: No, it’s mental” [ 44 ]. In Laidlaw et al. [ 46 ], with participants ranging from 18—22 years of age, most considered mental health distinctly different from and more clinical than mental well-being. However, Roose et al. [ 38 ], for example, the authors discovered a more multifaceted understanding of mental health, encompassing emotions, thoughts, and behavior. In Molenaar et al.[ 45 ], mental health was highlighted as a crucial aspect of health overall. In Chisholm et al. [ 42 ], the older age groups discussed mental health in a more positive sense when they considered themselves or people they knew, relating mental health to emotional well-being. Connected to the uncertainty in defining the concept of mental health was the uncertainty in identifying those with good or poor mental health. Due to the lack of visible proof, children and youths might doubt their peers’ reports of mental illness, wondering if they were pretending or exaggerating their symptoms [ 27 ].

A final uncertainty that emerged was difficulties in drawing the line between psychiatric conditions and mild to moderate mental health problems and everyday stressors or challenges . Perre et al. [ 43 ] described how the participants in their study were uncertain about the meaning of mental illness and mental health issues. While some linked depression to psychosis, others related it to simply ‘feeling down.’ However, most participants indicated that, in contrast to transient feelings of sadness, depression is a recurring concern. Furthermore, the duration of feeling depressed and particularly a loss of interest in socializing was seen as appropriate criteria for distinguishing between ‘feeling down’ and ‘clinical depression.’ Since feelings of anxiety, nervousness, and apprehension are common experiences among children and youth, defining anxiety as an illness as opposed to an everyday stressor was more challenging [ 43 ].

Terms used to conceptualize mental health

When children and youth were asked about mental health, they sometimes used neutral terms such as thoughts and emotions or a general ‘vibe’ [ 27 ], and some described it as ‘peace of mind’ and being able to balance your emotions [ 38 ]. The notion of mental health was also found to be closely linked with rationality and the idea of normality, although, according to the young people, Armstrong et al. [ 28 ], there was no consensus about what ‘normal’ meant. Positive aspects of mental health were described by the participants as good self-esteem, confidence [ 40 ], happiness [ 39 , 43 ], optimism, resilience, extraversion and intelligence [ 27 ], energy [ 43 ], balance, harmony [ 39 , 43 ], good brain, emotional and physical functioning and development, and a clear idea of who they are [ 27 , 41 ]. It also included a feeling of being a good person, feeling liked and loved by your parents, social support, and having people to talk with [ 27 , 39 ], as well as being able to fit in with the world socially and positive peer relationships [ 41 ], according to the children and youths, mental health includes aspects related to individuals (individual factors) as well as to people in their surroundings (relationships). Regarding mental illness, participants defined it as stress and humiliation [ 40 ], psychological distress, traumatic experiences, mental disorders, pessimism, and learning disabilities [ 27 ]. Also, in contrast to the normality concept describing mental health, mental illness was described as somehow ‘not normal’ or ‘different’ in Chisholm et al. [ 42 ].

Depression and bipolar disorder were the most often mentioned mental illnesses [ 27 ]. The inability to balance emotions was seen as negative for mental health, for example, not being able to set aside unhappiness, lying to cover up sadness, and being unable to concentrate on schoolwork [ 38 ]. The understanding of mental illness also included feelings of fear and anxiety [ 42 ]. Other participants [ 46 ] indicated that mental health is distinctly different from, and more clinical than, mental well-being. In that sense, mental health was described using reinforcing terms such as ‘serious’ and ‘clinical,’ being more closely connected to mental illness, whereas mental well-being was described as the absence of illness, feeling happy, confident, being able to function and cope with life’s demands and feeling secure. Among younger participants, a more varied and vague understanding of mental health was shown, framing it as things happening in the brain or in terms of specific conditions like schizophrenia [ 44 ].

Gender, age, socioeconomic status

Only one study had a gender theoretical perspective [ 40 ], but the focus of this perspective concerned gender differences in what influences mental health more than the conceptualization of mental health. According to Johansson et al.[ 39 ], older girls expressed deeper negative emotions (e.g., described feelings of lack of meaning and hope in various ways) than older boys and younger children.

Several of the included studies noticed differences in age, where younger participants had difficulty understanding the concept of mental health [ 39 , 44 ], while older participants used more words to explain it [ 39 ]. Furthermore, older participants seemed to view mental health and mental illness as a continuum, with mental illness at one end of the continuum and mental well-being at the other end [ 42 , 46 ].

Socioeconomic status

The role of socioeconomic status was only discussed by Armstrong et al. [ 28 ], finding that young people from schools in the most deprived and rural areas experienced more difficulties defining the term mental health compared to those from a less deprived area.

This scoping review aimed to map children's and youth’s perceptions and conceptualizations of mental health. Our main findings indicate that the concept of mental health is surrounded by uncertainty. This raises the question of where this uncertainty stems from and what it symbolizes. From our perspective, this uncertainty can be understood from two angles. Firstly, the young participants in the different studies show no clear and common understanding of mental health; they express uncertainty about the meaning of the concept and where to draw the line between life experiences and psychiatric conditions. Secondly, uncertainty exists regarding how to apply these concepts in research, making it challenging to interpret and compare research results. The shift from a positivistic understanding of mental health as an objective condition to a more subjective inner experience has left the conceptualization open ranging from a pathological phenomenon to a normal and common human experience [ 47 ]. A dilemma that results in a lack of reliability that mirrors the elusive nature of the concept of mental health from both a respondent and a scientific perspective.

“Happy” was commonly used to describe mental health, whereas "unhappy" was used to describe mental illness. The meaning of happiness for mental health has been acknowledged in the literature, and according to Layard et al. [ 48 ], mental illness is one of the main causes of unhappiness, and happiness is the ultimate goal in human life. Layard et al. [ 48 ] suggest that schools and workplaces need to raise more awareness of mental health and strive to improve happiness to promote mental health and prevent mental illness. On the other hand, being able to experience and express different emotions could also be considered a part of mental health. The notion of normality also surfaced in some studies [ 38 ], understanding mental health as being emotionally balanced or normal or that mental illness was not normal [ 42 ]. To consider mental illness in terms of social norms and behavior followed with the sociological alternative to the medical model that was introduced in the sixties portraying mental illness more as socially unacceptable behavior that is successfully labeled by others as being deviant. Although our results did not indicate any perceptions of what ‘normal’ meant [ 28 ], one crucial starting point to the understanding of mental health among adolescents should be to delineate what constitutes normal functioning [ 23 ]. Children and youths’ understanding of mental illness seems to a large extent, to be on the same continuum as a normality rather than representing a medicalization of deviant behavior and a disjuncture with normality [ 49 ].

Concerning gender, it seemed that girls had an easier time conceptualizing mental health than boys. This could be due to the fact that girls mature verbally faster than boys [ 50 ], but also that girls, to a larger extent, share feelings and problems together compared to boys [ 51 ]. However, according to Johansson et al. [ 39 ], the differences in conceptualizations of mental health seem to be more age-related than gender-related. This could be due to the fact that older children have a more complex view of mental health compared to younger children.. Not surprisingly, the older the children and youth were, the more complex the ability to conceptualize mental health becomes. Only one study reported socioeconomic differences in conceptualizations of mental health [ 28 ]. This could be linked to mental health literacy (MHL) [ 18 ], i.e., knowledge about mental illness, how to prevent mental illness, and help-seeking behavior. Research has shown that disadvantaged social and socioeconomic conditions are associated with low MHL, that is, people with low SES tends to know less about symptoms and prevalence of different mental health problems [ 19 , 21 ]. The perception and conceptualizations of mental health are, as we consider, strongly related to knowledge and beliefs about mental health, and according to von dem Knesebeck et al. [ 52 ] linked primarily to SES through level of education.

Chisholm et al. [ 42 ] found that the initial reactions from participants related to negative stereotypes, but further discussion revealed that the participants had more refined knowledge than at first glance. This illuminates the importance of talking to children and helping them verbalize their feelings, in many respects complex and diversified understanding of mental health. It is plausible that misunderstandings and devaluations of mental health and mental illness may increase self-reported mental health problems [ 5 ], as well as decrease them, preventing children and youth from seeking help. Therefore, increased knowledge of the nature of mental health can help individual cope with the situations and improve their mental well-being. Finding ways to incorporate discussions about mental well-being, mental health, and mental illness in schools could be the first step to decreasing the existing uncertainties about mental health. Experiencing feelings of sadness, anger, or upset from time to time is a natural part of life, and these emotions are not harmful and do not necessarily indicate mental illness [ 5 , 6 ]. Adolescents may have an understanding of the complexity of mental health despite using simplified language but may need guidance on how to communicate their feelings and how to manage everyday challenges and normal strains in life [ 7 ].

With the aim of gaining a better understanding of how mental health is perceived among children and youth, this study has highlighted the concept’s uncertainty. Children and youth reveal a variety of understandings, from diagnoses of serious mental illnesses such as schizophrenia to moods and different types of behaviors. Is there only one way of understanding mental health, and is it reasonable to believe that we can reach a consensus? Judging by the questions asked, researchers also seem to have different ideas on what to incorporate into the concept of mental health — the researchers behind the present study included. The difficulties in differentiating challenges being part of everyday life with mental health issues need to be paid closer attention to and seems to be symptomatic with the lack of clarity of the concepts.

A constructivist approach would argue that the language of mental health has changed over time and thus influence how adolescents, as well as society at large, perceive, talk about, and report their mental health [ 26 ]. The re-construction or adaptation of concepts could explain why children and youth re struggling with the meaning of mental health and that mental health often is used interchangeably with mental illness. Mental health, rather than being an umbrella term, then represents a continuum with a positive and a negative end, at least among older adolescents. But as mental health according to this review also incorporates subjective expressions of moods and feelings, the reconstruction seems to have shaped it into a multidimensional concept, representing a horizontal continuum of positive and negative mental health and a vertical continuum of positive and negative well-being, similar to the health cross by Tudor [ 53 ] referred to in Laidlaw et al. [ 46 ] A multidimensional understanding of mental health constructs also incorporates evidence from interventions aimed at reducing mental health stigma among adolescents, where attitudes and beliefs as well as emotional responses towards mental health are targeted [ 54 ].

The contextual understanding of mental health, whether it is perceived in positive terms or negative, started with doctors and psychiatrists viewing it as representing a deviation from the normal. A perspective that has long been challenged by health workers, academics and professionals wanting to communicate mental health as a positive concept, as a resource to be promoted and supported. In order to find a common ground for communicating all aspects and dimensions of mental health and its conceptual constituents, it is suggested that we first must understand the subjective meaning ascribed to the use of the term [ 26 ]. This line of thought follows a social-constructionist approach viewing mental health as a concept that has transitioned from representing objective mental descriptions of conditions to personal subjective experiences. Shifting from being conceptualized as a pathological phenomenon to a normal and common human experience [ 47 ]. That a common understanding of mental health can be challenged by the healthcare services tradition and regulation for using diagnosis has been shown in a study of adolescents’ perspectives on shared decision-making in mental healthcare [ 55 ]. A practice perceived as labeling by the adolescents, indicating that steps towards a common understanding of mental health needs to be taken from several directions [ 55 ]. In a constructionist investigation to distinguish everyday challenges from mental health problems, instead of asking the question, “What is mental health?” we should perhaps ask, “How is the word ‘mental health’ used, and in what context and type of mental health episode?” [ 26 ]. This is an area for future studies to explore.

Methodological considerations

The first limitation we want to acknowledge, as for any scoping review, is that the results are limited by the search terms included in the database searches. However, by conducting the searches with the help of an experienced librarian we have taken precautions to make the searches as inclusive as possible. The second limitation concerns the lack of homogeneous, or any results at all, according to different age groups, gender, socioeconomic status, and year when the study was conducted. It is well understood that age is a significant determinant in an individual’s conceptualization of more abstract phenomena such as mental health. Some of the studies approached only one age group but most included a wide age range, making it difficult to say anything specific about a particular age. Similar concerns are valid for gender. Regarding socioeconomic status, only one study reported this as a finding. However, this could be an outcome of the choice of methods we had — i.e., qualitative methods, where the aim seldom is to investigate differences between groups and the sample is often supposed to be a variety. It could also depend on the relatively small number of participants that are often used in focus groups of individual interviews- there are not enough participants to compare groups based on gender or socioeconomic status. Finally, we chose studies from countries that could be viewed as having similar development and perspective on mental health among adolescents. Despite this, cultural differences likely account for many youths’ conceptualizations of mental health. According to Meldahl et al. [ 56 ], adolescents’ perspectives on mental health are affected by a range of factors related to cultural identity, such as ethnicity, race, peer and family influence, religious and political views, for example. We would also like to add organizational cultures, such as the culture of the school and how schools work with mental health and related concepts [ 56 ].

Conclusions and implications

Based on our results, we argue that there is a need to establish a common language for discussing mental health. This common language would enable better communication between adults and children and youth, ensuring that the content of the words used to describe mental health is unambiguous and clear. In this endeavor, it is essential to actively listen to the voices of children and youth, as their perspectives will provide us with clearer understanding of the experiences of being young in today’s world. Another way to develop a common language around mental health is through mental health education. A common language based on children’s and youth’s perspectives can guide school personnel, professionals, and parents when discussing and planning health interventions and mental health education. Achieving a common understanding through mental health education of adults and youth could also help clarify the boundaries between everyday challenges and problems needing treatment. It is further important to raise awareness of the positive aspect of mental health—that is, knowledge of what makes us flourish mentally should be more clearly emphasized in teaching our children and youth about life. It should also be emphasized in competence development for school personnel so that we can incorporate knowledge about mental well-being in everyday meetings with children and youth. In that way, we could help children and youth develop knowledge that mental health could be improved or at least maintained and not a static condition.

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Twenge JM, Joiner TE, Rogers ML, Martin GN. Increases in depressive symptoms, suicide-related outcomes, and suicide rates among US adolescents after 2010 and links to increased new media screen time. Clin Psychol Sci. 2018;6(1):3–17.

Article   Google Scholar  

Potrebny T, Wiium N, Lundegård MM-I. Temporal trends in adolescents’ self-reported psychosomatic health complaints from 1980–2016: A systematic review and meta-analysis. PLOS one. 2017;12(11):e0188374. https://doi.org/10.1371/journal.pone.0188374 . [published Online First: Epub Date]|.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Petersen S, Bergström E, Cederblad M, et al. Barns och ungdomars psykiska hälsa i Sverige. En systematisk litteraturöversikt med tonvikt på förändringar över tid. (The mental health of children and young people in Sweden. A systematic literature review with an emphasis on changes over time). Stockholm: Kungliga Vetenskapsakademien; 2010.

Google Scholar  

Baxter AJ, Scott KM, Ferrari AJ, Norman RE, Vos T, Whiteford HA. Challenging the myth of an “epidemic” of common mental disorders: trends in the global prevalence of anxiety and depression between 1990 and 2010. Depress Anxiety. 2014;31(6):506–16. https://doi.org/10.1002/da.22230 . [published Online First: Epub Date]|.

Article   PubMed   Google Scholar  

Wickström A, Kvist LS. Young people’s perspectives on the symptoms asked for in the Health Behavior in School-Aged Children survey. Childhood. 2020;27(4):450–67.

Hellström L, Beckman L. Life Challenges and Barriers to Help Seeking: Adolescents’ and Young Adults’ Voices of Mental Health. Int J Environ Res Public Health. 2021;18(24):13101. https://doi.org/10.3390/ijerph182413101 . [published Online First: Epub Date]|.

Article   PubMed   PubMed Central   Google Scholar  

Hermann V, Durbeej N, Karlsson AC, Sarkadi A. ‘Feeling down one evening doesn’t count as having mental health problems’—Swedish adolescents’ conceptual views of mental health. J Adv Nurs. 2022. https://doi.org/10.1111/jan.15496 . [published Online First: Epub Date]|.

Boruchovitch E, Mednick BR. The meaning of health and illness: some considerations for health psychology. Psico-USF. 2002;7:175–83.

Piko BF, Bak J. Children’s perceptions of health and illness: images and lay concepts in preadolescence. Health Educ Res. 2006;21(5):643–53.

Millstein SG, Irwin CE. Concepts of health and illness: different constructs or variations on a theme? Health Psychol. 1987;6(6):515.

Article   CAS   PubMed   Google Scholar  

Campbell JD. Illness is a point of view: the development of children's concepts of illness. Child Dev. 1975;46(1):92–100.

Mouratidi P-S, Bonoti F, Leondari A. Children’s perceptions of illness and health: An analysis of drawings. Health Educ J. 2016;75(4):434–47.

Julia L. Lay experiences of health and illness: past research and future agendas. Sociol Health Illn. 2003;25(3):23–40.

World Health Organization. Promoting mental health: concepts, emerging evidence, practice (Summary Report). Geneva: World Health Organization; 2004. Available at: https://apps.who.int/iris/handle/10665/42940 .

American Psychiatric Association. What is mental illness?. Secondary What is mental illness? 2023. Retrieved February 10, 2023, from https://www.psychiatry.org/patients-families/what-is-mentalillness .

National board of health and welfare TSAoLAaRatSAfHTA, Assessment of Social Services. What is mental health and mental illness? Secondary What is mental health and mental illness? 2022. https://www.socialstyrelsen.se/kunskapsstod-och-regler/omraden/psykisk-ohalsa/vad-menas-med-psykisk-halsa-och-ohalsa/ .

Jorm AF, Korten AE, Jacomb PA, Christensen H, Rodgers B, Pollitt P. “Mental health literacy”: a survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Med J Aust. 1997;166(4):182–6.

Kutcher S, Wei Y, Coniglio C. Mental health literacy: Past, present, and future. Can J Psychiatry. 2016;61(3):154–8.

Bjørnsen HN, Espnes GA, Eilertsen M-EB, Ringdal R, Moksnes UK. The relationship between positive mental health literacy and mental well-being among adolescents: implications for school health services. J Sch Nurs. 2019;35(2):107–16.

Lam LT. Mental health literacy and mental health status in adolescents: a population-based survey. Child Adolesc Psychiatry Ment Health. 2014;8:1–8.

Campos L, Dias P, Duarte A, Veiga E, Dias CC, Palha F. Is it possible to “find space for mental health” in young people? Effectiveness of a school-based mental health literacy promotion program. Int J Environ Res Public Health. 2018;15(7):1426.

Mårtensson L, Hensing G. Health literacy–a heterogeneous phenomenon: a literature review. Scand J Caring Sci. 2012;26(1):151–60.

Aneshensel CS, Phelan JC, Bierman A. The sociology of mental health: Surveying the field. Handbook of the sociology of mental health: Springer; 2013. p. 1–19.

Book   Google Scholar  

Johansson EE, Bengs C, Danielsson U, Lehti A, Hammarström A. Gaps between patients, media, and academic medicine in discourses on gender and depression: a metasynthesis. Qual Health Res. 2009;19(5):633–44.

Dowbiggin IR. High anxieties: The social construction of anxiety disorders. Can J Psychiatry. 2009;54(7):429–36.

Stein JY, Tuval-Mashiach R. The social construction of loneliness: an integrative conceptualization. J Constr Psychol. 2015;28(3):210–27.

Teng E, Crabb S, Winefield H, Venning A. Crying wolf? Australian adolescents’ perceptions of the ambiguity of visible indicators of mental health and authenticity of mental illness. Qual Res Psychol. 2017;14(2):171–99.

Armstrong C, Hill M, Secker J. Young people’s perceptions of mental health. Child Soc. 2000;14(1):60–72.

Munn Z, Peters MD, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18:1–7.

Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. JBI Evidence Implementation. 2015;13(3):141–6.

Tricco A, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2004;169(7):467–73.

Järvensivu T, Törnroos J-Å. Case study research with moderate constructionism: conceptualization and practical illustration. Ind Mark Manage. 2010;39(1):100–8.

National Institute for Health and Care Excellence. Methods for the development of NICE public health guidance (third edition). Process and methods PMG4. 2012. Available at: https://www.nice.org.uk/process/pmg4/chapter/introduction .

Spencer L, Ritchie J, Lewis J, Dillon L. Quality in qualitative evaluation: A framework for assessing research evidence. Cabinet Office. 2004. Available at: https://www.cebma.org/wp-content/uploads/Spencer-Quality-in-qualitative-evaluation.pdf .

Critical Appraisal Skills Programme (CASP). CASP qualitative research checklist: 10 questions to help you make sense of qualitative research. 2013. Available at: https://www.casp-uk.net/#!casp-tools-checklists/c18f8 .

North Thames Research Appraisal Group (NTRAG). Critical review form for reading a paper describing qualitative research British Sociological Association (BSA). 1998.

Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8(1):1–10.

Roose GA, John A. A focus group investigation into young children’s understanding of mental health and their views on appropriate services for their age group. Child Care Health Dev. 2003;29(6):545–50.

Johansson A, Brunnberg E, Eriksson C. Adolescent girls’ and boys’ perceptions of mental health. J Youth Stud. 2007;10(2):183–202.

Landstedt E, Asplund K, Gillander GK. Understanding adolescent mental health: the influence of social processes, doing gender and gendered power relations. Sociol Health Illn. 2009;31(7):962–78.

Svirydzenka N, Bone C, Dogra N. Schoolchildren’s perspectives on the meaning of mental health. J Public Ment Health. 2014;13(1):4–12.

Chisholm K, Patterson P, Greenfield S, Turner E, Birchwood M. Adolescent construction of mental illness: implication for engagement and treatment. Early Interv Psychiatry. 2018;12(4):626–36.

Perre NM, Wilson NJ, Smith-Merry J, Murphy G. Australian university students’ perceptions of mental illness: a qualitative study. JANZSSA. 2016;24(2):1–15. Available at: https://janzssa.scholasticahq.com/article/1092-australian-university-students-perceptions-of-mental-illness-a-qualitative-study .

O’reilly M, Dogra N, Whiteman N, Hughes J, Eruyar S, Reilly P. Is social media bad for mental health and wellbeing? Exploring the perspectives of adolescents. Clin Child Psychol Psychiatry. 2018;23(4):601–13.

Molenaar A, Choi TS, Brennan L, et al. Language of health of young Australian adults: a qualitative exploration of perceptions of health, wellbeing and health promotion via online conversations. Nutrients. 2020;12(4):887.

Laidlaw A, McLellan J, Ozakinci G. Understanding undergraduate student perceptions of mental health, mental well-being and help-seeking behaviour. Stud High Educ. 2016;41(12):2156–68.

Nilsson B, Lindström UÅ, Nåden D. Is loneliness a psychological dysfunction? A literary study of the phenomenon of loneliness. Scand J Caring Sci. 2006;20(1):93–101.

Layard R. Happiness and the Teaching of Values. CentrePiece. 2007;12(1):18–23.

Horwitz AV. Transforming normality into pathology: the DSM and the outcomes of stressful social arrangements. J Health Soc Behav. 2007;48(3):211–22.

Björkqvist K, Lagerspetz KM, Kaukiainen A. Do girls manipulate and boys fight? Developmental trends in regard to direct and indirect aggression. Aggressive Behav. 1992;18(2):117–27.

Rose AJ, Smith RL, Glick GC, Schwartz-Mette RA. Girls’ and boys’ problem talk: Implications for emotional closeness in friendships. Dev Psychol. 2016;52(4):629.

von dem Knesebeck O, Mnich E, Daubmann A, et al. Socioeconomic status and beliefs about depression, schizophrenia and eating disorders. Soc Psychiatry Psychiatr Epidemiol. 2013;48(5):775–82. https://doi.org/10.1007/s00127-012-0599-1 . [published Online First: Epub Date]|.

Tudor K. Mental health promotion: paradigms and practice (1st ed.). Routledge: 1996. https://doi.org/10.4324/9781315812670 .

Ma KKY, Anderson JK, Burn AM. School-based interventions to improve mental health literacy and reduce mental health stigma–a systematic review. Child Adolesc Mental Health. 2023;28(2):230–40.

Bjønness S, Grønnestad T, Storm M. I’m not a diagnosis: Adolescents’ perspectives on user participation and shared decision-making in mental healthcare. Scand J Child Adolesc Psychiatr Psychol. 2020;8(1):139–48.

PubMed   PubMed Central   Google Scholar  

Meldahl LG, Krijger L, Andvik MM, et al. Characteristics of the ideal healthcare services to meet adolescents’ mental health needs: A qualitative study of adolescents’ perspectives. Health Expect. 2022;25(6):2924–36.

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Beckman, L., Hassler, S. & Hellström, L. Children and youth’s perceptions of mental health—a scoping review of qualitative studies. BMC Psychiatry 23 , 669 (2023). https://doi.org/10.1186/s12888-023-05169-x

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  • Mental health
  • Perceptions
  • Public health
  • Scoping review

BMC Psychiatry

ISSN: 1471-244X

literature review example on mental health

Recommendation 22 Literature Review Summary

  • Mental health literacy encompasses knowledge about mental health symptoms, interventions, and resources available, as well as positive attitudes and willingness to intervene when others are struggling.
  • Literacy campaigns targeted at mental health have been positively received in post-secondary institutions, though it is unclear how they might affect behavioural outcomes.
  • Mental health training can improve knowledge, attitudes and self-efficacy. However, improvements often diminish over time, and it is unclear how actual gatekeeping behaviours are affected.
  • Barriers to participating in training programs include lack of awareness, time constraints, resource limitations, and uncertainty about the benefits of training.

Literature Review Findings

Mental health literacy is broadly defined as knowledge of mental health symptoms, interventions, and resources available, as well as positive attitudes and self-efficacy toward helping others in need. Many students were aware of counselling services and symptoms related to depression, but fewer recognized other campus resources and types of mental health conditions. Health promotion and prevention of mental health issues were under-recognized; students only endorsed help-seeking actions when symptoms were severe. Additionally, students experiencing high levels of depression and distress were less likely to recognize symptoms of mental illness than others.

Various mental health literacy campaigns have been implemented in post-secondary settings. Feedback collected through focus groups and surveys tended to be positive, though response rates were often low and outcomes following exposure were minimal. Campaigns utilizing visual promotion materials are more effective when they are designed appealingly and with a student audience in mind. There is also a need for campaigns targeted at groups at higher risk of experiencing mental distress, such as LGBTQ+ and racialized student groups.

Mental health training programs are associated with short-term increases in self-reported knowledge, attitudes, and self-efficacy. However, there is mixed evidence supporting changes to actual behaviours; (quasi-)experimental studies found few differences in skills following training. Training programs that included components such as experiential learning exercises and scenarios tailored to post-secondary settings were the most effective at improving outcomes. Limitations of studies on training programs include low participation and response rates, lack of long-term follow-up assessments, and the use of instruments that have not been empirically validated.  

Faculty, staff and students described barriers to participating in training programs, such as lack of awareness about training opportunities, limited time and resources, and uncertainty about the benefits of training given the role of the person. Support from peers and leaders in the community was a strong enabling factor for participating in training.

Implications for Practice 

Mental health literacy campaigns need to be embedded into a larger policy and service framework that emphasizes health promotion and prevention as well as intervention and crisis management. Tailored campaigns for high risk groups, such as minority student populations and those experiencing high levels of mental distress, are recommended.

As part of a mental health literacy strategy, training programs need to be available to all members of the university community. Training programs that are specialized for post-secondary settings, incorporate experiential exercises, and which receive institutional resources and ongoing support, are likely to have the most impact.

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Published on 9.6.2020 in Vol 7 , No 6 (2020) : June

Peer Support in Mental Health: Literature Review

Authors of this article:

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  • Reham A Hameed Shalaby * , MD   ; 
  • Vincent I O Agyapong * , MD, PhD  

Department of Psychiatry, University of Alberta, Edmonton, AB, Canada

*all authors contributed equally

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Reham A Hameed Shalaby, MD

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Background: A growing gap has emerged between people with mental illness and health care professionals, which in recent years has been successfully closed through the adoption of peer support services (PSSs). Peer support in mental health has been variously defined in the literature and is simply known as the help and support that people with lived experience of mental illness or a learning disability can give to one another. Although PSSs date back to several centuries, it is only in the last few decades that these services have formally evolved, grown, and become an integral part of the health care system. Debates around peer support in mental health have been raised frequently in the literature. Although many authors have emphasized the utmost importance of incorporating peer support into the health care system to instill hope; to improve engagement, quality of life, self-confidence, and integrity; and to reduce the burden on the health care system, other studies suggest that there are neutral effects from integrating PSSs into health care systems, with a probable waste of resources.

Objective: In this general review, we aimed to examine the literature, exploring the evolution, growth, types, function, generating tools, evaluation, challenges, and the effect of PSSs in the field of mental health and addiction. In addition, we aimed to describe PSSs in different, nonexhaustive contexts, as shown in the literature, that aims to draw attention to the proposed values of PSSs in such fields.

Methods: The review was conducted through a general search of the literature on MEDLINE, Google Scholar, EMBASE, Scopus, Chemical Abstracts, and PsycINFO. Search terms included peer support, peer support in mental health, social support, peer, family support, and integrated care.

Results: There is abundant literature defining and describing PSSs in different contexts as well as tracking their origins. Two main transformational concepts have been described, namely, intentional peer support and transformation from patients to peer support providers. The effects of PSSs are extensive and integrated into different fields, such as forensic PSSs, addiction, and mental health, and in different age groups and mental health condition severity. Satisfaction of and challenges to PSS integration have been clearly dependent on a number of factors and consequently impact the future prospect of this workforce.

Conclusions: There is an internationally growing trend to adopt PSSs within addiction and mental health services, and despite the ongoing challenges, large sections of the current literature support the inclusion of peer support workers in the mental health care workforce. The feasibility and maintenance of a robust PSS in health care would only be possible through collaborative efforts and ongoing support and engagement from all health care practitioners, managers, and other stakeholders.

Introduction

Peer support services (PSSs) are novel interventions recently adopted in mental health systems worldwide. It is believed, however, that PSSs date back to more than three centuries to the moral treatment era [ 1 ], albeit on an informal basis. Diverse definitions and classifications for PSSs have been provided in the literature [ 2 - 4 ], and numerous reports have praised and supported the service provided by peer support workers (PSWs) [ 5 - 8 ]. However, other literature suggests the neutral effects of PSSs, with weak associated evidence to support such services [ 9 , 10 ]. The potential impact of PSWs on their peers [ 11 - 14 ] has received considerable attention in the literature.

PSSs have been introduced in different contexts, such as family PSWs [ 15 - 19 ], the forensic field [ 20 , 21 ], and online PSSs. A considerable number of strategies were proposed to generate an effective PSS in the mental health field amid a number of associated concerns and challenges [ 22 - 25 ].

This general review sheds light on PSWs’ experiences, benefits, challenges, opportunities to expand access to quality addiction, and mental health care using PSSs. The review was conducted through a general search of the literature on MEDLINE, Google Scholar, EMBASE, Scopus, Chemical Abstracts, and PsycINFO. Search terms included peer support, peer support in mental health, social support, peer, family support, and integrated care. We began the review with an examination of the definitions, origins, and types of peer support contributions and within different clinical contexts, aiming at deepening the view to the diverse effects of such a workforce. We then continued with examining the transition from a patient role to a PSW role and their incorporation into mental health systems. Thereafter, we provided a conceptual framework for the effects of peer support and stigma in relation to PSWs. We concluded the review by examining the benefits and challenges associated with PSSs and provided a commentary on future directions for PSSs in mental health.

Definitions

Peer support has diverse meanings in the literature. For example, it is a system of giving and receiving help founded on key principles of respect, shared responsibility, and an agreement of what is helpful [ 26 ]. A peer is defined as an equal , someone with whom one shares demographic or social similarities, whereas support refers to “the kind of deeply felt empathy, encouragement, and assistance that people with shared experiences can offer one another within a reciprocal relationship” [ 3 ]. The Mental Health Foundation in the United Kingdom defined peer support in mental health as “the help and support that people with lived experience of a mental illness or a learning disability can give to one another” [ 27 ]. Peer employees were also defined as “individuals who fill designated unique peer positions as well as peers who are hired into traditional MH positions” [ 28 ]. In 1976, authors defined self-help groups as “voluntary small group structures for mutual aid in the accomplishment of a specific purpose...usually formed by peers who have come together for mutual assistance in satisfying a common need, overcoming a common handicap or life-disrupting problem, and bringing about desired social and/or personal change” [ 28 ]. Although the mutual relationship was sometimes overlooked and rather described as an asymmetric or nearly one-directional relationship [ 29 ], it is emphasized upon as 1 of the 4 main tasks for peer support accomplishments, which are mutuality, connection, worldwide, and moving toward rather than moving away [ 30 ].

Origin and Growth of Peer Support

Davidson et al [ 11 ] have expressed the paradigm that calls for new models of community-based practice, which turned away from case management and from conceptualizing old practices under new terms. In the 1990s, peer support was formally introduced as a service in community mental health care. However, there is evidence of its practice throughout history, including during the moral treatment era in France at the end of the 18th century [ 1 ]. Recently, peer support has been rapidly growing in many countries and could attract a considerable amount of research [ 22 ]. Although Lunatic Friends’ Society is known as the earliest peer support group in mental health, which was founded in England in the middle of the 19th century [ 31 ], self-help groups were described as the oldest and most pervasive of peer support types [ 28 ]. Some peer-run groups also formed in Germany in the late 19th century, which protested on involuntary confinement laws. In addition to this, several individuals in the 18th and 19th centuries publicized their protests about their treatment in autobiographies and petitions [ 32 ]. The origin of peer support even reaches further back than the earliest asylums [ 33 ]. Some authors suggest that peer support is not based on psychiatric models and diagnostic criteria [ 3 ]; however, it is about “understanding another’s situation empathically through the shared experience of emotional and psychological pain” [ 34 ]. In the United States, the start of legitimacy for peer support was ignited in 2007 by considering the conditions under which PSSs could be reimbursed by Medicaid [ 35 ]. Although this reform was entailing a recovery model, which has been adopted by health care providers and stakeholders in many “English-speaking” countries, it was not the case in many other countries, in which this reform was yet to be well formulated [ 36 ].

Transformational Concepts in Peer Support Service

Intentional peer support: informal to formal peer support evolution.

Intentional peer support (IPS) is described as a philosophical descendant of the informal peer support of the ex-patients’ movement in the 1970s [ 3 ]. It depends on a way of communication that immerses the provider into the recipient experience by stepping back from one’s story and being eagerly open to others’ stories [ 30 ]. In the field of psychiatry, trauma is blamed for playing a pivotal role in the experience, diagnosis, and treatment, and peer support is described as the logical environment for disseminating trauma-informed care (TIC) or service, which enables building relationships based on mutuality, shared power, and respect [ 37 ]. In the same context, trauma-informed peer support usually begins with the main question, “What happened to you?” instead of “What is wrong with you?” [ 30 ]. TIC is an explanatory model that identifies PSWs sharing lived experiences, ensuring safety and functioning as an advocate, and a liaison to patient management plans, where empowerment and intervention models are strongly emphasized upon [ 38 , 39 ]. The shift from a traditional biomedical model to recovery-oriented practice is meant to perceive trauma as a coping mechanism rather than a pathology [ 38 , 40 ]. This clearly entails training of all service providers for better acknowledgment and comfort in dealing with trauma survivors , with an understanding of trauma as an expectation rather than an exception [ 41 ]. Although the TIC concept has evolved over the years, it still lacks guidance, training, staff knowledge, and governmental support, which are necessary to ensure successful policy implementation [ 40 ]. The role of PSWs also extended to support those at risk of trauma events because of the nature of their work, including child protection workers, who are at risk of posttraumatic stress disorder or anxiety disorder [ 42 ]. Although IPS grew from the informal practices of grassroots-initiated peer support, it differs from earlier approaches because it is a theoretically based, manualized approach with clear goals and a fidelity tool for practitioners [ 14 ]. It instead focuses on the nature and purpose of the peer support relationship and its attention to skill building to purposefully engage in peer support relationships that promote mutual healing and growth [ 3 ]. Transitioning from informal to formal roles provides not only well-formulated expectations of the role but also a better chance to identify the potential conflict of the PSWs’ mixed identity [ 43 ].

Research conducted on PSWs has been conceptualized throughout history [ 22 ]. Starting with feasibility studies, at the initial stage, it is followed by studies comparing peer staff with nonpeer staff and, finally, the studies that answer questions such as the following:

  • Do interventions provided by peers differ from those provided by nonpeers?
  • What makes peer support a unique form of service delivery?

If so, to the previous question, what are the active ingredients of these aspects of peer support, and what outcomes can they produce?

Studies that provide answers to the latter set of questions are expected to provide a deeper understanding of the philosophical underpinnings of the IPS concept for PSSs.

The Transformation From Patient to Peer Support Providers

The shift from being a service recipient to a service provider has been contributing as a driving force to restore fundamental human rights, especially among those with serious mental illnesses (SMIs) [ 22 ]. Telling the personal lived experience leads to a profound shift, from telling an “illness story” to a “recovery story” [ 4 ]. This involved an identity transformation from being perceived as a victim or a patient to a person fully engaged in life with various opportunities ahead [ 4 ]. This transition is seen as a gradual process and one that is supported by several other personal changes with expected challenges [ 44 ]. Moving a full circle to include PSWs as the service provider has been undertaken by mental health services to further exceed the transformational role, which was primarily the main aim of providing such a service [ 45 ]. A liminal identity was given for PSWs as laying between several roles, being service users, friends, and staff. Thus, the professionalism of the PSW role might not be a successful way to ensure individual well-being or to promote the peer support initiative [ 46 ]. Thus, successful transitioning from the patient to PSW role involves fundamental functional shifts achieved through overcoming multiple barriers at the personal, health system, and societal levels.

Effects of Peer Support Service in Different Contexts

Trained PSWs or mentors can use communication behaviors useful to different client groups. Many studies showed the effectiveness and feasibility of applying for peer support as follows:

Severe or Serious Mental Illness

Generally, the evidence for peer support interventions for people with SMIs has been described as moderate to limited with mixed intervention effects [ 2 , 47 ]. On the one hand, adding PSSs to intensive case management teams proved to improve activation in terms of knowledge, skills, confidence, and attitudes for managing health and treatment. Hence, patients become healthier, report better quality of life (QOL), engage in more health care practices, and report more treatment satisfaction [ 48 , 49 ]. On the other hand, a systematic review of randomized controlled trials (RCTs) involving adults with SMIs, while showing some evidence of positive effects on measures of hope, recovery, and empowerment at and beyond the end of the PSS intervention in this review, did not show any positive effects on hospitalization, satisfaction, or overall symptoms [ 10 ]. Similarly, a Cochrane systematic review of PSSs for people with schizophrenia found inconclusive results, with a high risk of bias in most of the studies and insufficient data to support or refute the PSS for this group [ 50 ].

Addiction and Drug Users

In recent years, peer recovery support services have become an accepted part of the treatment for substance use disorders, providing a more extensive array of services that are typically associated with the mutual supportive intervention [ 51 ]. This is in contrast to the use of peer support for SMIs where evidence is still developing. The Substance Abuse and Mental Health Services Administration (SAMHSA) defined peer recovery support for substance use disorders as “a set of nonclinical, peer-based activities that engage, educate, and support individuals so that they can make life changes that are necessary to recover from substance use disorders” [ 51 ]. Despite the long-term nature of substance abuse, immersion in peer support groups and activities and active engagement in the community are considered the 2 critical predictors of recovery for more than half the dependent substance users [ 52 ].

A number of trials studied the peer support effect on drug users, especially in the emergency department [ 53 , 54 ]. Another randomized trial found that a socially focused treatment can affect change in the patient’s social network and hence increase support for abstinence, for example, an increase of one nondrinking friend in the social network is translated into a 27% increase in the probability of reporting abstinence on 90% of days or more at all follow-up visits, which extended to 15 months [ 55 ].

Forensic Peer Support Service

The forensic peer system refers to the engagement of peer specialists who have histories of mental illness as well as criminal justice involvement and who are trained to help other patients sharing similar accounts [ 20 ]. As referred to by Davidson and Rowe [ 20 ], “Forensic Peer Specialists embody the potential for recovery for people who confront the dual stigmas associated with SMI and criminal justice system involvement.”

They offer day-to-day support for those released early from jail by accompanying them to initial probation meetings or treatment appointments and referring them to potential employers and landlords, helping people to negotiate and minimize continuing criminal sanctions and training professional staff on engaging consumers with criminal justice history [ 20 , 21 ]. PSWs with incarceration histories could successfully identify the liminal space in being supportive rather than providing support for the criminal offense, in contrast with the conventional methods that directly confront criminality [ 56 ]. In fact, having criminal history is the “critical component” for achieving recovery [ 56 ]. Multiple initiatives have been introduced to facilitate a reentry process for people recently released from incarceration, including Forensic Assertive Community Treatment, Assertive Community Treatment, Critical Time Intervention, and Women’s Initiative Supporting Health Transitions Clinic, through diverse community support groups involving PSWs [ 57 , 58 ].

A peer support program undertaken by older community volunteers was effective in improving general and physical health, social functioning, depression parameters, and social support satisfaction, especially in socially isolated, low-income older adults [ 59 ]. The Reclaiming Joy Peer Support intervention (a mental health intervention that pairs an older adult volunteer with a participant) has the potential for decreasing depression symptoms and improving QOL indicators for both anxiety and depression [ 60 ]. Engaging the community in health research could be of a high value in acknowledging their own health needs [ 61 ].

Youth and Adolescents

Peer support programs are mostly needed for university students, where challenges with loneliness and isolation are well recognized [ 62 ]. Hence, a need emerged for training peers to support their peer adolescents with the prospective challenges at this age [ 63 ]. Trained peer support students without necessarily having a lived experience were also examined in England [ 64 ]. The study included university students measuring the acceptability and impact of the volunteer peer support program through 6 weekly sessions. Students with lower mental well-being were more likely to complete the course, and an improvement in mental well-being was recorded for those who attended more frequently. Overall, peers remain to be an essential source of support for young people experiencing mental health and substance use problems [ 65 ].

Medically and Socially Disadvantaged Subgroups

A peer-led, medical self-management program intervention has been beneficial for medically and socially disadvantaged subgroups [ 60 ]. The Reclaiming Joy Peer Support intervention has the potential for increasing QOL and reducing depression in low-income older adults who have physical health conditions [ 60 ]. Similarly, for those who are “hardly reached,” it was indicated that the PSS provided is even more effective in these marginalized populations [ 66 ]. A Health and Recovery Peer program was delivered by mental health peer leaders for people with SMIs, resulting in an improvement in the physical health–related QOL parameters such as physical activity and medication adherence [ 49 ]. Peer-delivered and technology-supported interventions are feasible and acceptable and are associated with improvements in psychiatric, medical self-management skills, QOL, and empowerment of older adults with SMIs and or chronic health conditions [ 67 , 68 ].

Persons With Disabilities

The United Nations’ Convention on the Rights of Persons with Disabilities (CRPD) was adopted in 2007 and stated that “persons with disabilities should have equal recognition before the law and the right to exercise their legal capacity” [ 69 - 71 ]. Therefore, a positive emphasis upon the supported decision making and the fight against discrimination is evident through the convention. Nevertheless, these initiatives have been perceived as incomplete considering many challenges such as the community social status and ongoing perceived stigma of people with disabilities (PWDs) [ 70 , 72 ]. “Circle of support” is an elaborate example of an applicable peer support model for PWDs that has helped in decision making and facilitating communication [ 70 , 73 , 74 ]. This is clearly aligned with the paradigm shift from the biomedical to the socially supportive model of disability, which was provided by CRPD [ 70 ].

Peer Support for Families

Families may act either as sources of understanding and support or stigmatization through ignorance, prejudice, and discrimination, with subsequent negative impact [ 19 ]. In addition, the distress and burden associated with caring for a family member with mental illness are evident, where 29% to 60% endure significant psychological distress [ 17 ]. Family support can be financial or emotional; however, moral support was perceived as the substantial motivating factor for relatives who are ill [ 19 ]. In the last few decades, consistent and growing evidence that supports the inclusion of family members in the treatment and care of their misfortunate relatives has been developed. This has been mainly evident in the youth mental health system that urged the transformation change, which incorporates family members in the health care service provided to their youth [ 18 , 75 ]. Many PSWs have been engaged in family psychoeducation as family peers or parent partners, especially for those with the first episode of psychosis [ 76 ]. Although familial education is crucial and needs to be provided through different scales [ 19 ], an extensive matching of PSWs and the caregivers has not been perceived as a necessity to create a successful volunteer mentoring relationship [ 77 ]. Multiple initiatives have taken place all over the world. In India, a program titled “Saathi” was established for family members of residential and outpatient mental health service users that had dual goals of offering information and developing a peer support mechanism for family members of people with different mental health conditions [ 19 ]. In Melbourne, Australia, “Families Helping Families” was developed, where family PSWs are positioned in the service assessment area and in the inpatient unit to ensure early involvement [ 18 ]. An impressive peer support guide for parents of children or youth with mental health problems is provided by the Canadian Mental Health Association, British Colombia Division [ 15 ]. In Ontario, family matters programs are provided through provincial peer support programs [ 16 ].

The term “transforming mental health care” entails active involvement of families in orienting the mental health system toward recovery [ 78 ]. Family members are to have access to timely and accurate information that promotes learning, self-monitoring, and accountability [ 79 ]. The inclusion of family members as partners of the medical service is the new philosophy, with a subsequent shift from the concept of clinic-based practice to a community-based service approach [ 78 ].

Peer Support Service in Low- and Middle-Income Countries

Several initiatives took place in low- and middle-income countries, such as in rural Uganda, where a trained peer-led team provided 12 successful training sessions of perinatal service for a group of parents over a 6-month period, which resulted in better maternal well-being and child development, compared with another control group [ 80 ]. Similarly, successful community peer groups were conducted in rural India and Nepal, with high feasibility and effectiveness rates, and perceived as “potential alternative to health-worker-led interventions” [ 81 - 83 ]. In addition, adding counseling and social support groups entailing PSWs to the conventional medication treatment for patients with psychotic disorders was tried in a cohort study in Uganda; however, the results were not significantly different from those who received only medications [ 84 ]. This might be because of the underpowering of community services offered, compared with the robust medication regimens [ 85 ].

It is evident from the aforementioned information that there is mixed evidence on the effectiveness of PSW interventions in different contexts. For example, for patients with SMIs, systematic reviews suggest that there is some evidence of positive effects on measures of hope, recovery, and empowerment but no positive effects on hospitalization, satisfaction, or overall symptoms [ 10 ]. Similarly, for patients with addiction issues, although being involved in a peer network did not reduce social assistance for alcohol, they somewhat increased behavioral and attitudinal support for abstinence as well as involvement with Alcoholics Anonymous [ 55 ]. Furthermore, although many observational studies support the PSW role in the other contexts described above, there is a current dearth of literature involving RCTs and systematic reviews reporting on the effectiveness of PSWs in these specific contexts. Thus, there exist opportunities for conducting RCTs in the described contexts.

The Conceptual Framework for the Effects of Peer Support Service

The conceptual framework is based on empirical evidence, suggesting that the impact of PSWs reflects upon the recipients of such a service [ 4 , 76 , 86 - 90 ], the global health system [ 22 , 47 , 76 , 86 , 91 , 92 ], and the PSWs themselves [ 13 , 28 , 76 , 93 ], as shown in Figure 1 . The framework has, therefore, been developed by authors through a general review of the literature that examines the effects of PSSs on patients, health care systems, and also PSWs themselves so as to provide evidence-based material supporting all possible effects of PSW roles.

Supportive social relationships can have a dual opposing effect on individuals’ lives, either as a family member or as social and professional networks through sharing their disappointments and pains or their joy and successes [ 11 ]. Useful roles for PSSs are identified in many studies. For example, adding 3 peer specialists to a team of 10 intensive case managers provided better QOL with greater satisfaction [ 12 ], stigma reduction, and less health service utilization [ 89 , 91 ]. The economic impact of PSSs has been extensively studied in the literature, concluding cost containment for the health care system in terms of reduction of readmission rates, emergency visits, and fewer hospital stays, which altogether substantially exceed the cost of running a peer support program [ 92 ]. Moreover, PSWs are looked at as providers of a service at a cheaper cost compared with other health care providers [ 94 , 95 ]. For example, about US $23,000 is paid to PSWs in the United States compared with around US $100,000 for a nurse practitioner [ 96 ]. However, a PSS is not posited as a substitute for clinical services, rather it is perceived as an intrapersonal and social service that provides a dual role of effective service and with humanizing care and support [ 14 , 26 , 97 ]. This role extends to cover PSWs themselves, in terms of improved overall well-being and self-confidence, reframing identity, and enhancing responsibility either toward themselves or their peers [ 13 , 93 ].

literature review example on mental health

Although PSWs can play a variety of tasks, managers who hire them may want to ensure that improving patient activation is included in their range of duties [ 48 ]. In 2 concurrent studies, a significant increase in QOL satisfaction, reduction of rehospitalization rates, and reduction in the number of hospital days were recorded when adding PSSs to usual care [ 22 , 98 ]. In another study engaging 31 peer providers in diverse mental health, agencies identified 5 broad domains of wellness, including foundational, emotional, growth and spiritual, social, and occupational wellness [ 4 ]. In a systematic literature review for people with SMIs, peer-navigator interventions and self-management were the most promising interventions [ 47 ]. PSWs’ effects are diversified through sharing in different contexts. For example, positive impacts on the physical health of their peers have been recorded [ 49 ]. Peer-based approaches have been used to deliver behavioral weight loss interventions [ 90 ]. For young students, structured peer support for depression may have benefits in improving students’ mental well-being [ 64 ]. In the case of crisis houses, greater satisfaction was achieved through a provided informal PSS [ 99 ]. Robust studies, therefore, recommend implementing peer support programs [ 10 , 18 ].

On the other hand, authors found that PSSs met moderate levels of evidence and that effectiveness varied across service types, for example, with “peers in existing clinical roles” was described as being less effective than the “peer staff added to traditional services” and “peer staff delivering structured curricula” [ 3 ]. Other reviews suggested that current evidence does not support recommendations or mandatory requirements from policy makers to offer programs for peer support [ 9 , 10 ].

Peer Support Workers’ Satisfaction and Challenges

PSWs experience different problems alongside their diverse job roles, including low pay, stigma, unclear work roles, alienation, struggling with skill deficits, lack of training opportunities, emotional stress in helping others, and, on top of that, maintaining their personal physical and mental health wellness [ 100 , 101 ]. Researchers found that PSWs experience discrimination and prejudice from nonpeer workers, in addition to the encountered difficulties of how to manage the transition from being a patient to a PSW. As a result, high attrition rates were noted among PSWs in mental health settings [ 102 , 103 ]. Peer job satisfaction is strongly dependent on several factors [ 100 , 104 , 105 ]. Role clarity and psychological empowerment, organizational culture, and working partnership with peers were the most significant predictors of PSW job satisfaction, while professional prejudice was not perceived as a significant predictor [ 106 , 107 ]. Other studies noted that the main problems were experiencing marginalization, lack of understanding, and a sense of exclusion [ 108 - 110 ]. Payment could also contribute to the amount of satisfaction of PSWs [ 76 ], as compensation helps through facilitation and engagement motivation [ 109 ]. Nevertheless, it seems that not the payment, which ranged from US $10 to US $20 per hour, but the lack of recognition and acknowledgment are the causes for job nonsatisfaction [ 104 ].

An interesting literature review grouped these challenges and barriers facing PSWs during fulfilling their assigned roles into 6 main categories: nature of the innovation, individual professional, service user, social context, organizational context, and economic and political contexts [ 111 ].

It is evident from the abovementioned information that the PSW role is challenged at multiple levels, including at the personal, societal, and organizational levels. These challenges have a direct bearing on PSW satisfaction, and the successful integration of the PSW role into the health care system depends to a great extent on how these challenges are overcome.

Novel Technology in Peer Support Service (Online and Telephone)

Online support groups are usually conducted through bulletin boards, emails, or live chatting software [ 28 ]. Online groups are familiar with people whose illnesses are similar to SMIs or affecting the body shape that have forced them to experience embarrassment and social stigmatization [ 23 , 24 ]. Therefore, they split from the social contexts and redirect toward novel ways of help, such as PSWs and online support groups, and web-based communities provided a suitable medium for people with SMIs by following and learning from their peers on the web, which positively helped them to fight against stigma, instilling hope and gaining insight and empowerment for better health control [ 25 ]. Increasingly, social media grew as a target for individuals with SMIs, such as schizophrenia, schizoaffective disorder, or bipolar disorder, seeking advice and supporting each other [ 112 - 114 ]. For someone with SMIs, the decision to reach out and connect with others typically occurs at a time of increased instability or when facing significant life challenges [ 115 ]. In a qualitative study, popular social media, such as YouTube, appeared useful for allowing people with SMIs to feel less alone, find hope, support each other, and share personal experiences and coping strategies with day-to-day challenges of living with mental illness through listening and posting comments [ 114 ]. Mobile phone–based peer support was found to be a feasible and acceptable way to the youngsters during their pregnancy as well as in the postpartum period [ 116 ]. In addition, when coupled with frequent face-to-face meetings with PSWs and with “text for support,” it could be of high value for patients with different mental illnesses [ 117 ]. Although online peer networks actively fight against discrimination and stigma, their accessibility to diverse patients’ sectors regarding their income and ethnicity is still questionable [ 25 ].

Future of Peer Support Services

Potential new roles, such as community health workers, peer whole health coaches, peer wellness coaches, and peer navigators, have been suggested for such a workforce [ 76 ]. They are described as an “ill-defined potential new layer of professionals” [ 118 ]. Through an initiative undertaken by SAMHSA via its “Bringing Recovery Supports to Scale Technical Assistance Center Strategy,” a successful identification of abilities and critical knowledge necessarily required for PSWs who provide help and support for those recovering from mental health and substance abuse was noted [ 76 ]. At present, peer support is seen as a growing paradigm in many countries, including the United Kingdom, Canada, New Zealand, France, and the Netherlands [ 103 , 119 ]. As an evolving culture, peer support has the opportunity to forge not just mental health system change but social change as well [ 37 ]. A novel peer support system termed “Edmonton peer support system” (EPSS) is currently being tested in a randomized controlled pilot trial [ 117 ]. In this study, investigators are evaluating the effectiveness of an innovative peer support program that incorporates leadership training, mentorship, recognition, and reward systems for PSWs, coupled with automated daily supportive text messaging, which has proven effectiveness in feasibility trials involving patients with depression and alcohol use disorders [ 120 , 121 ]. Previous studies have examined the effect of PSSs in different contexts, including outpatient departments [ 122 ], emergency departments [ 53 , 54 ], community mental health clinics [ 123 , 124 ], and inpatient sites [ 125 ]. On the contrary, the EPSS study focuses on patients who have been discharged from acute care hospitals. These patients are being randomized into 1 of the 4 main groups: enrollment in a peer support system, enrollment in a peer support system plus automated daily supportive and reminder text messages, enrollment in automated daily supportive and reminder text messages alone, or treatment as usual follow-up care. The research team hypothesizes that patients who are assigned to a peer support system plus automated daily supportive and reminder text messages will show the best outcome.

Organizations may facilitate peer support through their values, actions, and oversight [ 119 ] and through a robust supervision system with available educational access, which could be the adequate path for creating a positive and risk-free environment for PSWs throughout their complex workloads [ 126 ]. On the other hand, ethics committees play essential roles in the inclusion of PSWs in applied research studies by avoiding repetition of the work of other trusted agencies and considering the ethical validity of consent procedures for peer support interventions [ 127 ].

There is an internationally growing trend to adopt PSSs within addiction and mental health services, and despite the ongoing challenges, large sections of the current literature support the inclusion of the PSWs into the mental health care workforce. The literature suggests that the benefits of PSSs impact not only the recipients of mental health services but also extend to the PSWs and the whole health care system. Although the expected benefits of PSSs might be directly measured in terms of service utilization or patient improvement indicators, this could also extend to include wellness and empowerment for PSWs, who may still be fragile, vulnerable, and in need of ongoing acknowledgment and recognition. Thus, the potential for PSSs to be embedded into routine care and the opportunities for the development of innovative models of care for addiction and mental health patients such as the EPSS, which incorporates PSSs and supportive text messaging [ 117 ], are evidently a high valued priority. However, the feasibility and maintenance of a robust PSS in health care would only be possible through collaborative efforts and ongoing support and engagement from all health care practitioners, managers, and other stakeholders.

This literature review has several limitations. First, the review is not a systematic review or meta-analysis, and as such, there were no well-defined inclusion or exclusion criteria of studies, which potentially could lead to the exclusion of some essential related studies. Second, the search was conducted in English publications only. Consequently, there is a high probability of missing critical related publications published in non-English languages. Finally, as the review depended mainly on the available literature from the aforementioned sources, which showed marked variability in their design and covered diverse ideas under the central theme, the different weights for each idea throughout the review could be noted.

Acknowledgments

This work was supported by Douglas Harding Trust Fund and Alberta Health Services.

Conflicts of Interest

None declared.

  • Weiner DB. The apprenticeship of Philippe Pinel: a new document, 'observations of Citizen Pussin on the insane'. Am J Psychiatry 1979 Sep;136(9):1128-1134. [ CrossRef ] [ Medline ]
  • Chinman M, George P, Dougherty RH, Daniels AS, Ghose SS, Swift A, et al. Peer support services for individuals with serious mental illnesses: assessing the evidence. Psychiatr Serv 2014 Apr 1;65(4):429-441. [ CrossRef ] [ Medline ]
  • Penney D. Advocates for Human Potential. 2018. Defining 'Peer Support': Implications for Policy, Practice, and Research   URL: https:/​/www.​ahpnet.com/​AHPNet/​media/​AHPNetMediaLibrary/​White%20Papers/​DPenney_Defining_peer_support_2018_Final.​pdf [accessed 2019-03-30]
  • Moran GS, Russinova Z, Gidugu V, Yim JY, Sprague C. Benefits and mechanisms of recovery among peer providers with psychiatric illnesses. Qual Health Res 2012 Mar;22(3):304-319. [ CrossRef ] [ Medline ]
  • Clarke GN, Herinckx HA, Kinney RF, Paulson RI, Cutler DL, Lewis K, et al. Psychiatric hospitalizations, arrests, emergency room visits, and homelessness of clients with serious and persistent mental illness: findings from a randomized trial of two ACT programs vs. usual care. Ment Health Serv Res 2000 Sep;2(3):155-164. [ CrossRef ] [ Medline ]
  • Davidson L, Shahar G, Stayner DA, Chinman MJ, Rakfeldt J, Tebes JK. Supported socialization for people with psychiatric disabilities: lessons from a randomized controlled trial. J Commun Psychol 2004;32(4):453-477. [ CrossRef ]
  • O'Donnell M, Parker G, Proberts M, Matthews R, Fisher D, Johnson B, et al. A study of client-focused case management and consumer advocacy: the Community and Consumer Service Project. Aust N Z J Psychiatry 1999 Oct;33(5):684-693. [ CrossRef ] [ Medline ]
  • Solomon P, Draine J. The efficacy of a consumer case management team: 2-year outcomes of a randomized trial. J Ment Health Adm 1995;22(2):135-146. [ CrossRef ] [ Medline ]
  • Pitt V, Lowe D, Hill S, Prictor M, Hetrick SE, Ryan R, et al. Consumer-providers of care for adult clients of statutory mental health services. Cochrane Database Syst Rev 2013 Mar 28(3):CD004807. [ CrossRef ] [ Medline ]
  • Lloyd-Evans B, Mayo-Wilson E, Harrison B, Istead H, Brown E, Pilling S, et al. A systematic review and meta-analysis of randomised controlled trials of peer support for people with severe mental illness. BMC Psychiatry 2014 Feb 14;14:39 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Davidson L, Tondora J, Staeheli M, Martha C, Maria F, Jennifer M, et al. Recovery guides: an emerging model of community-based care for adults with psychiatric disabilities. In: Lightburn A, Sessions P, editors. Handbook Of Community-based Clinical Practice. London: Oxford University Press; 2005:476-501.
  • Felton CJ, Stastny P, Shern DL, Blanch A, Donahue SA, Knight E, et al. Consumers as peer specialists on intensive case management teams: impact on client outcomes. Psychiatr Serv 1995 Oct;46(10):1037-1044. [ CrossRef ] [ Medline ]
  • Beales A, Wilson J. Peer support – the what, why, who, how and now. J Ment Health Train Educ Prac 2015;10(5):314-324. [ CrossRef ]
  • MacNeil C, Mead S. A narrative approach to developing standards for trauma-informed peer support. Am J Eval 2016;26(2):231-244. [ CrossRef ]
  • Canadian Mental Health Association.: Canadian Mental Health Association, BC Division; 2007. Peer Support Guide: For Parents of Children or Youth with Mental Health Problems   URL: https://cmha.bc.ca/wp-content/uploads/2016/07/ParentPeerSupportGuide.pdf [accessed 2020-02-29]
  • Mood Disorders Association of Ontario. Family Matters Peer Support and Recovery Program   URL: https://www.mooddisorders.ca/family-matters-programs [accessed 2020-02-29]
  • Quinn J, Barrowclough C, Tarrier N. The Family Questionnaire (FQ): a scale for measuring symptom appraisal in relatives of schizophrenic patients. Acta Psychiatr Scand 2003 Oct;108(4):290-296. [ CrossRef ] [ Medline ]
  • Leggatt M, Woodhead G. Family peer support work in an early intervention youth mental health service. Early Interv Psychiatry 2016 Oct;10(5):446-451. [ CrossRef ] [ Medline ]
  • Mahomed F, Stein MA, Chauhan A, Pathare S. 'They love me, but they don't understand me': Family support and stigmatisation of mental health service users in Gujarat, India. Int J Soc Psychiatry 2019 Feb;65(1):73-79. [ CrossRef ] [ Medline ]
  • Davidson L, Rowe M. The Family-Run Executive Director Leadership Association (FREDLA). 5600 Fishers Ln, Rockville, MD 20857: The CMHS National GAINS Center; 2008 May. Peer Support within Criminal Justice Settings: The Role of Forensic Peer Specialists   URL: https://fredla.org/wp-content/uploads/2016/01/davidsonrowe_peersupport1.pdf [accessed 2020-03-01]
  • Short R, Woods-Nyce K, Cross SL, Hurst MA, Gordish L, Raia J. The impact of forensic peer support specialists on risk reduction and discharge readiness in a psychiatric facility: A five-year perspective. Int J Psychosoc Rehabil 2012;16(2):3-10 [ FREE Full text ]
  • Davidson L, Bellamy C, Guy K, Miller R. Peer support among persons with severe mental illnesses: a review of evidence and experience. World Psychiatry 2012 Jun;11(2):123-128 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Berger M, Wagner TH, Baker LC. Internet use and stigmatized illness. Soc Sci Med 2005 Oct;61(8):1821-1827. [ CrossRef ] [ Medline ]
  • Highton-Williamson E, Priebe S, Giacco D. Online social networking in people with psychosis: a systematic review. Int J Soc Psychiatry 2015 Feb;61(1):92-101. [ CrossRef ] [ Medline ]
  • Naslund JA, Aschbrenner KA, Marsch LA, Bartels SJ. The future of mental health care: peer-to-peer support and social media. Epidemiol Psychiatr Sci 2016 Apr;25(2):113-122 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Mead S, Hilton D, Curtis L. Peer support: a theoretical perspective. Psychiatr Rehabil J 2001;25(2):134-141. [ CrossRef ] [ Medline ]
  • Mental Health Foundation. Peer Support   URL: https://www.mentalhealth.org.uk/a-to-z/p/peer-support [accessed 2020-02-29]
  • Solomon P. Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatr Rehabil J 2004;27(4):392-401. [ CrossRef ] [ Medline ]
  • Davidson L, Chinman M, Sells D, Rowe M. Peer support among adults with serious mental illness: a report from the field. Schizophr Bull 2006 Jul;32(3):443-450 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Mead S. Intentional Peer Support: An Alternative Approach. West Chesterfield, NH: Intentional Peer Support; 2014.
  • Sunderland K, Mishkin W, Peer Leadership Group, Mental Health Commission of Canada. Mental Health Commission of Canada. 2013. Guidelines for the Practice and Training of Peer Support   URL: https://www.mentalhealthcommission.ca/sites/default/files/peer_support_guidelines.pdf.pdf [accessed 2020-02-29]
  • Peterson D. A Mad People’s History of Madness. Pittsburgh, PA: University Of Pittsburgh Press; 1981.
  • Shaw C. Together: A leading UK mental health charity. 2014. Peer Support in Secure Services: Final Report   URL: https:/​/www.​together-uk.org/​wp-content/​uploads/​downloads/​2014/​11/​Peer-Support-in-Secure-Settings-Final-Report-4-Nov-14.​pdf [accessed 2020-02-28]
  • Mead S. Defining Peer Support. 2003 Mar.   URL: http://164.156.7.185/parecovery/documents/DefiningPeerSupport_Mead.pdf [accessed 2020-02-29]
  • Ostrow L, Steinwachs D, Leaf PJ, Naeger S. Medicaid reimbursement of mental health peer-run organizations: results of a national survey. Adm Policy Ment Health 2017 Jul;44(4):501-511. [ CrossRef ] [ Medline ]
  • Stratford AC, Halpin M, Phillips K, Skerritt F, Beales A, Cheng V, et al. The growth of peer support: an international charter. J Ment Health 2019 Dec;28(6):627-632. [ CrossRef ] [ Medline ]
  • Mead S. Google Docs. PO Box 259, West Chesterfield, NH 03466: Intentional Peer Support; 2001. Peer Support as a Socio-Political Response to Trauma and Abuse   URL: https://docs.google.com/document/d/1trJ35i4dXX5AIWRnbg78OaT7-RfPE9_DbPm5kSST9_Q/edit [accessed 2020-02-28]
  • Wilson AM, Hutchinson M, Hurley J. Literature review of trauma-informed care: implications for mental health nurses working in acute inpatient settings in Australia. Int J Ment Health Nurs 2017 Aug;26(4):326-343. [ CrossRef ] [ Medline ]
  • Goetz SB, Taylor-Trujillo A. A change in culture: violence prevention in an acute behavioral health setting. J Am Psychiatr Nurses Assoc 2012;18(2):96-103. [ CrossRef ] [ Medline ]
  • Ashmore TR. Massey University. 2013. The Implementation of Trauma Informed Care in Acute Mental Health Inpatient Units: A Comparative Study   URL: https://mro.massey.ac.nz/bitstream/handle/10179/5855/02_whole.pdf [accessed 2020-02-29]
  • Brown VB, Harris M, Fallot R. Moving toward trauma-informed practice in addiction treatment: a collaborative model of agency assessment. J Psychoactive Drugs 2013;45(5):386-393. [ CrossRef ] [ Medline ]
  • Guay S, Tremblay N, Goncalves J, Bilodeau H, Geoffrion S. Effects of a peer support programme for youth social services employees experiencing potentially traumatic events: a protocol for a prospective cohort study. BMJ Open 2017 Jun 24;7(6):e014405 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Gillard SG, Edwards C, Gibson SL, Owen K, Wright C. Introducing peer worker roles into UK mental health service teams: a qualitative analysis of the organisational benefits and challenges. BMC Health Serv Res 2013 May 24;13:188 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Tookey P, Mason K, Broad J, Behm M, Bondy L, Powis J. From client to co-worker: a case study of the transition to peer work within a multi-disciplinary hepatitis c treatment team in Toronto, Canada. Harm Reduct J 2018 Aug 14;15(1):41 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Stastny P, Brown C. [Peer specialist: origins, pitfalls and worldwide dissemination]. Vertex 2013;24(112):455-459. [ Medline ]
  • Simpson A, Oster C, Muir-Cochrane E. Liminality in the occupational identity of mental health peer support workers: a qualitative study. Int J Ment Health Nurs 2018 Apr;27(2):662-671 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Cabassa LJ, Camacho D, Vélez-Grau CM, Stefancic A. Peer-based health interventions for people with serious mental illness: a systematic literature review. J Psychiatr Res 2017 Jan;84:80-89. [ CrossRef ] [ Medline ]
  • Chinman M, Oberman RS, Hanusa BH, Cohen AN, Salyers MP, Twamley EW, et al. A cluster randomized trial of adding peer specialists to intensive case management teams in the Veterans Health Administration. J Behav Health Serv Res 2015 Jan;42(1):109-121 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Druss BG, Zhao L, von Esenwein SA, Bona JR, Fricks L, Jenkins-Tucker S, et al. The Health and Recovery Peer (HARP) Program: a peer-led intervention to improve medical self-management for persons with serious mental illness. Schizophr Res 2010 May;118(1-3):264-270 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Chien W, Clifton AV, Zhao S, Lui S. Peer support for people with schizophrenia or other serious mental illness. Cochrane Database Syst Rev 2019 Apr 4;4:CD010880. [ CrossRef ] [ Medline ]
  • Reif S, Braude L, Lyman DR, Dougherty RH, Daniels AS, Ghose SS, et al. Peer recovery support for individuals with substance use disorders: assessing the evidence. Psychiatr Serv 2014 Jul;65(7):853-861. [ CrossRef ] [ Medline ]
  • Best DW, Lubman DI. The recovery paradigm - a model of hope and change for alcohol and drug addiction. Aust Fam Physician 2012 Aug;41(8):593-597. [ Medline ]
  • Watson DP, Brucker K, McGuire A, Snow-Hill NL, Xu H, Cohen A, et al. Replication of an emergency department-based recovery coaching intervention and pilot testing of pragmatic trial protocols within the context of Indiana's Opioid State Targeted Response plan. J Subst Abuse Treat 2020 Jan;108:88-94. [ CrossRef ] [ Medline ]
  • McGuire AB, Powell KG, Treitler PC, Wagner KD, Smith KP, Cooperman N, et al. Emergency department-based peer support for opioid use disorder: emergent functions and forms. J Subst Abuse Treat 2020 Jan;108:82-87. [ CrossRef ] [ Medline ]
  • Litt MD, Kadden RM, Kabela-Cormier E, Petry N. Changing network support for drinking: initial findings from the network support project. J Consult Clin Psychol 2007 Aug;75(4):542-555. [ CrossRef ] [ Medline ]
  • Barrenger SL, Hamovitch EK, Rothman MR. Enacting lived experiences: peer specialists with criminal justice histories. Psychiatr Rehabil J 2019 Mar;42(1):9-16. [ CrossRef ] [ Medline ]
  • Angell B, Matthews E, Barrenger S, Watson AC, Draine J. Engagement processes in model programs for community reentry from prison for people with serious mental illness. Int J Law Psychiatry 2014;37(5):490-500 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Thomas K, Wilson JL, Bedell P, Morse DS. 'They didn't give up on me': a women's transitions clinic from the perspective of re-entering women. Addict Sci Clin Pract 2019 Apr 2;14(1):12 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Kim SH. [Effects of a volunteer-run peer support program on health and satisfaction with social support of older adults living alone]. J Korean Acad Nurs 2012 Aug;42(4):525-536. [ CrossRef ] [ Medline ]
  • Chapin RK, Sergeant JF, Landry S, Leedahl SN, Rachlin R, Koenig T, et al. Reclaiming joy: pilot evaluation of a mental health peer support program for older adults who receive Medicaid. Gerontologist 2013 Apr;53(2):345-352. [ CrossRef ] [ Medline ]
  • Ahmed SM, Palermo AS. Community engagement in research: frameworks for education and peer review. Am J Public Health 2010 Aug;100(8):1380-1387. [ CrossRef ] [ Medline ]
  • Student Minds. 2014. Grand Challenges in Student Mental Health   URL: https://www.studentminds.org.uk/uploads/3/7/8/4/3784584/grand_challenges_report_for_public.pdf [accessed 2020-02-29]
  • Davies EB, Wardlaw J, Morriss R, Glazebrook C. An experimental study exploring the impact of vignette gender on the quality of university students' mental health first aid for peers with symptoms of depression. BMC Public Health 2016 Feb 25;16:187 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Byrom N. An evaluation of a peer support intervention for student mental health. J Ment Health 2018 Jun;27(3):240-246. [ CrossRef ] [ Medline ]
  • Lubman DI, Cheetham A, Jorm AF, Berridge BJ, Wilson C, Blee F, et al. Australian adolescents' beliefs and help-seeking intentions towards peers experiencing symptoms of depression and alcohol misuse. BMC Public Health 2017 Aug 16;17(1):658 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Sokol R, Fisher E. Peer support for the hardly reached: a systematic review. Am J Public Health 2016 Jul;106(7):e1-e8. [ CrossRef ] [ Medline ]
  • Fortuna KL, DiMilia PR, Lohman MC, Bruce ML, Zubritsky CD, Halaby MR, et al. Feasibility, acceptability, and preliminary effectiveness of a peer-delivered and technology supported self-management intervention for older adults with serious mental illness. Psychiatr Q 2018 Jun;89(2):293-305 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Whiteman KL, Naslund JA, DiNapoli EA, Bruce ML, Bartels SJ. Systematic review of integrated general medical and psychiatric self-management interventions for adults with serious mental illness. Psychiatr Serv 2016 Nov 1;67(11):1213-1225 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Pathare S, Shields LS. Supported decision-making for persons with mental illness: a review. Pub Health Rev 2012;34(15). [ CrossRef ]
  • Mahomed F, Stein MA, Patel V. Involuntary mental health treatment in the era of the United Nations Convention on the Rights of Persons with Disabilities. PLoS Med 2018 Oct;15(10):e1002679 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Morrissey F. The United Nations Convention on the Rights of Persons with Disabilities: a new approach to decision-making in mental health law. Eur J Health Law 2012 Dec;19(5):423-440. [ CrossRef ] [ Medline ]
  • Szmukler G. 'Capacity', 'best interests', 'will and preferences' and the UN Convention on the Rights of Persons with Disabilities. World Psychiatry 2019 Feb;18(1):34-41 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Jeste DV, Eglit GM, Palmer BW, Martinis JG, Blanck P, Saks ER. Supported decision making in serious mental illness. Psychiatry 2018;81(1):28-40 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Craigie J. A fine balance: reconsidering patient autonomy in light of the UN convention on the rights of persons with disabilities. Bioethics 2015 Jul;29(6):398-405. [ CrossRef ] [ Medline ]
  • Henderson JL, Cheung A, Cleverley K, Chaim G, Moretti ME, de Oliveira C, et al. Integrated collaborative care teams to enhance service delivery to youth with mental health and substance use challenges: protocol for a pragmatic randomised controlled trial. BMJ Open 2017 Feb 6;7(2):e014080 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Gagne CA, Finch WL, Myrick KJ, Davis LM. Peer workers in the behavioral and integrated health workforce: opportunities and future directions. Am J Prev Med 2018 Jun;54(6 Suppl 3):S258-S266 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Smith R, Greenwood N. The impact of volunteer mentoring schemes on carers of people with dementia and volunteer mentors: a systematic review. Am J Alzheimers Dis Other Demen 2014 Feb;29(1):8-17. [ CrossRef ] [ Medline ]
  • Huang L, Stroul B, Friedman R, Mrazek P, Friesen B, Pires S, et al. Transforming mental health care for children and their families. Am Psychol 2005 Sep;60(6):615-627. [ CrossRef ] [ Medline ]
  • Hogan MF. The President's New Freedom Commission: recommendations to transform mental health care in America. Psychiatr Serv 2003 Nov;54(11):1467-1474. [ CrossRef ] [ Medline ]
  • Singla DR, Kumbakumba E, Aboud FE. Effects of a parenting intervention to address maternal psychological wellbeing and child development and growth in rural Uganda: a community-based, cluster randomised trial. Lancet Glob Health 2015 Aug;3(8):e458-e469 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM, Members of the MIRA Makwanpur trial team. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 2004;364(9438):970-979. [ CrossRef ] [ Medline ]
  • Balaji M, Andrews T, Andrew G, Patel V. The acceptability, feasibility, and effectiveness of a population-based intervention to promote youth health: an exploratory study in Goa, India. J Adolesc Health 2011 May;48(5):453-460 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Tripathy, Nair N, Barnett S, Mahapatra R, Borghi J, Rath S, et al. Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial. Lancet 2010 Apr 3;375(9721):1182-1192 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Jordans MJ, Aldridge L, Luitel NP, Baingana F, Kohrt BA. Evaluation of outcomes for psychosis and epilepsy treatment delivered by primary health care workers in Nepal: a cohort study. Int J Ment Health Syst 2017;11:70 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Kohrt B, Asher L, Bhardwaj A, Fazel M, Jordans M, Mutamba B, et al. The role of communities in mental health care in low- and middle-income countries: a meta-review of components and competencies. Int J Environ Res Public Health 2018 Jun 16;15(6):pii: E1279 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Arnold I. Workplace Strategies for Mental Health. 2005. Peer Support Programs   URL: https://www.workplacestrategiesformentalhealth.com/job-specific-strategies/peer-support-programs [accessed 2020-02-29]
  • Bartels SJ, DiMilia PR, Fortuna KL, Naslund JA. Integrated care for older adults with serious mental illness and medical comorbidity: evidence-based models and future research directions. Psychiatr Clin North Am 2018 Mar;41(1):153-164 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Bates A, Kemp V, Isaac M. Peer support shows promise in helping persons living with mental illness address their physical health needs. Can J Commun Ment Health 2008;27(2):21-36. [ CrossRef ]
  • Hardy S, Hallett N, Chaplin E. Evaluating a peer support model of community wellbeing for mental health: a coproduction approach to evaluation. Ment Health Prev 2019;13(7):149-158 [ FREE Full text ] [ CrossRef ]
  • Cabassa LJ, Stefancic A, O'Hara K, El-Bassel N, Lewis-Fernández R, Luchsinger JA, et al. Peer-led healthy lifestyle program in supportive housing: study protocol for a randomized controlled trial. Trials 2015 Sep 2;16:388 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Repper J, Carter T. A review of the literature on peer support in mental health services. J Ment Health 2011 Aug;20(4):392-411. [ CrossRef ] [ Medline ]
  • Fisher EB, Coufal MM, Parada H, Robinette JB, Tang PY, Urlaub DM, et al. Peer support in health care and prevention: cultural, organizational, and dissemination issues. Annu Rev Public Health 2014;35:363-383. [ CrossRef ] [ Medline ]
  • MacLellan J, Surey J, Abubakar I, Stagg HR. Peer support workers in health: a qualitative metasynthesis of their experiences. PLoS One 2015;10(10):e0141122 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Fisher EB, Boothroyd RI, Coufal MM, Baumann LC, Mbanya JC, Rotheram-Borus MJ, et al. Peer support for self-management of diabetes improved outcomes in international settings. Health Aff (Millwood) 2012 Jan;31(1):130-139 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Singh P, Chokshi DA. Community health workers--a local solution to a global problem. N Engl J Med 2013 Sep 5;369(10):894-896. [ CrossRef ] [ Medline ]
  • Kangovi S, Long JA, Emanuel E. Community health workers combat readmission. Arch Intern Med 2012 Dec 10;172(22):1756-1757. [ CrossRef ] [ Medline ]
  • Fisher EB, Ayala GX, Ibarra L, Cherrington AL, Elder JP, Tang TS, Peers for Progress Investigator Group. Contributions of peer support to health, health care, and prevention: papers from peers for progress. Ann Fam Med 2015 Aug;13(Suppl 1):S2-S8 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Tondora J, O'Connell M, Miller R, Dinzeo T, Bellamy C, Andres-Hyman R, et al. A clinical trial of peer-based culturally responsive person-centered care for psychosis for African Americans and Latinos. Clin Trials 2010 Aug;7(4):368-379 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Sweeney A, Fahmy S, Nolan F, Morant N, Fox Z, Lloyd-Evans B, et al. The relationship between therapeutic alliance and service user satisfaction in mental health inpatient wards and crisis house alternatives: a cross-sectional study. PLoS One 2014;9(7):e100153 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Mancini MA. An exploration of factors that effect the implementation of peer support services in community mental health settings. Community Ment Health J 2018 Feb;54(2):127-137. [ CrossRef ] [ Medline ]
  • Ahmed AO, Hunter KM, Mabe AP, Tucker SJ, Buckley PF. The professional experiences of peer specialists in the Georgia Mental Health Consumer Network. Community Ment Health J 2015 May;51(4):424-436. [ CrossRef ] [ Medline ]
  • Walker G, Bryant W. Peer support in adult mental health services: a metasynthesis of qualitative findings. Psychiatr Rehabil J 2013 Mar;36(1):28-34. [ CrossRef ] [ Medline ]
  • Villani M, Kovess-Masféty V. [Peer support programs in mental health in France: Status report and challenges]. Encephale 2018 Nov;44(5):457-464. [ CrossRef ] [ Medline ]
  • Cronise R, Teixeira C, Rogers ES, Harrington S. The peer support workforce: results of a national survey. Psychiatr Rehabil J 2016 Sep;39(3):211-221. [ CrossRef ] [ Medline ]
  • Corrigan PW, Kosyluk KA, Rüsch N. Reducing self-stigma by coming out proud. Am J Public Health 2013 May;103(5):794-800. [ CrossRef ] [ Medline ]
  • Davis JK. Predictors of job satisfaction among peer providers on professional treatment teams in community-based agencies. Psychiatr Serv 2013 Feb 1;64(2):181-184. [ CrossRef ] [ Medline ]
  • Clossey L, Solomon P, Hu C, Gillen J, Zinn M. Predicting job satisfaction of mental health peer support workers (PSWs). Soc Work Ment Health 2018;16(6):682-695. [ CrossRef ]
  • Kemp V, Henderson AR. Challenges faced by mental health peer support workers: peer support from the peer supporter's point of view. Psychiatr Rehabil J 2012;35(4):337-340. [ CrossRef ] [ Medline ]
  • Greer AM, Amlani A, Burmeister C, Scott A, Newman C, Lampkin H, et al. Peer engagement barriers and enablers: insights from people who use drugs in British Columbia, Canada. Can J Public Health 2019 Apr;110(2):227-235 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Clossey L, Gillen J, Frankel H, Hernandez J. The experience of certified peer specialists in mental health. Soc Work Ment Health 2015;14(4):408-427. [ CrossRef ]
  • Vandewalle J, Debyser B, Beeckman D, Vandecasteele T, Van Hecke A, Verhaeghe S. Peer workers' perceptions and experiences of barriers to implementation of peer worker roles in mental health services: A literature review. Int J Nurs Stud 2016 Aug;60:234-250. [ CrossRef ] [ Medline ]
  • Gowen K, Deschaine M, Gruttadara D, Markey D. Young adults with mental health conditions and social networking websites: seeking tools to build community. Psychiatr Rehabil J 2012;35(3):245-250. [ CrossRef ] [ Medline ]
  • Miller BJ, Stewart A, Schrimsher J, Peeples D, Buckley PF. How connected are people with schizophrenia? Cell phone, computer, email, and social media use. Psychiatry Res 2015 Feb 28;225(3):458-463. [ CrossRef ] [ Medline ]
  • Naslund JA, Grande SW, Aschbrenner KA, Elwyn G. Naturally occurring peer support through social media: the experiences of individuals with severe mental illness using YouTube. PLoS One 2014;9(10):e110171 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Perry BL, Pescosolido BA. Social network activation: the role of health discussion partners in recovery from mental illness. Soc Sci Med 2015 Jan;125:116-128 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Chyzzy B, Dennis C. 16. Mobile phone-based peer support in the prevention of postpartum depression among adolescent mothers: a pilot randomized controlled trial. J Adolesc Health 2019;64(2):S8-S9. [ CrossRef ]
  • Urichuk L, Hrabok M, Hay K, Spurvey P, Sosdjan D, Knox M, et al. Enhancing peer support experience for patients discharged from acute psychiatric care: protocol for a randomised controlled pilot trial. BMJ Open 2018 Aug 17;8(8):e022433 [ FREE Full text ] [ CrossRef ] [ Medline ]
  • Hurley J, Cashin A, Mills J, Hutchinson M, Graham I. A critical discussion of Peer Workers: implications for the mental health nursing workforce. J Psychiatr Ment Health Nurs 2016 Mar;23(2):129-135. [ CrossRef ] [ Medline ]
  • Burke EM, Pyle M, Machin K, Morrison AP. Providing mental health peer support 1: A Delphi study to develop consensus on the essential components, costs, benefits, barriers and facilitators. Int J Soc Psychiatry 2018;64(8):799-812. [ CrossRef ]
  • Agyapong VI, Juhás M, Mrklas K, Hrabok M, Omeje J, Gladue I, et al. Randomized controlled pilot trial of supportive text messaging for alcohol use disorder patients. J Subst Abuse Treat 2018 Nov;94:74-80. [ CrossRef ] [ Medline ]
  • Agyapong VI, Ahern S, McLoughlin DM, Farren CK. Supportive text messaging for depression and comorbid alcohol use disorder: single-blind randomised trial. J Affect Disord 2012 Dec 10;141(2-3):168-176. [ CrossRef ] [ Medline ]
  • Gill K. New Moves: Targeting physical and mental illness well-being in people with mental illness. Health Issues J 2012;108(1):18-23 [ FREE Full text ] [ CrossRef ]
  • Martin M, Martin SL. Healthy Amistad: improving the health of people with severe mental illness. Issues Ment Health Nurs 2014 Oct;35(10):791-795. [ CrossRef ] [ Medline ]
  • Lorig K, Ritter PL, Pifer C, Werner P. Effectiveness of the chronic disease self-management program for persons with a serious mental illness: a translation study. Community Ment Health J 2014 Jan;50(1):96-103. [ CrossRef ] [ Medline ]
  • Bouchard L, Montreuil M, Gros C. Peer support among inpatients in an adult mental health setting. Issues Ment Health Nurs 2010 Sep;31(9):589-598. [ CrossRef ] [ Medline ]
  • Hurley J, Cashin A, Mills J, Hutchinson M, Kozlowski D, Graham I. Qualitative study of peer workers within the 'Partners in Recovery' programme in regional Australia. Int J Ment Health Nurs 2018 Feb;27(1):187-195. [ CrossRef ] [ Medline ]
  • Simmons D, Bunn C, Nakwagala F, Safford MM, Ayala GX, Riddell M, et al. Challenges in the ethical review of peer support interventions. Ann Fam Med 2015 Aug;13(Suppl 1):S79-S86 [ FREE Full text ] [ CrossRef ] [ Medline ]

Abbreviations

Edited by J Torous; submitted 21.07.19; peer-reviewed by F Mahomed, K Machin; comments to author 27.07.19; revised version received 06.09.19; accepted 15.02.20; published 09.06.20

©Reham A Hameed Shalaby, Vincent I O Agyapong. Originally published in JMIR Mental Health (http://mental.jmir.org), 09.06.2020.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Mental Health, is properly cited. The complete bibliographic information, a link to the original publication on http://mental.jmir.org/, as well as this copyright and license information must be included.

REVIEW article

Factors that predispose undergraduates to mental issues: a cumulative literature review for future research perspectives.

\nPierpaolo Limone

  • Learning Science Hub, University of Foggia, Foggia, Italy

Distress and mental health issues among college students is an emerging topic of study. The aim of this research work is to illustrate academic and social risk factors and how they prove to be predictors of anxiety and depressive disorders. The methodology used is a cumulative literature review structured over 10 systematic phases, and is replicable. Showing considerable potential for cumulative research, the relevance of this study reflects the concern of the academic community and international governments. The articles selected range from categorization of disorders in relation to mental health, to reporting the condition of rhinestones and difficulties of students in university contexts. In conclusion, the research focusses upon predisposing, concurrent or protective factors relating to the mental health of university students, so that institutions can act on concrete dynamics or propose targeted research on this topic.

Introduction

Mental health and mental health-related issues have been a matter of concern for quite a long time earning little regard and interest from the respective healthcare facilities and systems. Governments have put inadequate measures to ensure that citizens' mental challenges are handled rightfully to achieve high levels of mentally healthy people. The perpetuated issue has also developed in various sectors of society. The current situation in a learning institution is worth raising eyebrows, and therefore it deserves serious attention. Most of the undergraduate students and yet to graduate college students depict high levels of mental illness among the students, thus, depicting discomfort of the students and the level of neglect the health sector is faced with. The majority of today's people who are suffering from mental issues in society constitute college and university students ( 1 ). College students endorse high rates of mental health problems. While many colleges offer on-campus services, many students who could benefit from mental health services do not receive car. Indeed, nearly half of students who screen positive for depression, for example, do not receive treatment ( 2 ).

Adverse consequences are synonymous with undergraduate students with mental distress. The victims are likely to experience challenges such as impaired functioning in cognition, substance abuse, poor performance in their school work, and learning disabilities. They are likely to abuse drugs such as tobacco, alcohol, cigarette smoking, and other hard drugs that impair normal body functioning ( 3 ). Most of these drugs are associated with various risk behaviors, depression, and anxiety ( 3 ). This suggests that emotional discomfort raises the likelihood of developing additional mental health issues. For this reason, the prevalence of mental illnesses among university students is higher compared to people in other environments. The situation is almost similar in most colleges since they are predisposed to similar conditions and forms of livelihood. This inherent condition puts the future generation, which is inherently composed of the schooling individuals, at more risk in line with mental health and other health conditions that may arise due to the mental disorders.

Several factors have contributed to the mental distress and discomfort associated with undergraduates. For instance, sex has a significant contribution to the mental illnesses that people experience in learning institutions. The prevalence of the conditions tends to be a notch higher among female students than male students ( 4 ). Some students lack interest in fieldwork which affects their mental health in the long run. Introvert students are also more likely to fall victims and students who face various social challenges such as poverty ( 4 ). Most of the learning institutions have tight schedules and continuous sequences of study, which affects the students' performance and their mental well-being. Challenges and the predisposing factors that affect the students are bound to result from their school environment or their history; therefore, the growth environment and interaction play a significant role in determining one's health. Some of the predisposing factors are avoidable, while others are accustomed and tied to the students. Therefore, it is prudent to come up with measures to ensure control and regulation of the inherent situation of the undergraduate students who make up the future and continuity of our current society.

Common Mental Illnesses Among Undergraduates

Undergraduate students face many mental issues; however, the prevalence of some of the health conditions is a bit higher than others. Experts and researchers use terminology like “crisis” and “epidemic” to describe American college student's mental health issues today. Mood disruptions are only one of the many mental health problems that college students face. Suicide, addiction, and eating disorders are examples of significant issues ( 5 ). Although mental health specialists emphasize the need to talk about such concerns, students often regard these pressures as a typical livelihood in learning institutions. In other circumstances, individuals may be unable to seek help due to a lack of time, energy, will, or financial resources ( 5 ). It is, therefore, a challenge in coming up with a satisfactory solution to the challenges of problems. Drawing the students' goodwill and desire to have their mental issues fixed is also a challenge as some of them may feel shy or mentally healthy, and that there is no need to go through medication. Similarly, identifying the deserving students and coming up with radical measures to satisfactorily come up with a solution is also challenging since acquiring the required resources is quite expensive. However, solving the problem is arguably easy through addressing some of the major health conditions that most undergraduate students experience.

Below, we investigate some of the most common mental illnesses among college students, such as depression, anxiety, suicidal thoughts, eating disorders, and addiction.

Depression is a widespread chronic medical illness that can affect thoughts, mood, and physical health. It is characterized by low mood, lack of energy, sadness, insomnia, and an inability to enjoy life ( 6 ). Victims of the condition tend to develop varying episodes of discomfort and displeasure that destruct them from their normative activities. Students may grow poor performance and the inability to fit in with their schoolmates in co-curricular and curriculum activities. According to the ACHA's 2018 poll, 40% of American students had at least one significant depressive episode that same year ( 5 ). A person may also feel sad, hopeless, powerless, and get overwhelmed with life situations and challenges that one may be facing. Trouble in completing assignments, challenges in paying attention, and reading are also synonymous with depression among undergraduates ( 5 ). It might be challenging to spot these concerns in others since students often minimize or refuse to discuss issues that are bothering them.

In ICD-10, Generalized anxiety disorder includes anxiety neurosis, anxiety reaction, and anxiety state, but excludes neurasthenia. ICD-10 also proposes diagnostic criteria for research: (i) at least 6 months with prominent tension, worry, and feelings of apprehension about everyday events and problems; and (ii) at least four symptoms out of a list of 22 items, of which at least one item is from a list of four items of autonomic arousal (palpitations/accelerated heart rate, sweating, trembling/shaking, dry mouth).

Anxiety was identified as a significant student mental disorder by 61 percent of survey respondents in the University of Pennsylvania study published by Locke et al. ( 7 ). Anxiety disorder symptoms are frequently misdiagnosed as everyday stress or dismissed as someone overly concerned. Panic attacks might be misinterpreted as a medical ailment, like a tension headache or heart attack, depending on how your body responds to high amounts of specific chemicals ( 7 ). Since each person's symptoms present differently, what sighs the existence of anxiety to one person may not be similar in another ( 7 ). Consequently, the causes of anxiety differ from one person to another; however, some causes are common among campus students. For instance, stress, life experiences, genetics, and brain chemicals commonly cause anxiety in people ( 7 ). It, therefore, requires adequate measures of utmost keenness to ensure that the condition gets eliminated from the learners' livelihood.

The APA defines completed suicide as a self-injurious act that results in death and attempted suicide as a non-fatal, self-inflicted, potentially harmful act that is intended to result in death but may or may not result in injury ( 8 ).

Approximately 20% of university students in the United States were reported to be suicidal in 2018 ( 9 ). Therefore, it implies that the mental condition is rampant and makes up one of the major mental illnesses common among American students. According to the Los Angeles Times' Healstaff ( 10 ) report, teenagers and young adults record the highest suicide cases in America. Since the population inherently dominates the composition of the universities, it insinuates that undergraduate students register the highest number of suicide cases. Many students experience dissatisfaction and doubt, but these feelings can spiral out of control, leading some to consider suicide seriously. Suicidal ideation manifests itself in a variety of ways. Speech, temperament, and behavior are all examples of common warning indicators ( 10 ). Persons may describe themselves as stuck, burdening others, as if they have no reason to live and have no purpose to live. Suicidal ideation causes a wide range of emotions: anxiety, impatience, loss of interest in previously appreciated activities, shame, rage, and melancholy ( 11 ). People may engage in certain activities, such as giving up valued items, withdrawing from family and friends, unexpectedly visiting someone to say bye, and searching the internet for ways to commit suicide ( 11 ). They also may sleep poorly or excessively, act rashly, show anger, and increase their drug and alcohol use ( 11 ). Whenever one is seen with the symptoms, a bold and patient approach should help the victim seek medical attention from a psychiatrist and facilitate the healing process.

Eating disorders are a group of illnesses characterized by significant changes in one's eating habits and a preoccupation with a person's shape or body. Eating disorders (EDs), including anorexia nervosa, bulimia nervosa, and binge-eating disorder, constitute a class of common and deadly psychiatric disorders ( 12 ). The health conditions can entail binge eating and deprivation of food, which sometimes results in purging. According to 2018 estimates from the National Eating Disorders Association, 10–20% of female college students suffer from an eating disorder, with rates continuing to grow ( 13 ). Male students have a lower incidence rate of 4–10% ( 13 ). The typical eating disorders among undergraduates include bulimia nervosa, anorexia nervosa, and binge eating disorder. Emaciation is a specific symptom of anorexia nervosa, characterized by an excessive preoccupation with thinness, a disordered body image, and anxieties about gaining weight ( 14 ). Constant desires that occur at any time of day and lead to binge eating characterize binge eating disorder ( 14 ). This condition is frequently linked to low self-esteem and a negative body image. Bulimia nervosa is a form of binge eating condition characterized by recurrent and frequent bouts of eating abnormally large amounts of food, followed by compensatory behaviors such as purging, fasting, or excessive exercise ( 14 ). The symptoms and indications of eating preconditions differ from person to person and condition to condition, and many are dependent on the mental state of the person suffering from the problem ( 14 ). Many college students fail to seek treatment for their eating disorders since they do not have an awareness that they have one.

Alcohol and recreational substances are commonly used by college students, which can be troublesome ( 15 ). Addiction is a psychological or physical dependency pattern on one or more substances, characterized by strong cravings and substance abuse despite knowing risks and consequences ( 16 ). Alcohol is the leading cause of many disorders and deaths for campus students, while some abuse drugs to induce their studying habits ( 17 ). The recreational activities that undergraduates use alcohol and other drugs for result in addiction which causes many diseases. Besides alcohol, students also abuse marijuana, cocaine, ecstasy, and benzodiazepines ( 17 ). The dire need and desire to abuse drugs for various purported gains may lead to health complications resulting in death and body organs' failure.

Mental Illness Prevalence Among Undergraduates

Mental health disorders are common among students, with a higher incidence than in the general population. Statistically, more than half of the students in American public universities suffer from depression and anxiety ( 18 ). Similarly, a poll of undergraduate students at Coventry University in the United Kingdom found that many students had suffered mental health disorders such as anxiety and depression in 2006 ( 19 ). Maser et al. ( 20 ) showed that the prevalence of mental health disorders such as anxiety and depression cases are a notch higher in medical school compared to the general non-student community of the same age, which supports these findings. Over the last two decades, these investigations have shown that the frequency of Seasonal Affective Disorder (SAD) amongst students has remained more significant than the general population.

SAD is not only common, but it is also persistent among students. Zivin et al. ( 18 ) found that more than half of students maintain their higher anxiety and sadness over time by performing a 2-year follow-up survey research and study of students. This phenomenon could be related to a lack of SAD therapy or the persistence of pre-existing risk factors.

Methodology

The cumulative literature review, a new and rigorous research method, is divided into 10 phases ( 21 ):

1. Selection of key concepts (especially of independent and dependent variables and the relationships between them).

2. Creation of a search string (in addition to selecting the keywords, it is necessary to include and exclude the studies found through the criteria used). The final goal of this phase of the research is to find a manageable number of studies through the following procedure: (1) query two or three search engines or databases; (2) use keywords in combination with “and/or”; (3) use filters to manage the enormity of the results (comparison with a second researcher as in this study would be desirable).

3. Export of the results from the databases and a merging of all the transcribed results in the form of a bibliography on a single worksheet.

4. Selection of primary sources by eliminating duplicates and excluding irrelevant studies based on titles. This step is necessary to create a separate list of systematic reviews on the topic. It is also essential for drawing up a list of the individual choices of the cumulative review.

5. Verification of the secondary bibliography, by checking the bibliographies of all the included studies. Studies that cite primary sources, such as other systematic reviews on the topic, must therefore be included under the studies not found in the initial search.

6. Data extraction (produced by the reviewers' work), in which the characteristics of the selected studies are extrapolated. These characteristics include key variables, type of research project, context, results, year of publication, etc. The exclusion criteria are also cumulative; i.e., they are formulated on the basis of the time available and the studies retrieved from the databases.

7. Updating of the results on the basis of recent publications, which may prompt an update regarding the initial work carried out. This must be done before the conclusion of the cumulative review.

8. Verification by the second reviewer, who checks the included studies.

9. Writing of the last phase of the report.

10. Exercising due care in the publicization of the revision. This involves making the data collection work explicit within the format of the paper: keywords, extracted data, results, etc.

Each phase is illustrated below, retracing the steps taken to carry out the cumulative review, in order to make the study replicable.

In this study, research, which was based on the cumulative literature review model, followed the ten-phase model set out in the previous paragraph. Specifically, the following keywords were selected: mental disease, risk factors, university, students (phase 1). Scopus, WoS and Google Scholar were selected as search engines. The search yielded 797 results that were selected, based on comparison by researchers, using the following inclusion-exclusion criteria: inclusion of all literature reviews in the 2011–2020 period, related studies on risk factors toward mental disorders of university students (phase 2), with exclusion based on primary source titles. The raw research data was transcribed on a spreadsheet, in order to enable a global view of the studies located and to start the selection work (phase 3). The file was “cleaned up,” in order to remove duplicate contributions and create a second list of systematic reviews of the literature ( n = 4), one book, and one book chapter (phase 4). In the first file named “primary sources,” significant studies were selected and placed based on the title. The cleaned file contained n = 33 papers. For the second file containing the systematic reviews of the literature, the secondary bibliography included was consulted, and the studies already present in the first file of the present research were eliminated. In this case, 67% of the studies had already been identified in the comparison of the cumulative literature reviews. It would be desirable to build a reliability index of the cumulative review that took into account this value, i.e., the degree of replicability of the systematic studies already conducted (phase 5). Construction of a grid ( Table 1 ) was carried out, using the results of the research and data extraction by the researchers who analyzed the key variables (key variables, type of research project, context, results, year of publication, etc.), by selecting as reported in the table, only the fields relevant to the research (phase 6). The research carried out in the first months of 2021 has been updated with more recent publications that have introduced a surveys studies of mental illness among university students (effects of the COVID emergency in terms of physical, cognitive and relational consequences). On the basis of the inclusion-exclusion criteria, other ( n = 2) papers were included (phase 7). The complete file, containing the studies considered significant for the purposes of the construction of this work, was analyzed by the second researcher, in order to avoid errors in the research (phase 8). Steps 9 and 10 resulted in the production of this research paper.

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Table 1 . Summary of the results.

It is clear from the selected articles that the idea present in the introduction is confirmed: the highest number of studies were on mental disorders, as well as on alimentary disorders. On the contrary, technology and other new addictions among university students are still little studied. They were therefore excluded from this study ( Table 1 ).

Risk Factors

From the analysis of the literature, several risk factors emerge that are involved in the development of mental problems in students. In particular, it is possible to classify the main factors in: academic factors, social factors, psychological risk factors, lifestyle factors and physiological factors.

Among the academic factors, the inverse correlation between time spent in study and poor results emerges. Academic results are, in fact, correlated with job placement and other higher education programs. It follows that, at times, this can be detrimental to students' mental health. In addition, elements such as loneliness and social isolation can often induce worry and melancholic states that play a major role in learning. One example is the pandemic situation that has forced millions of students into a scarcity of relationships for a very long time. Additional pivotal factors are those of a psychological nature: disappointments, stress, and perceived anxiety can have a major impact on academic performance; in addition, abuse and mistreatment negatively affect cognitive, emotional, and social development.

The period of change characterized by entry into college often involves changes in lifestyle as well: there may be a tendency to increase intake of drugs, alcohol, and various substances that, if abused, can alter functioning patterns. One of the pivotal factors, however, is the biological makeup of the individual: genetic history and health status have high implications in mental health.

Academics Factors

SAD can get caused by a variety of university-related academic pressures. The degree's subject is one of these strongly prevalent factors. When compared to their non-medical colleagues, nursing, medical and health-related students have a greater prevalence of depression and anxiety ( 23 ). Medical and nursing students, who have both theoretical and patient-related responsibilities, typically have an enormous workload among undergrads and, as a result, experience higher anxiety and despair ( 24 ). Furthermore, students majoring in psychology and philosophy, like medical and nursing students, are more likely than others to acquire depression during their studies ( 34 ). Medical and nursing students who work with people's health may develop melancholy and anxiety due to their worries about making mistakes that could hurt them or their patients ( 23 ). Students whose degrees include practical components may travel to new locations for fieldwork and job experience, adding to their anxiety and stress ( 23 ). However, it's essential to determine whether students with underlying mental health issues are more prone to pick disciplines like philosophy or psychology or subjects that lead to caring careers like nursing and medicine.

Furthermore, some prospective students, particularly those studying nursing and medical, often lack explicit knowledge of the workload and curriculum associated with their field of study before enrolling in university, and as a result, they may become disillusioned once they begin their studies ( 23 ). It's worth noting that not all research discovered a link between the study's subject and the development of SAD ( 35 ). Variances can explain this phenomenon in sample type and size, resulting in disparities in workload and curriculum, such as courses taught in different universities across the world.

Studying for a degree at the university level can be a challenging endeavor that necessitates mental work. Mastery of the subject has been shown to negatively affect anxiety, self-esteem, and depression among college and university students, with those who have a mastery of the subject displaying less stress and anxiety ( 32 ). Additionally, students studying in a foreign environment where there is a use of a non-native language sigh high levels of anxiety and sadness during their freshman year, with their stress levels decreasing with time ( 32 ). This is due to the fact that students studying in a foreign language are typically people who have moved abroad and thus take a while in adjusting to their new form of livelihood. Domestic and international students' depression and anxiety levels can be linked to the year of study, with newcomers entering university. On the other hand, final-year students experience the highest levels of anxiety and depression, and various risk factors ( 32 ). First-year students experience SAD due to difficulties adjusting to university life, negative family experiences in the past, social isolation, and a lack of friends. Final-year students report unpredictability about their years ahead, prospective work opportunities, university debt repayment, and adjusting to life after school as major risk factors for SAD ( 32 ). As a result, as students go through their degrees and learning process, there is a change in SAD potential risk themes.

Students spend a large percentage of time engaged in academic pursuits at university, and poor academic performance can harm their mental health. Receiving worse grades during their studies can have a severe impact on student's mental health, leading to the development of SAD ( 28 ). Academic achievement throughout undergraduate education can influence degree categorization, affecting students' opportunities, including job placement or entrance to postgraduate programs. On the other hand, both the cases of students suffering from mental problem symptoms and the severity of their SAD increase during test time, indicating a direct link between academic stress and students' psychological health states ( 38 ). However, there is no direct correlation that is well-established. There are chances that depression and other related disorders such as momentary memory loss and lack of concentration are causes of bad academic marks, or that students get anxious and depressed due to their poor exam performance ( 39 ). Grades and mental health can have a reciprocal relationship, with poor mental health causing students to receive poorer grades ( 40 ), creating a vicious loop of academic performance and mental health. Interestingly, students' social connection and coherence to the campus community during exam periods decreased ( 38 ). This phenomenon can be explained by students' lower participation in university social events and clubs and a higher sense of competitiveness among their peers. Furthermore, students interact with lecturers, instructors, tutors, and other staff members both directly and indirectly; as a result, the interaction between academic staff and students can impact students' mental health. Another factor that contributes to SAD among undergrads is a bad and abusive interaction with teachers and mentors.

Part-time students are more likely to be emotionally stable and free from mental illnesses compared to full-time students. Students enrolled for part-time studies are more likely to be employed, and therefore they have a constant flow of income. Similarly, they are less likely to experience some social predisposes that may induce mental illnesses due to their schedule. Unlike full-time students, they are free-wheel and do not have a limited and timed duration to complete their courses. Their financial advantage puts them in a better position; however, they are also likely to experience other forms of predisposing factors. The negative predisposes that are more likely to cut across all students, for this reason, include the pressure accrued from school workload, phobia of performing poorly. They also entail the wrong expectations built on the courses and institutions of learning, a student's year of study, poor relationship with the staff with which a student interacts at the university.

Social Factors

In human livelihood, everyone is exposed to society and that an individual and society are two inseparable entities. Society has a significant influence on a person's thought ideology and self-actualization. Naturally, a person's description and identification of oneself gets determined by society. For this reason, society dramatically influences a person's state of mental health. Whenever a person coexists with others in a relatively fair environment or at par with the majority fortunate, the individual's mental health state is likely to be boosted. The case is dissimilar when a person belongs to a few unfortunate members of the community. Some of the social predisposes are therefore likely to perpetuate disorders in undergraduate students or otherwise breed them.

Loneliness and social isolation are a matter of concern among students, especially due to the advent of online learning, which discourages interaction. In modern society, especially after the COVID-19 pandemic, most institutions of higher learning have adopted online learning to facilitate the continuity of education and the learning process. This form of learning has hindered students' possibility of interaction with their peers in a classroom environment. This phenomenon has perpetuated the inherent social condition and situations of some students, especially introverts. According to Loades et al. ( 33 ), young adults, who make up the undergraduate population, are prone to experiencing high depression rates, which can also cause anxiety. The isolation and limitation of interaction among the young population require mitigation to ensure that the issue gets resolved at the early stages of inception ( 33 ). Self-solation and loneliness are also associated with having few friends, thus putting one at risk of experiencing mental illnesses in college. More often than not, loneliness can lead to low self-esteem and confidence, which breeds anxiety.

Social disadvantages such as poor housing and poverty pose more risk of mental disorders among students. Among learners, poverty is associated with poor performance in school in line with behavior, cognition, and attention-related issues ( 22 ). Therefore, it is associated with anxiety, schizophrenia, depression, delinquency, and other mental health disorders that are synonymous with young adults. Additionally, poverty increases one's risk of getting traumas and abuse, especially during childhood, and losing crucial family members ( 22 ). High-income inflow in a home setup reduces chances and risk of domestic violence. It, therefore, goes without saying that when the condition is otherwise, the students are likely to get exposed to unbearable environments at home, which yields mental conditions. Similarly, students coming from poor backgrounds have instilled internal pressure and desire to evict themselves from poverty. The fear of poverty and the desire to become wealthy gives students discomfort and pressure since they always think that it is likely to cost them severely ( 22 ). Students who live in poor housing facilities are also likely to develop low self-esteem and confidence. They view themselves as inferior to other classes of students ( 22 ). Other students may also discriminate and underrate them, thus brewing mental conditions that are stringent and adverse. Therefore, it is wise and socially acceptable that students should not let their social situation of poverty and poor housing ruin their idea and sense of self-esteem and confidence.

Bullying and social discrimination impose mental health conditions that may affect the students' performance and cause long-term health conditions. Bullying, especially in the school environment, affects both the victims and the perpetrators in different ways ( 41 ). It may cause trauma, behavior, and bodily implications and affect one's identity. Contemporary cyberbullying is also characterized by imposing anxiety, low self-esteem, and depression among young adults ( 41 ). The psychological discomforts and distress may yield a personal thought toward a person, thus harming oneself. The individuals are likely to behave in a manner that can trigger suicide attempts and other forms of self-harm ( 41 ). As a result of low self-esteem, a person may also become an introvert, thus interfering with one's potential to interact with other people. Perpetrators are likely to have interaction problems and the inability to socialize with their fellow students since they have instilled fear. The situation is almost similar when one experiences various forms of discrimination. Discriminated individuals end up with low self-esteem and confidence, as well as the desire to rise above their perpetrators ( 29 ). This state breeds anxiety and depression among the victims.

Psychological Risk Factors

University and college students also get exposed to various psychological stressors and displeasures that negatively impact their mental health and performance. Some social predisposes are also likely to cause psychological discomfort and resulting mental illnesses in a university or college setup. Some early childhood preconditions are also likely to impact a person psychologically, even at the tertiary level of education ( 44 ). For instance, childhood trauma, abuse, and neglect are likely to be more disastrous when a person reaches the university or college level. Trauma greatly impacts a person's thoughts and feelings about oneself and how they relate with other people in society. Students, especially females, who have gone through a traumatic experience are likely to develop mental illnesses and conditions such as post-traumatic stress disorder (PTSD), depression, or anxiety ( 45 , 46 ). Childhood maltreatment has a negative impact on cognitive, social development, and emotional development leading to problems with interaction and communication, as well as making people more prone to negative emotions in general and noticeable behavior problems like emotional maladjustment and anxiousness, hyperactivity, antisocial traits, and delinquent behaviors ( 45 ). Mistreatment during childhood is also likely to cause poor emotional intelligence, inhibited until college or university. Social support and refraining from mistreatment lead to mitigation of long-term adverse conditions such as depression and emotional self-regulation among children. Whenever the mitigation measures are not implemented, the victims are affected in adulthood. The instances are more severe among university and college students.

Long-term and severe stress is synonymously associated with causing mental illnesses among graduates. When stress becomes overwhelming and prolonged, the risks for mental health problems and medical problems increase. Long-term stress increases the risk of mental health problems such as anxiety and depression, substance use problems, sleep problems, pain, and bodily complaints such as muscle tension. Research indicates that stressful events cause significant psychological such as anxiety, distress, and depression ( 27 ). Similarly, severe and long-term academic stress leads to loss of welfare of the victims. Students suffering from academic stress are likely to perform poorly in their schoolwork ( 27 ). Poor performance perpetuates stress in the long run, as many students are accustomed to fearing academic failure and poor performance. Undergraduates may also get challenged by stressful life instances, such as breaking the law, which can cause mental discomfort and disorder. Its severity is also likely to cause other health conditions such as hypertension and asthma. It is, therefore, a predisposing factor that may inherently dominate a person's livelihood in the university.

Poor performance in school work leaves undergraduate students in thought which breeds mental illnesses. Whenever one performs poorly, there are chances that the person will get challenged mentally and develop the desire to work toward changing their results. However, failure for the same can cause a mental disorder due to the inherent academic expectations a person may develop. Similarly, mental illnesses affect a student's performance; therefore, the two risk factors are reversible, hence pausing the risk of cycle perpetuation. Attention to the students performing poorly in colleges and universities is essential in ensuring the cases of mental ill-health and continual unfolding of situations causing a cycle is fixed. This motive will help improve the learners' performance and work toward preventing some mental conditions that are likely to be incurred due to poor academic performance.

Lifestyle Factors

Moving away from family and starting a new life necessitates adaptability and flexibility for one to acclimatize to a new way of life. Most undergraduate students change their behavior and lifestyles as they leave their family setting and start a new life alongside their colleagues, friends, and classmates. SAD can be influenced by various lifestyle factors like alcohol intake, tobacco use, food habits, fitness, and drug usage. Students with mental problems consume a lot of alcohol ( 26 ). Alcohol is the most abused by undergraduates. It is synonymous with a series of mental disorders that they face. Alcohol is also addictive, and that when students overuse it, they are likely to experience various addiction disorders.

Another risk factor linked to SAD is tobacco smoking. It is widespread among students, particularly those from Eastern developing and developed nations like Japan, China, and South Korea ( 47 ). As a result of social bonding, many of the learners, especially male undergraduates, smoke, and the rate of social smoking is directly connected with SAD ( 47 ). Social smokers are less likely to give up their habit and are more likely to continue doing so, resulting in long-term detrimental psychological and physical health implications ( 47 ). Another key component in mental health among young individuals is illegal substance misuse ( 36 ). Academic stress and the social milieu in university dorms and student housing can lead students to take illegal drugs, smoke cigarettes, or consume excessive amounts of alcohol as a coping strategy, causing mental disorders ( 42 ). Students who felt supported by their university were less stressed and were less likely to engage in substance abuse, demonstrating the importance of social support in preventing and treating depression symptoms ( 42 ). It is especially important since a new social behavior or habit formed early in life might persist for a long time. Additionally, students who do not live a healthy lifestyle may experience shame, which can exacerbate their SAD symptoms ( 36 ). Rosenthal et al. ( 37 ) discovered negative behaviors associated with alcohol consumption, such as missing the next day's class, careless actions, self-harm, physical fight or verbal argument, the indulgence of unwanted sexual acts, shame, and regrets. The quantity of alcohol consumed can be the cause of depression and anxiety.

In universities and colleges, graduates adopt diverse sleeping habits that may yield mental illnesses and disorders. Many young people do not get enough sleep, causing sleep deprivation, a serious risk factor for depression and low mood ( 37 ). Students in the United States frequently report significant stress levels and inadequate sleep ( 43 ). The majority of undergraduates strive for academic brilliance, financial security, and the preservation of their lifestyle, which leads to poor sleep. Inadequate sleep can create a vicious cycle in which academic stress causes sleep deprivation. Insufficient sleep causes stress due to poor academic performance, as sleep quality and quantity are linked to academic performance ( 26 ). In general, poor sleeping habits are linked to lower learning ability, anxiety, and stress, leading to depression. Inadequate sleep, therefore, is likely to perpetuate a person's mental illness or otherwise fuel its inception.

In contrast with the predisposing factors, engaging physical exercise among students in colleges and universities is essential in protecting against mental dysfunctions. Students who claim to have limited time and fixed schedules may fail to engage in physical exercise and workouts. The development of SAD symptoms characterizes such students. Engagement in physical exercise and workouts makes the mind occupied and can also free off one's thoughts, which may cause mental illnesses. It also increases a person's interaction and enhances the social capabilities of interaction, which helps prevent some conditions. Physical exercise is also a form of therapy that requires one to exert physical exercise on the activity.

Physiobiological Factors

Physiobiological factors entail the factors that get affected directly and are related to the victim's biological composition, genetic history, and other health factors. For example, the mental health of an individual is inseparable from the family's history. Common disorders tied to an individual's family history include bipolar disorders, schizophrenia, dementia, depression, and anxiety ( 25 ). The genetic makeup determines the vulnerability of a person toward mental issues ( 25 ). People whose predecessors are associated with a certain mental illness are more likely to experience the same based on their genetic composition. Similarly, if one's family has a history of mental illness, one has likely been exposed to stressful conditions at some point in life. Growing up in a challenging environment or being abused by a parent or relative raises the risk of getting depression or anxiety ( 25 ). Epigenetics habits can also alter a person's emotions and habits, influencing people's biological composition, and it is likely to get passed to the next generation ( 30 ). Stress caused by mental health issues in great-grandparents, grandparents, or parents changes one's DNA, making them more vulnerable to difficulty ( 30 ). Furthermore, if a person's ancestors ate bad diets, had exposure to environmental pollutants, living with chronic stress, or did not receive proper prenatal nutrition, their genes—and thus an individual's—got altered, making them more likely to show mental illness health disorders.

Other biological factors such as pregnancy and birth complications, brain injury, chronic diseases, alcohol consumption, and drug abuse, as well as poor nutrition, are likely to predispose a victim to mental conditions. Some students have a history of complications during birth. Such students may inhibit the health conditions till the university or college level of study, and they are likely to cause mental disorders ( 31 ). Brain trauma and injury are also significant factors that may cause disorders in undergraduates. Some students have chronic illnesses such as diabetes and cancer, which expose them to discrimination, depression, anxiety, and low self-esteem. The diseases may also cause brain impairments, leaving the students mentally unwell ( 31 ). Usage of drugs and alcoholic drinks also influences the health status of an individual. Some drugs, such as marijuana, are associated with paranoia, resulting in adverse mental illnesses ( 31 ). Too much usage of drugs can also impair a person's eating habits which affect the learner's nutrition. It is, therefore, yields various eating disorders.

Mental health-related issues and social well-being predisposing factors are a matter of concern in the community, especially among undergraduates. The prevalence of mental disorders is a notch higher among college and university students, raising the alarm on establishing some of the causes of the phenomenon. The predisposing factors include social, psychological, biological, lifestyle-based factors and academic factors. Academic excellence pressure and exerts various emotional feelings among students. The emotions and failure to meet their expectations land students into mental conditions that may perpetuate for a while. Change of environment and desire to adjust to a new form of livelihood in the university also causes a resultant change in lifestyle. More often than not, students commence drug and substances abuse which puts them at risk. A person's history of the family's genetic composition, chronic illnesses, and injuries of the brain also causes brain challenges ( 48 ). Interaction and other socio-economic factors are also crucial to a student's mental health that, when neglected, may result in disorders. Therefore, it is wise for the community to make haste and limit instances of the unfolding of the predisposing factors to achieve high standards of mental health among the undergraduates. This move will help in creating a future society that is mentally healthy.

Author Contributions

PL: introduction. GT: methodology and conclusion. Both authors contributed to the 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.

1. Larson LR, Mullenbach LE, Browning MHEM, Rigolon A, Thomsen J, Metcalf EC, et al. Greenspace and park use associated with less emotional distress among college students in the united states during the COVID-19 pandemic. Environ Res. (2022) 204:112367. doi: 10.1016/j.envres.2021.112367

PubMed Abstract | CrossRef Full Text | Google Scholar

2. Lattie EG, Cohen KA, Hersch E, Williams KDA, Kruzan KP, MacIver C, et al. Uptake and effectiveness of a self-guided mobile app platform for college student mental health. Internet Interv. (2022) 27:100493. doi: 10.1016/j.invent.2021.100493

3. Hersi L, Tesfay K, Gesesew H, Krahl W, Ereg D, Tesfaye M. Mental distress and associated factors among undergraduate students at the University of Hargeisa, Somaliland: a cross-sectional study. Int J Ment Health Syst. (2017) 11:1–8. doi: 10.1186/s13033-017-0146-2

4. Soh NLW, Norgren S, Lampe L, Hunt GE, Malhi GS, Walter G. Mental distress in Australian medical students and its association with housing and travel time. J Contemp Med Educ. (2013) 1:163–9. doi: 10.5455/jcme.20130302044909

CrossRef Full Text | Google Scholar

5. Joseph S. Depression, anxiety rising among US college students. Reuters Health News. (2019). p. 370.

Google Scholar

6. Cui R. Editorial: a systematic review of depression. Curr Neuropharmacol. (2015) 13:480. doi: 10.2174/1570159X1304150831123535

7. Locke B, Wallace D, Brunner J. Emerging issues and models in college mental health services. New Direct Stud Serv. (2016) 2016:19–30. doi: 10.1002/ss.20188

8. APA. Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors (2010).

9. Younghans J. One in Five College Students Reported Thoughts of Suicide in Last Year . Association of American Universities (AAU). Aau.edu (2018). Available online at: https://www.aau.edu/research-scholarship/featured-research-topics/one-five-college-students-reported-thoughts-suicide (accessed November 23, 2021).

10. Healstaff M. Suicide rates for US teens and young adults are the highest on record Los Angeles Times (2019).

11. Stasak B, Epps J, Schatten HT, Miller IW, Provost EM, Armey MF. Read speech voice quality and disfluency in individuals with recent suicidal ideation or suicide attempt. Speech Commun. (2021) 132:10–20. doi: 10.1016/j.specom.2021.05.004

12. Lutter M. Emerging treatments in eating disorders. Neurotherapeutics. (2017) 14:614–22. doi: 10.1007/s13311-017-0535-x

13. Flatt RE, Thornton LM, Fitzsimmons-Craft EE, Balantekin KN, Smolar L, Mysko C, et al. Comparing eating disorder characteristics and treatment in self-identified competitive athletes and non-athletes from the National Eating Disorders Association online screening tool. Int J Eat Disord. (2021) 54:365–75. doi: 10.1002/eat.23415

14. Wade TD, Keski-Rahkonen A, Hudson JI. Epidemiology of eating disorders. In: Jones P, editor. Textbook of Psychiatric Epidemiology . London (2011). p. 343–60.

15. White HR, Stevens AK, Hayes K, Jackson KM. Changes in alcohol consumption among college students due to COVID-19: effects of campus closure and residential change. J Stud Alcohol Drugs. (2020) 81:725–30. doi: 10.15288/jsad.2020.81.725

16. Zou Z, Wang H, Uquillas FDO, Wang X, Ding J, Chen H. Definition of substance and non-substance addiction. Subst Non Subst Addict. (2017) 1010:21–41. doi: 10.1007/978-981-10-5562-1_2

17. Karch SB editor. Drug Abuse Handbook . Boca Raton, FL: CRC Press (2019).

18. Zivin K, Eisenberg D, Gollust SE, Golberstein E. Persistence of mental health problems and needs in a college student population. J Affect Disord. (2009) 117:180–5. doi: 10.1016/j.jad.2009.01.001

19. Turner AP, Hammond CL, Gilchrist M, Barlow JH. Coventry university students' experience of mental health problems. Couns Psychol Q. (2007) 20:247–52. doi: 10.1080/09515070701570451

20. Maser B, Danilewitz M, Guérin E, Findlay L, Frank E. Medical student psychological distress and mental illness relative to the general population: a Canadian cross-sectional survey. Acad Med. (2019) 94:1781–91. doi: 10.1097/ACM.0000000000002958

21. Ghirotto L. La Systematic Review Nella Ricerca Qualitativa. Rome: Carocci (2020).

22. Anakwenze U, Zuberi D. Mental health and poverty in the inner city. Health Soc Work. (2013) 38:147–57. doi: 10.1093/hsw/hlt013

23. Chernomas WM, Shapiro C. Stress, depression, and anxiety among undergraduate nursing students. Int J Nurs Educ Scholarsh. (2013) 10:255–66. doi: 10.1515/ijnes-2012-0032

24. Fares J, Al Tabosh H, Saadeddin Z, El Mouhayyar C, Aridi H. Stress, burnout and coping strategies in preclinical medical students. N Am J Med Sci. (2016) 8:75. doi: 10.4103/1947-2714.177299

25. Grant JE, Chamberlain SR. Family history of substance use disorders: significance for mental health in young adults who gamble. J Behav Addict. (2020) 9:289–97. doi: 10.1556/2006.2020.00017

26. Ghodasara SL, Davidson MA, Reich MS, Savoie CV, Rodgers SM. Assessing student mental health at the Vanderbilt University School of Medicine. Acad Med. (2011) 86:116–21. doi: 10.1097/ACM.0b013e3181ffb056

27. Hassanzadeh A, Heidari Z, Feizi A, Hassanzadeh Keshteli A, Roohafza H, Afshar H, et al. Association of stressful life events with psychological problems: a large-scale community-based study using grouped outcomes latent factor regression with latent predictors. Comput Math Methods Med. (2017) 2017:3457103. doi: 10.1155/2017/3457103

28. Ishii T, Tachikawa H, Shiratori Y, Hori T, Aiba M, Kuga K, et al. What kinds of factors affect the academic outcomes of university students with mental disorders? A retrospective study based on medical records. Asian J Psychiatry. (2018) 32:67–72. doi: 10.1016/j.ajp.2017.11.017

29. Jochman JC, Cheadle JE, Goosby BJ, Tomaso C, Kozikowski C, Nelson T. Mental health outcomes of discrimination among college students on a predominately White campus: a prospective study. Socius. (2019) 5:1–16. doi: 10.1177/2378023119842728

30. Kenney M, Müller R. Of rats and women: narratives of motherhood in environmental epigenetics. Biosocieties. (2017) 12:23–46. doi: 10.1057/s41292-016-0002-7

31. Kim MH. Factors affecting mental health among college students-Sassang constitution and ego state centered approach. J Korean Public Health Nurs. (2013) 27:564–77. doi: 10.5932/JKPHN.2013.27.3.564

32. Lee KH, Ko Y, Kang KH, Lee HK, Kang J, Hur Y. Mental health and coping strategies among medical students. Korean J Med Educ . (2012) 24:55–63. doi: 10.3946/kjme.2012.24.1.55

33. Loades ME, Chatburn E, Higson-Sweeney N, Reynolds S, Shafran R, Brigden A, et al. Rapid systematic review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19. J Am Acad Child Adolesc Psychiatry. (2020) 59:1218–39. doi: 10.1016/j.jaac.2020.05.009

34. Kawase E, Hashimoto K, Sakamoto H, Ino H, Katsuki N, Iida Y, et al. Variables associated with the need for support in mental health check-up of new undergraduate students. Psychiatry Clin Neurosci. (2008) 62:98–102. doi: 10.1111/j.1440-1819.2007.01781.x

35. Macaskill A. The mental health of university students in the United Kingdom. Br J Guid Counsel. (2013) 41:426–41. doi: 10.1080/03069885.2012.743110

36. Mofatteh M. Risk factors associated with stress, anxiety, and depression among university undergraduate students. AIMS Public Health. (2021) 8:36. doi: 10.3934/publichealth.2021004

37. Rosenthal SR, Clark MA, Marshall BD, Buka SL, Carey KB, Shepardson RL, et al. Alcohol consequences, not quantity, predict major depression onset among first-year female college students. Addict Behav. (2018) 85:70–6. doi: 10.1016/j.addbeh.2018.05.021

38. Scholz M, Neumann C, Ropohl A, Paulsen F, Burger PHM. Risk factors for mental disorders develop early in German students of dentistry. Ann Anat Anatomischer Anzeiger. (2016) 208:204–7. doi: 10.1016/j.aanat.2016.06.004

39. Schweizer S, Kievit RA, Emery T, Henson RN. Symptoms of depression in a large healthy population cohort are related to subjective memory complaints and memory performance in negative contexts. Psychol Med. (2018) 48:104–14. doi: 10.1017/S0033291717001519

40. Stallman HM. Psychological distress in university students: a comparison with general population data. Aust Psychol. (2010) 45:249–57. doi: 10.1080/00050067.2010.482109

41. Skilbred-Fjeld S, Reme SE, Mossige S. Cyberbullying involvement and mental health problems among late adolescents. Cyberpsychology . (2020) 14:1–16. doi: 10.5817/CP2020-1-5

42. Tavolacci MP, Ladner J, Grigioni S, Richard L, Villet H, Dechelotte P. Prevalence and association of perceived stress, substance use and behavioral addictions: a cross-sectional study among university students in France, 2009–2011. BMC Public Health. (2013) 13:1–8. doi: 10.1186/1471-2458-13-724

43. Wallace DD, Boynton MH, Lytle LA. Multilevel analysis exploring the links between stress, depression, and sleep problems among two-year college students. J Am Coll Health. (2017) 65:187–96. doi: 10.1080/07448481.2016.1269111

44. Limone P, Toto GA. Psychological and emotional effects of digital technology on children in Covid-19 pandemic. Brain Sci. (2021) 11:1126. doi: 10.3390/brainsci11091126

45. Allen B. An analysis of the impact of diverse forms of childhood psychological maltreatment on emotional adjustment in early adulthood. Child Maltreat. (2008) 13:307–12. doi: 10.1177/1077559508318394

46. Limone P, Zefferino R, Toto GA, Tomei G. Work stress, mental health and validation of professional stress scale (pss) in an italian-speaking teachers sample. Healthcare (Basel). (2021) 9:1434. doi: 10.3390/healthcare9111434

47. Cai D, Zhu M, Lin M, Zhang XC, Margraf J. The bidirectional relationship between positive mental health and social rhythm in college students: a three-year longitudinal study. Front Psychol. (2017) 8:1119. doi: 10.3389/fpsyg.2017.01119

48. WHA. International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) (2010).

Keywords: anxiety, depression, online learning, COVID-19, medical education, SAD, mental health, psychiatrist

Citation: Limone P and Toto GA (2022) Factors That Predispose Undergraduates to Mental Issues: A Cumulative Literature Review for Future Research Perspectives. Front. Public Health 10:831349. doi: 10.3389/fpubh.2022.831349

Received: 08 December 2021; Accepted: 24 January 2022; Published: 16 February 2022.

Reviewed by:

Copyright © 2022 Limone and Toto. 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: Giusi Antonia Toto, giusi.toto@unifg.it

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.

MERRIMACK COLLEGE MCQUADE LIBRARY

Clinical mental health counseling.

  • Get Started
  • Gathering Background Information
  • Find Articles
  • Open Educational Resources (OER)

Writing a Literature Review (University Library, UC Santa Cruz)

"the literature" and "the review" (virginia commonwealth university).

  • Evaluate Sources
  • Cite Sources
  • Annotated Bibliography
  • Statistics & Assessment

Additional Online Resources

  • How to: Literature reviews The Writing Center, University of North Carolina Chapel Hill
  • The Literature Review A basic overview of the literature review process. (Courtesy of Virginia Commonwealth University)
  • The Process: Search, Assess, Summarize, Synthesize Getting Started: Assessing Sources/Creating a Matrix/Writing a Literature Review (Courtesy of Virginia Commonwealth University)
  • Review of Literature The Writing Center @ Univeristy of Wisconsin - Madison
  • Tools for Preparing Literature Reviews George Washington University
  • Write a Literature Review University Library, UC Santa Cruz

1. Introduction

Not to be confused with a book review, a  literature review  surveys scholarly articles, books and other sources (e.g. dissertations, conference proceedings) relevant to a particular issue, area of research, or theory, providing a description, summary, and critical evaluation of each work. The purpose is to offer an overview of significant literature published on a topic.

2. Components

Similar to primary research, development of the literature review requires four stages:

  • Problem formulation—which topic or field is being examined and what are its component issues?
  • Literature search—finding materials relevant to the subject being explored
  • Data evaluation—determining which literature makes a significant contribution to the understanding of the topic
  • Analysis and interpretation—discussing the findings and conclusions of pertinent literature

Literature reviews should comprise the following elements:

  • An overview of the subject, issue or theory under consideration, along with the objectives of the literature review
  • Division of works under review into categories (e.g. those in support of a particular position, those against, and those offering alternative theses entirely)
  • Explanation of how each work is similar to and how it varies from the others
  • Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research

In assessing each piece, consideration should be given to:

  • Provenance—What are the author's credentials? Are the author's arguments supported by evidence (e.g. primary historical material, case studies, narratives, statistics, recent scientific findings)?
  • Objectivity—Is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
  • Persuasiveness—Which of the author's theses are most/least convincing?
  • Value—Are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

  3. Definition and Use/Purpose

A literature review may constitute an essential chapter of a thesis or dissertation, or may be a self-contained review of writings on a subject. In either case, its purpose is to:

  • Place each work in the context of its contribution to the understanding of the subject under review
  • Describe the relationship of each work to the others under consideration
  • Identify new ways to interpret, and shed light on any gaps in, previous research
  • Resolve conflicts amongst seemingly contradictory previous studies
  • Identify areas of prior scholarship to prevent duplication of effort
  • Point the way forward for further research
  • Place one's original work (in the case of theses or dissertations) in the context of existing literature

The literature review itself, however, does not present new  primary  scholarship.

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Mental Health Considerations in Older Adults: a literature review

Posted on 8th August 2019 by Samina Miah

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During the final year of their Paramedic Science (BSc Hons) course at Oxford Brookes University, students carry out a literature review and critical appraisal of a topic relevant to their future practice. This blog presents the abstract of a literature review on ‘ Mental Health Considerations in Older Adults ‘. Other Paramedic topic blogs can be found here .

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Examining the short and long-term impacts of child sexual abuse: a review study

  • Review Paper
  • Open access
  • Published: 15 February 2024
  • Volume 4 , article number  56 , ( 2024 )

Cite this article

You have full access to this open access article

  • Sana Ali   ORCID: orcid.org/0000-0003-3474-000X 1 , 2 ,
  • Saadia Anwar Pasha   ORCID: orcid.org/0000-0002-6416-7358 3 ,
  • Ann Cox   ORCID: orcid.org/0000-0002-8399-8050 4 &
  • Enaam Youssef 5  

Child sexual abuse is a growing problem, representing an egregious abuse of power, trust, and authority with far-reaching implications for the victims. This review study highlights the intricate psychological impacts of child sexual abuse, addressing both short and long-term consequences. Existing literature highlights the deep impacts on the victims’ psychological health and well-being, necessitating an in-depth examination of the subject. Drawing from a sample of n = 19 research articles selected through stringent inclusion and exclusion criteria and the PRISMA approach, this study synthesizes results from publications spanning 2010 to 2022. The review reveals various detrimental impacts on the victims’ psychological well-being, including short-term consequences, i.e., isolation, bullying, stress, anxiety, and post-traumatic stress disorder (PTSD). Long-term effects encompass PTSD in later life, disrupted intimate relationships, social and emotional health concerns, revictimization, and more. In conclusion, the study emphasizes the lack of a definitive number of impacts, highlighting the need to discuss and raise awareness about child sexual abuse. This increased awareness is important for parents, guardians, and responsible authorities to effectively counteract these crimes against children. Also, providing emotional support to victims is important to mitigate the long-term impacts. The researchers offer implications and discuss limitations, providing an extensive overview and foundation for future research and interventions.

Avoid common mistakes on your manuscript.

Introduction

Child sexual abuse is prevalent across class, race, and ethnicity, with both short-term and long-term impacts. It mainly involves an interaction between the abuser and the child, in which the child is the focus of the sexual stimulation of an observer or the offender (Wagenmans et al. 2018 ). Child sexual abuse is anticipated as silencing the minor, and consequently, reporting such incidents is much less. Even without knowing the full ratio of the relevant incidents, experts agree that 500,000 children face sexual abuse yearly (YWCA.org 2017 ). This sexual offence against children has always been an existing phenomenon in all societies and historical eras. For instance, ancient civilizations openly adopted child sexual abuse as a normal, cultural, and social practice aimed at the learning and development of children (Ali 2019 ). Despite the perceptions about child sexual abuse historically varied, we found varying perceptions ranging from acceptance (justifiable) to rejection (children’s rights violation) (DiLillo et al. 2014 ). Child sexual abuse is not limited only to penetration; instead, showing a child pornographic photos, voyeurism, touching a child’s genitals, and even making the child touch or see the perpetrator’s private body parts is also considered sexual abuse (National Sexual Violence Resource Center 2011 ). It is also notable that both boys and girls are strongly susceptible to sexual abuse. However, girls are more vulnerable as they confront sexual abuse three times more than boys, while boys are more likely to be severely injured or die after sexual molestation (National Sexual Violence Resource Center 2011 ). A report by the World Health Organization in 2006 revealed that more than 20% of women and 8% of men in 39 countries reported that they had faced sexual abuse during childhood.

Similarly, data from 2012 to 2013 shows that 2% of boys and 4% of girls experience some sexual abuse every year (Chan et al. 2013 ). Another report (UNICEF 2020a ) revealed that more than 120 million individuals worldwide face forced sexual acts during their childhood. Most are females (89%), and 11% are males. Globally, this statistic is much higher as every one out of four girls and one in every six boys during the early years of their lives (YWCA.org 2017 ).

Similarly, sexual abuse of children is possible in almost every social setting and location, i.e., schools, roads, justice institutions, and homes. Also, it is prevalent equally among all socio-economic classes and age groups; children facing sexual abuse sometimes cannot realize their molestation (Selengia et al. 2020 ). Around 92.0 of the reported incidents were linked by acquittances (closed relatives), indicating the prevalence of incestuous abuse (Ali et al. 2021 ). Notably, there are three dynamic factors behind child sexual abuse, i.e., psychological, economic, and social. For instance, social factors involve one’s personal experience of sexual exploitation during childhood (Middleton et al. 2017 ). Economic factors involve poverty. For example, parents may ask their girl child to look for a capable man to take care of her primary needs, which may further lead to engaging in sexual activities in return for monetary support (Simuforosa 2015 , p. 1792).

On the other hand, psychological factors are mainly defined as sexual interest in children due to a mental disorder (Tenbergen et al. 2015 ). However, the economic factors responsible for perpetuating child sexual abuse mainly involve forcibly engaging children in sexual acts, selling or buying children pornography, and all the other relevant factors that lead to the economic benefits for the perpetrators (Ali 2019 ). Notably, the impacts of child sexual use are detrimental from different aspects. For instance, these impacts are immediate yet prolonged, indicating their severity during adulthood. According to (Downing et al. 2021 ), stress-induced variations in the pro-inflammatory substances, i.e., alterations in gene expression and cortisol, mediate these detrimental impacts.

Additionally, risky sexual behaviours against children and the opposite gender are further attributed to the impacts of child sexual abuse (Fisher et al. 2017 , p. 11). Child sexual abuse poses an influential societal challenge, demanding careful examination to understand its complexities fully.

Aim and purpose

This research aims to scrutinize the role of Child Sexual Abuse as a risk factor for causing several psychological concerns among the victims. The researcher has reviewed some studies on Child Sexual Abuse and its impacts. Drawing on the aims of this article, the study aims to examine (1) the short-term psychological impacts of Child Sexual Abuse and (2) the long-term psychological impacts of Child Sexual Abuse according to studies conducted during the past twelve years (2010–2022). The overarching goal is to provide a comprehensive synthesis of existing literature, shedding light on the multifaceted consequences of child sexual abuse over both short and long-term durations. By systematically analyzing and assessing a selected set of articles, this study seeks to contribute to the understanding of prevalent themes, methodologies, and gaps in the existing literature surrounding the psychological impacts of child sexual abuse. The significance of this work extends to informing future research, interventions, and policymaking related to child protection and well-being. Finally, the aim is to facilitate the development of targeted and effective strategies for preventing, intervening, and supporting individuals affected by children.

In response to the urgent need for a comprehensive understanding, this review study uses the PRISMA approach to navigate existing literature. Addressing the CSA in current knowledge, we highlight the major difficulties associated with unravelling the complexities of child sexual abuse. This review not only synthesizes an extensive body of research but also discusses their findings and insights to overcome the inherent challenges in comprehending the short and long-term impacts of child sexual abuse. Our study seeks to make a distinctive contribution by explaining the intercity of this fragile subject matter, thus laying the groundwork for more effective interventions and support systems. It addresses the following research questions based on the aims and purposes of current research.

RQ1. What constitutes Child Sexual Abuse, and how can it be accurately defined within the current literature?

RQ2. How does Child Sexual Abuse affect the mental health and overall well-being of individuals, considering both short-term and long-term impacts?

This study is based on the systematic literature review approach. The review-based studies are a significant part of the existing literature as they closely witness the ongoing trends and complexities in the field under study (Ali and Pasha 2022 ). Besides, the relevant studies also highlight the major findings to further the gap and conduct an in-depth analysis of the other aspects of the same concern.

Assumptions and justifications

In the context of this systematic literature review, certain assumptions were made to facilitate the synthesis and analysis of the selected studies. These assumptions are integral to the nature of the review process. First, it was deemed that the definitions of key terms, i.e., “child sexual abuse” and “psychological impacts,” were relatively consistent across the selected studies. This assumption is grounded in the anticipation that researchers within the field comply with widely accepted definitions and classifications. While variations in terminologies exist, a comprehensive screening process and compliance with inclusion criteria mitigated possible discrepancies. The study focused on articles with clear and relevant definitions, assuring homogeneity in the selected literature.

Further, the decision to include articles published from 2010 onwards was based on the assumption that recent research mirrors current trends and developments in comprehending the psychological impacts of child sexual abuse. The rationale is rooted in the dynamic nature of research, focusing on current perspectives. This assumption allows for analyzing the most recent insights into the subject matter and recognizing the evolving nature of societal attitudes and academic discourse.

Evaluation of assumptions

While these assumptions were important for the systematic review process, it is important to acknowledge their probable impact on the results. A few considerations emphasize how these assumptions may affect the outcomes. For example, despite efforts to ensure consistency, variations in definitions across studies may introduce complexities in interpreting psychological impacts. This could influence the synthesis of results, and readers should be aware of the potential heterogeneity in conceptualizing key terms. Besides, the focus on recent publications assumes that newer research accurately represents the current landscape. However, this may bias contemporary perspectives, potentially bypassing practical insights from earlier studies.

Thus, considering the problem’s complexity and continuous research, the researcher selected three specialized platforms: PubMed, Science Direct, and APA PsycNet. However, the selection criteria were not restricted to any age, gender, race, ethnicity, nationality, and language. The keywords for the search were “impacts of child sexual abuse, child sexual abuse, psychological effects of child sexual abuse, short-term effects of child sexual abuse, and long-term effects of child sexual abuse. Later the researcher tabulated the data using Microsoft Excel, which further helped calculate the included articles’ percentages and frequencies. The researcher used the PRISMA method for systematic review, as suggested by (Page and McKenzie 2021 ). Table  1 summarizes the inclusion and exclusion criteria used in the current study:

Based on the PRISMA method of screening, evaluation and Selection, the researchers gathered a total of 113 records from the selected database. After removing the duplicates, 106 total articles were further screened for full-text availability (93). Finally, the researchers selected n  = 19 articles adhering to the selection criteria (See Fig.  1 ).

figure 1

PRISMA flow chart for the articles selection process

Table  2 summarizes the frequencies and percentages of the literature according to their database. It is observable that most of the articles were from PubMed (n = 11 or 57.8). APA PsyNet provided n = 7 or 36.8% articles, while n  = 1 (5.2%) article was obtained from Science Direct.

Table  3 summarizes the frequencies and percentages of the selected literature according to their publication years. As visible, most of the studies ( n  = 12, 63.1%) were published from 2015 to 2020, indicating that these years focused mainly on research scholars in psychology, communication, sociology, criminology, and other fields. These results also reflect the prevalence of the relevant concern demanding a strong consideration towards children’s rights and health protection (Ali and Pasha 2022 ). Followed by 04 or 21.0% of studies published between 2010–2015, n  = 03 or 1.7% of studies published until the end of November 2022.

Concerning the frequencies and percentages of the cited literature according to their designs, most studies (09 or 47.3%) were based on a review approach. Followed by experimental design ( n  = 06 or 31.5%), 03 or 15.7% of studies were based on the perspective method. Finally, online n  = 1 (5.2%) of the study was based on the case study method, and the same number of studies ( n  = 1, 5.2%) was categorized as “other” (See Table  4 ). Additionally, n  = 11 or 7.8% of studies were based on a qualitative approach, n = 11 or 57.8% were based on the quantitative approach, and only one study was based on the mixed method approach (See Table  5 ).

The researchers calculated the frequencies and percentages of the cited literature according to the data-gathering approaches used by the relevant researchers (See Table  3 ). Most studies ( n  = 13, 68.4%) were based on the survey method. Besides, the interview approach was preferred in 04% of studies. While n  = 1 (5.2%) study was based on the literature review approach, and the same number of literature ( n  = 1, 5.2%) was categorized as “other”.

Validation of selected methodology

The methodology used in this systematic literature review underwent a thorough validation process to ensure its reliability and comprehensiveness. Key elements of the validation process are.

Adherence to PRISMA Guidelines: The systematic review methodology rigorously adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, as Page and McKenzie ( 2021 ) recommended. PRISMA guidelines are widely recognized and accepted standards for conducting systematic reviews, assuring a systematic and transparent approach to literature synthesis.

Inclusion and Exclusion Criteria: Establishing clear and strict inclusion and exclusion criteria contributed to the robustness of the methodology. These criteria were designed to select studies that specifically addressed the psychological impacts of child sexual abuse, enhancing the relevance and reliability of the synthesized literature.

Search Strategy: The search strategy employed in selecting articles was exhaustive, using three specialized platforms—PubMed, Science Direct, and APA PsycNet. The chosen keywords were carefully selected to encompass diverse dimensions of child sexual abuse and its psychological impacts, minimizing the risk of overlooking pertinent studies.

Data Tabulation and Analysis: Using Microsoft Excel for data tabulation provided a structured and organized approach to handling the extensive information extracted from the selected articles. This facilitated a systematic calculation of frequencies and percentages, assuring accuracy and consistency in reporting.

PRISMA Flow Chart: A PRISMA flow chart (Fig.  1 ) visually represents the systematic article selection, screening, and inclusion process. This chart improves transparency and serves as a visual validation of the methodological stringency applied in the study.

While this systematic review does not involve the same type of validation as experimental or modelling studies, the validation lies in compliance with established guidelines, rigorous criteria for article selection, and transparent reporting of the review process. These elements collectively contribute to the robustness and credibility of the methodology used in this study.

Review of literature

Defining child sexual abuse.

According to (Pulverman et al. 2018 ), the definition of child sexual abuse has been a major concern for many researchers since the 1970s. The prevalent cases and recent concerns indicate that providing and establishing the definition of child sexual abuse is urgent and needs strong consideration. Notably, it is important to keep the complexity and sensitivity of the relevant issue under consideration when providing a potential definition of child sexual abuse (Pulverman et al. 2018 ) theoretically defined child sexual abuse as the unconscionability of the acts, which further indicates four types of activities such as the relationship of power between an adult and child, the child in the lower position facing inequality, the child’s susceptibility is exploited based on their detriment, and truancy of true consent (Table 6 ).

Defining sexual abuse can vary on a different basis. For instance, (Vaillancourt-Morel et al. 2016 ) argue that child sexual abuse mainly relies on the legal definition. Several self-reported cases of child sexual abuse remained affirmed, leading to further legal actions, yet some cases indicate doubtful accusations. As in the empirical study (Vaillancourt-Morel et al. 2016 ), results indicated 21.3% sexual abuse among females and 19.6% among males. At the same time, 7.1% of females and 3.8% remained consistent with self-defined child sexual abuse. However, (Ma 2018 ) stated that the relevant definition could vary according to the prevalence estimation. Besides, this definition is based on five criteria, including the age of the childhood, the age of the perpetrator or the age difference between the victim and the perpetrator, the relationship between the victim and the perpetrator, the type of sexual acts performed by the perpetrator, and the extension of the coercion. According to (Pulverman et al. 2018 ), child sexual abuse can be defined as unwanted sexual activities between an adult and a child, including vaginal, oral, and anal penetration. Besides, online child sexual abuse, including online sex, child pornography, and others, is also considered a vital type of child sexual abuse.

Impacts of child sexual abuse

Child sexual abuse is strongly detrimental to children’s physical and psychological health. In this regard, researchers and medical experts claim physical consequences as serious as brain damage and immediate death. Minor injuries are also found in some cases. However, death is the most common physical outcome of child sexual abuse (Habes et al. 2022 ). As noted by (Beltran 2010 ), no single impact patterns exist. Sometimes, a victim does not show any prominent impacts that may impede the development of a psychological syndrome that adversely affects a child’s social, emotional and cognitive abilities. Some researchers claim that only 20–30% of children remain emotionally and physically stable after sexual molestation. However, although they remain normal, internally, they develop latent effects of sexual abuse. The short-term and immediate psychological impacts of sexual abuse may involve painful emotions, Post-traumatic stress disorder, cognitive distortions, and disturbed mood. These victims respond to sexual abuse in diverse ways that can be changed over time. However, the psychological harm is still severe and can result in even adverse consequences. During sexual abuse, victims can feel fear, anxiety, self-blame, guilt, confusion, and anger. They feel self-conscious and humiliated, unable to talk about what happened, which can result in stress and frustration (Pulverman et al. 2018 ). Table  1 below provides a summary of studies witnessing the physical and psychological consequences of child sexual abuse (Table 7 ).

(Batool and Abtahi 2017 ) named short-term effects “initial effects”, as these reactions mainly occur during the first two years of abuse. Previous studies revealed that 66.0% of children were emotionally disturbed due to sexual abuse, 5.2% were mild to moderately disturbed, and 24.0% remained stable after the sexual abuse. Similarly, a study conducted by (Fontes et al. 2017 ) also witnessed the short-term impacts of sexual abuse on the mental health of the victims. Results gathered by using the Propensity Score Matching technique revealed that 13.3% of sexually abused children reported a greater feeling of loneliness, 7.5% were having difficulty in making friends, and 9.5% reported insomnia. Despite these effects differing among male and female children, both were equally confronting to the relevant mental disturbances.

Further, regarding the long-term effects of child sexual abuse, (Petersen et al. 2014 ) stated that it results in both short and long-term effects. A survivor may feel peer rejection, confusion, lack of self-confidence, conduct disorder, oppositional defiant disorder, and aggression. Similarly, in the later years, the survivor may also develop other extreme psychiatric disorders such as depression, low economic productivity, drug addiction and even severe medical illness. According to (Hodder and Gow 2012 ), long-term child sexual abuse can also result in substance abuse, long-term depression, negative attributions, and even eating disorders. Most recently, practitioners also found even more chronic mental disorders such as delusions, schizophrenia, and personality disorders. However, children who have experienced abuse involving penetration are more likely to develop these chronic psychotic and schizophrenic disorders. Likewise, sexually abused children also have low self-esteem and overly sexualized behaviour, which, in many cases, results in teen pregnancy and motherhood and even an increased vulnerability to another victimization (Townsend 2013 ). Besides, socially isolated children with a disability or emotional disorder are comparatively more vulnerable to victimization. Once the abuse has happened, they also face threats to end the relationship if they refuse to perform sex or threats to publicly share their sexual images (UNICEF 2020b ) (Table 8 ).

Wagenmans et al. ( 2018 ) highlighted the occurrence of prolonged and severe psychological disorders among individuals who previously experienced child sexual abuse. As noted, the prolonged effects are more common when there is a repetitive and interpersonal nature of abuse, mostly leading to develop Post-Traumatic Stress Disorder (PTSD) in later years. Those with a history of Child Sexual Abuse risk developing issues in interpersonal relationships, emotional regulation, and self-concept that result in “Complex PTSD” (p. 2). As (Gupta and Garg 2020 ) noted, child sexual abuse indicates an increased self-harming behaviour, fear, depression, impaired brain development, and others that are criteria for developing Post-Traumatic Stress Disorder (PTSD). Notably, this sexual abuse is not limited to physical and sexual harm; it also involves emotional abuse that further indicates the severity of the relevant issue today. It is also worth mentioning that most victims report sexual abuse in their later life. These victims also indicate their revictimization as one of the most consistent outcomes of child sexual abuse (Papalia et al. 2021 ). The term revictimization is also defined as any further victimization even during childhood, adolescence, or adulthood after the first incident of sexual abuse during childhood (P.1). However, there can be different factors, including sex, mental health issues, age at initial abuse, and others as different determinants of revictimization (Papalia et al. 2021 ). (MacIntosh and Ménard 2021 ) synthesized the status of research witnessing the long-term impacts of child sexual abuse over the past thirty years. As noted, different researchers have witnessed different impacts. Disturbed academic functioning, substance abuse and alcoholism in later years, revictimization and developing Post-Traumatic Stress Disorder (PTSD). Besides, sexual disorders, sex-related cognitions, disturbed intimate relationships, and emotional aspects of sexuality remain highlighted, witnessed, and still need much more consideration. Finally, the study by (Schreier et al. 2017 ) highlighted another important dimension regarding the impacts of child sexual abuse, as their focus was on the victims’ siblings as an important factor to determine in post-abuse scenarios. As noted, siblings can confront several emotional responses after disclosing the child’s sexual abuse. Siblings’ reactions are important as negative behaviour can increase the post-abuse stress among the victim and the family. Thus, it is concluded that the siblings should also be provided clinical services to reduce the negative impacts of child sexual abuse. Siblings also indicate symptoms of distress on an average level that needs strong consideration.

The gathered evidence unequivocally highlights the pervasive and profound negative impacts of child sexual abuse on the psychological health, cognitive development, and overall well-being of victims. The complex dynamics of the relationship between the abuser and the child, initially built on trust and affection, morph into a distressing paradigm of power, domination, victimization, and, in some examples, revictimization. The susceptibility of children in such situations places their psychological health at considerable risk, necessitating urgent and effective preventive measures to protect their well-being. This study serves to highlight the enduring and detrimental repercussions of child sexual abuse that can persist throughout a child’s life. The complexities of the psychological toll highlight the need for targeted interventions and support mechanisms. Our findings indicate that discussions and heightened awareness surrounding child sexual abuse are imperative. It is not merely a matter of quantifying impacts but a call to action to proactively empower parents, guardians, and responsible authorities to counteract these blatant crimes against children. Thus, our study affirms the critical importance of providing emotional support to victims, recognizing it as an integral component in mitigating the long-term impacts of child sexual abuse. By shedding light on the deep consequences and supporting awareness, we aim to contribute to the collective efforts toward a safer environment for children, free from the effects of sexual abuse.

Implications

Incidents of child sexual abuse are prevalent, especially since access to vulnerable children is even more feasible due to social media and other digital platforms (Ali et al. 2021 ). Consequently, children are at increased risk of maltreatment, particularly sexual abuse. Consequently, this research has some implications for the service and police departments, parents, and mental healthcare practitioners across the globe.

Families should receive prevention support and guidance through proper risk assessment and multi-level parent education (Tener et al. 2020 ). Parents informing the children about the protection measures can also help them prevent any detrimental incident that may further nullify the impacts of sexual abuse.

Providing mental healthcare services to the victims, their families, and their siblings, as also emphasized by (Schreier et al. 2017 ), also ensures the children’s mental well-being and development, especially among those who have been through any abusive exposure.

Besides psychological impacts, there are other detrimental impacts that child faces after sexual abuse that necessitate the provision of adequate healthcare services. These healthcare services aim to ensure the different consequences of abuse and that the victim may overcome the incident (Rahnavardi et al. 2022 ).

Medical healthcare providers, including staff, should also support and guide the victim and their families. Although exposure to a CSA victim can be traumatizing for healthcare practitioners, their behaviour and support patterns can help the victims cope with the challenges, especially with the psychological impacts (Pérez-Fuentes et al. 2013 ).

A victim can also face other consequences that may further worsen the impact of sexual abuse, including bullying. Schools and teachers can also effectively nullify these impacts by supporting and scrutinizing the victims. The focus should be on avoiding any further outcomes on their mental health (Sawyerr and Bagley 2017 ).

Implementing laws and active consideration towards welfare programs and training sessions for children, parents, and teachers as caregivers can also mitigate the impacts of child sexual abuse (Batool and Abtahi 2017 ).

Limitations and recommendations

Although this study synthesized the findings of recent literature witnessing both short-term and long-term impacts of child sexual abuse, it also contains some primary limitations. First, this study does not involve human subjects or clinical trials that may witness the impacts under study in a particular setting. Second, the Selection of the cited articles was strict and based on only three databases, limiting its scope. Third, the research does not provide any country-specific evidence. Instead, the cited literature is scattered and based on studies from around the world. Finally, although the study empirically witnesses the impacts of child sexual abuse, there are many regions where empirical research on child sexual abuse, its impacts, and causes are understudied. Consequently, this study emphasizes conducting more research on the impacts of child sexual abuse, its prevalence, and causal factors that may further provide strong insights regarding the relevant issue and help propose implications and nullify its impacts.

Data availability

No data is associated with this research project.

Code availability

No codes are available for this study.

Ali S (2019) Understanding paedophilia through different perspectives, 1st edn. LAP LAMBERT Academic Publishing

Google Scholar  

Ali S, Haykal HA, Youssef EYM (2021) Child sexual abuse and the internet—a systematic review. Human Arenas. https://doi.org/10.1007/s42087-021-00228-9

Ali S, Pasha SA (2022) A systematic review of the technology enabled child sexual abuse (OCSA) & its impacts. J Leg Ethical Regul Issues 25(5S):1–20

MathSciNet   Google Scholar  

Batool S, Abtahi A (2017) Psychosocial impact of childhood sexual abuse: perspective of victims. J Arts Soc Sci 4(2):36–48

Beltran NP (2010) Long-term psychological consequences of child sexual abuse. Papeles Del Psicólogo 31(2):191–201

Chan KL, Yan E, Brownridge DA, Ip P (2013) Associating child sexual abuse with child victimization in China. J Paediatr 162(5):1028–1034. https://doi.org/10.1016/j.jpeds.2012.10.054

Article   Google Scholar  

DiLillo DK, Fortier MA, Perry AR (2014) Child abuse and neglect psychology. Department of Faculty Publications, Department of Child Abuse and Neglect. November 2005

Downing NR, Akinlotan M, Thornhill CW (2021) The impact of childhood sexual abuse and adverse childhood experiences on adult health-related quality of life. Child Abuse Negl 120(May):105181. https://doi.org/10.1016/j.chiabu.2021.105181

Article   PubMed   Google Scholar  

Fisher C, Goldsmith A, Hurcombe R, Soares C (2017) The impacts of child sexual abuse: a rapid evidence assessment. IICSA Research Team, USA

Fontes LFC, Conceição OC, Machado S (2017) Violência sexual na adolescência, perfil da vítima e impactos sobre a saúde mental. Ciencia E Saude Coletiva 22(9):2919–2928. https://doi.org/10.1590/1413-81232017229.11042017

Gupta S, Garg S (2020) Causes and effects of child sexual abuse. Int J Innov Sci Res Technol 5(5):1867–1870. https://doi.org/10.38124/ijisrt20may650

Habes M, Elareshi M, Ali S, Ziani A (2022) Analyzing the portrayals of child sexual abuse of Urdu newspapers in developing countries. Pertanika J Soc Sci Humanit 30(4). https://doi.org/10.47836/pjssh.30.4.03

Hodder L, Gow K (2012) The long-term effects of childhood sexual abuse. In: Individual trauma: recovering from deep wounds and exploring the potential for renewal, vol 11, pp 101–114. https://doi.org/10.1097/00005053-199903000-00004

Chapter   Google Scholar  

Ma Y (2018) Prevalence of childhood sexual abuse in China: a meta-analysis. J Child Sex Abuse 27(2):107–121. https://doi.org/10.1080/10538712.2018.1425944

MacIntosh HB, Ménard AD (2021) Where are we now? A consolidation of the research on long-term impact of child sexual abuse. J Child Sex Abuse 30(3):253–257. https://doi.org/10.1080/10538712.2021.1914261

Mathews B, Collin-Vézina D (2019) Child sexual abuse: toward a conceptual model and definition. Trauma Violence Abuse 20(2):131–148. https://doi.org/10.1177/1524838017738726

Middleton W, Sachs A, Dorahy MJ (2017) The abused and the abuser: victim–perpetrator dynamics. J Trauma Dissociation 18(3):249–258. https://doi.org/10.1080/15299732.2017.1295373

National Sexual Violence Resource Center (2011) Overview: what is child sexual abuse?

Page MJ, McKenzie JE (2021). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Systematic Reviews. Full Text. https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-021-01626-4

Papalia N, Mann E, Ogloff JRP (2021) Child sexual abuse and risk of revictimization: impact of child demographics, sexual abuse characteristics, and psychiatric disorders. Child Maltreat 26(1):74–86. https://doi.org/10.1177/1077559520932665

Pérez-Fuentes G, Olfson M, Villegas L, Morcillo C, Wang S, Blanco C (2013) Prevalence and correlates of child sexual abuse: a national study. Compr Psychiatry 54(1):16–27. https://doi.org/10.1016/j.comppsych.2012.05.010

Petersen AC, Joseph J, Feit M (2014) New directions in child abuse and neglect research. New Directions Child Abuse Neglect Res. https://doi.org/10.17226/18331

Pratiwi AA, Asyary A (2017) The impact of child sexual abuse. J Ultimate Public Health 1(1):13–17. https://doi.org/10.22236/jump-health.v1.i1.p13-17

Pulverman CS, Kilimnik CD, Meston CM (2018) The impact of childhood sexual abuse on women’s sexual health: a comprehensive review. Sexual Med Rev 6(2):188–200. https://doi.org/10.1016/j.sxmr.2017.12.002

Rahnavardi M, Shahali S, Montazeri A, Ahmadi F (2022) Health care providers’ responses to sexually abused children and adolescents: a systematic review. BMC Health Serv Res 22(1):441. https://doi.org/10.1186/s12913-022-07814-9

Article   PubMed   PubMed Central   Google Scholar  

Sawyerr A, Bagley C (2017) Child sexual abuse and adolescent and adult adjustment: a review of British and world evidence, with implications for social work, and mental health and school counselling. Adva Appl Soc 7(1):Article 1. https://doi.org/10.4236/aasoci.2017.71001

Schreier A, Pogue JK, Hansen DJ (2017) Impact of child sexual abuse on non-abused siblings: a review with implications for research and practice. Aggress Violent Behav 34:254–262. https://doi.org/10.1016/j.avb.2016.11.011

Selengia V, Thuy HNT, Mushi D (2020) Prevalence and patterns of child sexual abuse in selected countries of Asia and Africa: a review of literature. Open J Social Sci 08(09):146–160. https://doi.org/10.4236/jss.2020.89010

Simuforosa M (2015) Factors contributing to child sexual abuse: an ecological analysis. Int J Curr Res 7(6). http://www.journalcra.com

Tenbergen G, Wittfoth M, Frieling H, Ponseti J, Walter M, Walter H, Beier KM, Schiffer B, Kruger THC (2015) The neurobiology and psychology of pedophilia: recent advances and challenges. Front Human Neurosci 9(June). https://doi.org/10.3389/fnhum.2015.00344

Tener D, Marmor A, Katz C, Newman A, Silovsky JF, Shields J, Taylor E (2020). Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier connect, the company’s public news and information.

Townsend C (2013) Prevalence and consequences of child sexual abuse compared with other childhood experiences. Darkness to Light, pp 1–19

UNICEF (2020a) Sexual violence against children. UNICEF. https://www.unicef.org/protection/sexual-violence-against-children

UNICEF (2020b) Sexual violence against children. UNICEF

Vaillancourt-Morel M-P, Godbout N, Bédard MG, Charest É, Briere J, Sabourin S (2016) Emotional and sexual correlates of child sexual abuse as a function of self-definition status. Child Maltreat 21(3):228–238. https://doi.org/10.1177/1077559516656069

Wagenmans A, Van Minnen A, Sleijpen M, De Jongh A (2018) El impacto del abuso sexual infantil en los resultados del tratamiento intensivo centrado en el trauma para el TEPT. Eur J Psychotraumatology 9(1). https://doi.org/10.1080/20008198.2018.1430962

Young Women’s Christian Association (2017) Child Sexual Abuse Facts. https://ywcaweekwithoutviolence.org/wp-content/uploads/2019/08/20190809-WWV19-CSAFactSheet-1.pdf

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Ali, S., Pasha, S., Cox, A. et al. Examining the short and long-term impacts of child sexual abuse: a review study. SN Soc Sci 4 , 56 (2024). https://doi.org/10.1007/s43545-024-00852-6

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literature review example on mental health

Recognising Signs of Deterioration in a Person’s Mental State

During national consultation for the  National Consensus Statement: Essential elements for recognising and responding to deterioration in a person’s mental state  the Commission identified the need to develop consensus on a set of signs that can be used for monitoring deterioration in a person’s mental state. The Commission engaged Gaskin Research to undertake the project and provide a report on Recognising Signs of Deterioration in a Person’s Mental State.

The authors conducted a literature review and interviews with key stakeholders to generate a list of signs. They then undertook a sequential survey process to develop consensus on the signs, resulting in a proposed set of 28 clusters of signs, arranged into five indicators:

  • Reported change
  • Loss of touch with reality or consequences of behaviours
  • Loss of function
  • Elevated risk to self, others or property.

These five indicators provide an overarching framework for monitoring deterioration in a person’s mental state, and are outlined in the  signs of deterioration in a person's mental state table .

The Commission will undertake further work with stakeholders on the alignment of the proposed signs with existing systems to ensure safe and effective response to deterioration in a person’s mental state.

An updated literature review was conducted in 2019.

Recognising Signs of Deterioration in a Person's Mental Health State An Updated Literature Review 2019 Publication, report or update

If you would like further information about any of the Commission’s work in mental health, please email:  [email protected]

  • Emergency mental health contact details

‘A nightmare’: Special counsel’s assessment of Biden’s mental fitness triggers Democratic panic

WASHINGTON — President Joe Biden sidestepped any criminal charges as the investigation into his handling of classified documents concluded, but the political blowback from the special counsel’s report Thursday could prove even more devastating, reinforcing impressions that he is too old and impaired to hold the highest office.

Special counsel Robert Hur’s portrait of a man who couldn’t remember when he served as Barack Obama’s vice president, or the year when his beloved son Beau died, dealt a blow to Biden’s argument that he is still sharp and fit enough to serve another four-year term.

In deciding not to charge Biden with any crimes, the special counsel wrote that in a potential trial, “Mr. Biden would likely present himself to a jury, as he did during our interview with him, as a sympathetic, well-meaning, elderly man with a poor memory.”

It was tough enough for Biden to reassure voters about his health before Hur’s report hit like a thunderclap Thursday afternoon, prompting members of his own party to question whether he could remain the nominee in November.

“It’s a nightmare,” said a Democratic House member who asked to speak anonymously to provide a frank assessment, adding that “it weakens President Biden electorally, and Donald Trump would be a disaster and an authoritarian.”

“For Democrats, we’re in a grim situation.”

Biden wasted little time before attempting to minimize the fallout. He held an unexpected exchange with reporters in the White House on Thursday night, in which he disputed Hur's assessment of his mental acuity.

Biden grew emotional when invoking the part of the report addressing the date of his son's death.

"How in the hell dare you raise that?" Biden said. "Frankly, when I was asked the question I thought to myself, 'It wasn't any of their damn business.' "

‘Beyond devastating’

Polling has long shown that age looms as Biden’s greatest liability in his expected rematch with Trump. A January poll by NBC News found that 76% of voters have major or moderate concerns about Biden’s mental and physical health.

“It’s been a problem since way before this ever happened,” said a longtime Democratic operative who noted that when focus groups are asked to apply one word to Biden, it is often “old.”

Just this week, Biden twice referred to conversations he’s had as president with foreign leaders who’ve long since died. In his remarks Thursday night defending his competency, while talking about the war in Gaza, he referred to Egyptian President Abdel Fattah el-Sissi as being the head of Mexico. White House press aides have downplayed such lapses as the sort of mistake anyone in public life can make.

The Hur report strips away the defenses that Biden’s press operation has used to protect him and raises fresh doubts about whether Biden is up to the rigors of the presidency, Democratic strategists said in interviews.

“This is beyond devastating,” said another Democratic operative, speaking on condition of anonymity to talk candidly about Biden’s shortcomings. “It confirms every doubt and concern that voters have. If the only reason they didn’t charge him is because he’s too old to be charged, then how can he be president of the United States?”

Asked if Hur’s report changes the calculus for Democrats who expect Biden to be the party’s nominee, this person said: “How the f--- does it not?”

Another Biden ally called it “the worst day of his presidency.”

“I think he needs to show us this is a demonstrably false characterization of him and that he has what it takes to win and govern.”

Biden has overwhelmingly won the first primary contests — notching victories in New Hampshire, South Carolina and Nevada. It would be virtually impossible for anyone else to challenge him at this point; the deadline has passed in more than 30 states to get on primary ballots.

Some of the president’s allies were quick to defend him. They pointed to the timing of the interview with the special counsel — days after Hamas’ attack on Israel, which had captured much of the president’s focus. Others said that in their own dealings with Biden, he shows no sign of infirmity.

“He did so well in this discussion with members,” Rep. Susan Wild, D-Pa., told NBC News after seeing the president on Thursday. “He’s very sharp, no memory issues, and his only stumbling is when he trips over words consistent with his lifelong speech impediment.”

‘Prejudicial language’

Though Biden was fortunate to escape indictment, the special counsel report may give Trump additional fodder as he fights charges for allegedly mishandling classified records at his Mar-a-Lago social club. Republicans are already accusing Biden of benefiting from a double standard . Trump will likely brandish the Hur report as proof that Biden has “weaponized” the Justice Department for political advantage.

What’s more, Democrats will now be hard-pressed to capitalize on Trump’s indictment over retaining classified records. Before Hur’s report came out, Democrats argued that the two cases were very different. Whereas Trump failed to turn over classified records even after he was asked to do so, Biden willingly cooperated with authorities and relinquished all the material he had, Biden allies had argued.

“The public understands the essential difference between presidents or vice presidents like Joe Biden who occasionally behaved in sloppy ways with respect to where they were taking documents, and a president like Trump, who deliberately makes off with hundreds of classified government documents and then hides them and refuses to return them,” Rep. Jamie Raskin, D-Md., said on Wednesday, before the report was released. (Trump has denied any wrongdoing.)

Now, the distinctions may be harder for Biden allies to draw, given that Hur wrote that there was evidence Biden “willfully retained and disclosed classified material after his vice presidency when he was a private citizen.”

The report mentions an instance in February 2017, when he was no longer vice president, when Biden read notes containing classified information “nearly verbatim” to a ghostwriter helping him with his book, “Promise Me, Dad.”

Storage of sensitive government secrets was haphazard. The report describes certain classified records involving the war in Afghanistan in Biden’s Delaware garage inside a “badly damaged box surrounded by household detritus.”

Before the report was released, Biden aides had been bracing for a finding that he had simply been careless in his treatment of classified records, a person familiar with the White House’s thinking said.

The political fallout from the report, though, is likely to be “worse,” this person said. What will stick in people’s minds is what Hur said about Biden’s memory, the person added.

Biden’s lawyers disputed the report’s description of Biden’s forgetfulness.

“We do not believe that the report’s treatment of President Biden’s memory is accurate or appropriate,” two of his lawyers wrote in a letter to Hur. “The report uses highly prejudicial language to describe a commonplace occurrence among witnesses: a lack of recall of years-old events.”

In the hours after the report was released, people close to the Biden campaign rolled out a different rebuttal. Jim Messina, who ran Obama’s 2012 re-election campaign, wrote on X, the site formerly known as Twitter, that Hur is a Republican who “knew exactly how his swipes could hurt Biden politically.”

That’s a familiar argument. Trump has also claimed that law enforcement is trying to sway the election, meaning both sides are now claiming victimization at the hands of partisan prosecutors.

“Hur knew exactly what he was doing here,” Stephanie Cutter, a veteran Democratic operative, wrote on X. “To provide political cover for himself for not prosecuting, he gratuitously leveled a personal (not legal) charge against the president that he absolutely knows is a gift to Trump. And, guess what we are all talking about?”

literature review example on mental health

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Mental Health Research in Ghana: A Literature Review

1 Department of Anthropology, University College London, 14 Taviton St, London, UK, WC1H 0BW

2 P O Box 060, Institute of Psychiatry, King's College London, Denmark Hill, London, SE5 8AF

Context/Background

Mental health is a neglected area in health care in Ghana. With few clinicians and trained researchers in the field, research has been limited both in quantity and quality.

A search of the available literature revealed 98 articles published between 1955 and 2009. Sixty-six are reviewed in this paper.

Topics covered included hospital and community-based prevalence studies, psychosis, depression, substance misuse, self-harm, and help-seeking. Much of the research was small in scale and thus largely speculative in its conclusions. Epidemiological data is scarce and unreliable and no large-scale studies have been published. There are very few studies of clinical practice in mental health.

Conclusions

The existing literature suggests several important areas for future research to inform the development of targeted and effective interventions in mental health care in Ghana.

Introduction

Psychiatry in Ghana is neglected in health care and research. In 1972 Adomakoh proclaimed in this journal ‘There is a dearth of detailed knowledge of psychiatric illness in this country’. 1 Nearly 40 years later the research record has expanded, but accurate data on epidemiology, treatment and outcomes is still sorely needed. In the absence of reliable evidence, the gaps are filled by data extrapolated from international research, “guesstimates”, and anecdotal evidence.

The first study of mental illness in the then Gold Coast was commissioned by the Colonial Office to study ‘the forms of neurosis and psychosis among West Africans’. Four hundred cases of mental disorder were identified with the help of census enumerators and chiefs. 2 This was followed in the 1950s by ethnographic research of people with mental disorder attending rural shrines. 3 Following independence and the training of Ghanaian psychiatrists, local psychiatrists began to publish clinically-based research. However with limited resources and research expertise, the studies were small and output was limited. This situation has persisted until recently. The majority of research in mental health has been undertaken by the country's few psychiatrists, occasionally assisted by expatriate researchers or clinicians and has remained small in scale.

Recently a new impetus for mental health in Ghana has seen the establishment of mental health NGOs, the drafting of a new mental health bill, increased training for psychiatrists and psychiatric nurses, proposals for training new cadres of primary health care specialists in mental health, and increased media attention. There has also been an increase in the number of research projects and publications on mental health from a diversity of disciplines including psychology, sociology and anthropology.

The Kintampo Health Research Centre has supported studies of risk factors for psychosis, mental disorders among older people, an ethnography of psychosis, 4 , 5 and an epidemiology of postnatal depression. The Mental Health and Poverty Project , which conducted research on mental health policy in four African countries including Ghana, 6 has produced several publications in indexed journals. 7 , 8 , 9 , 10 , 11

The PubMed indexing of the African Journal of Psychiatry and the online publication of the Ghana Medical Journal (GMJ) present new opportunities for mental health research in Ghana to provide a much-needed contribution to regional and international research on African mental health. This paper aims to provide an overview of the current state of research on mental health in Ghana, and a critical review of published research papers. The findings of these papers are synthesised to highlight priority areas for mental health research in Ghana which should be of value to both clinicians and researchers in the field.

A literature search was conducted of social science and medical journals in Ghana and the UK. The authors conducted an on-line search of Pubmed using MeSH terms ‘ psychiatry AND Ghana ’, ‘ mental disorders AND Ghana ’ ‘ mental health services AND Ghana ’, ‘ mental health AND Ghana’, ‘self-injurious behaviour AND Ghana’ , in addition to a manual search of the libraries of Korle-Bu Teaching Hospital (KBTH), the Institute of Psychiatry, UK, and the London School of Hygiene and Tropical Medicine (LSHTM).

Ninety-nine articles published between 1955 and 2009 were identified. Thirty-three articles were excluded (see Table 1 ). Sixty-six were included in this review. Articles were grouped under the most relevant topics however there was overlap in some papers (see Table 2 ).

Papers excluded from the review

Reviewed papers by topic

Epidemiology

Early researchers and clinicians predicted an increase in mental disorders in Ghana as a result of the presumed stresses of industrialisation and ‘acculturation’. 12 , 13 Yet to date the true prevalence of mental illness in Ghana remains uncertain. Epidemiological studies are based on small numbers and rely on clinical case-finding methods. Prevalence rates drawn from such data are below expected rates from international comparative studies and in the absence of data from population-based epidemiological studies are likely to be an underestimation.

Since psychiatric hospitals are the most easily accessible research sites, particularly for hard-pressed clinicians, a number of studies have been undertaken drawing on records at Accra Psychiatric Hospital (APH). In a study of first admissions to APH between 1951 and 1971 Forster observed a sharp increase in admissions from 265 in 1951 to 2284 in 1967 followed by a decline to 736 in 1971. 15 This change was attributed this to the political crisis between 1961–1966, however since then admissions approximate to the 1960s figure despite political stability and economic development in recent years. Hospital admissions are unreliable indicators of psychiatric morbidity since they are confounded by population growth and increased awareness and exclude many cases who do not attend psychiatric services. 14

The few community-based prevalence studies do not employ standardised research diagnoses or methods. 12 , 16 , 17 , 18 epidemiological In Kumasi 194 participants were interviewed using the mental state examination (MSE) and the Self-Reporting Questionnaire (SRQ). Thirty-eight were diagnosed with depressive illness, of which 33 were women. Five women were diagnosed with schizophrenia and five men with somatisation disorder. Despite the limitations of the methodology, the author calculated an overall prevalence of psychiatric illness of 27.51%. 18 Noting the popularity of prayer camps and shrines in the treatment of mental disorders, Turkson suggests that epidemiological studies of mental illness in Ghana should include these. 19

chizophrenia/psychosis

In 1968 Field stated there had been an explosive increase in schizophrenia within the last 20 years (p.31). 20 However she had no data with which to substantiate such a claim. Her longitudinal study of hundreds of cases attending rural shrines in Ashanti and Brong Ahafo 12 , 20 , 21 provided a wealth of clinical and contextual detail however she did not quantify most of her work. In one exception she approached chiefs and elders of rural towns and villages and identified 41 cases of chronic schizophrenia in 12 villages with a combined population of 4,283. In the 1960s Fortes and Mayer, conducted a study of psychosis among the Tallensi in Northern Ghana. Mayer diagnosed 17 cases of psychosis, eight men and nine women. 17

In the 1980s a study of the prevalence of schizophrenia in Labadi, Greater Accra using clinical interviews and a review of medical records identified 28 cases of schizophrenia including 19 males in a population of 45,195. Thirty-one vagrants were also found to be psychotic. 16 Methods were restricted to tracing cases from APH and Pantang Hospital, screening patients at the polyclinic, visiting a shrine and assessing 175 vagrants. No house-to-house case-finding was conducted.

Studies at APH consistently record schizophrenia and psychosis as the most commonly recorded diagnosis for about 70-75% of inpatients. 1 , 22 In the only identified study of mentally disordered offenders at APH, most had been diagnosed with psychotic illness including 31% with schizophrenia, 20.2% with drug-induced psychoses, and 13.3% with non-specified psychosis. Most of those charged with murder or attempted murder had been diagnosed with psychotic illness, nearly half (48.6%) with schizophrenia. 23

The preponderance of schizophrenia as a diagnosis among inpatients continues to the present day. This is probably since only the most severe cases are admitted. The symptoms of acute psychosis also present grave difficulties for family members to manage at home, and are likely to prompt help-seeking. A Delphi consensus study of resource utilisation for neuropsychiatric disorders in developing countries, including Ghana, suggested that acute psychosis, manic episodes, and severe depression were the most common disorders treated within inpatient psychiatric care. 14

Colonial psychiatrists asserted the virtual absence of depression among Africans, which was later challenged by Field among others. Field surmised that the self-accusations of women who confessed to witchcraft were akin to the self-reproach expressed by women with depression in Britain. 3 , 21 and that ‘Depression is the commonest mental illness of Akan rural women’ (p. 149). 3 Two studies of psychiatric morbidity in general hospitals and clinics suggest that more neurotic and affective disorders may be seen in these facilities than in the psychiatric hospitals although numbers are small. 24 , 25 In a survey of psychiatric morbidity at 6 polyclinics in Accra, of 172 patients, 27 were found to have psychiatric illness, with a further seven having physical illness with concomitant psychiatric illness. Of these 23 (72%) were diagnosed with ‘neurosis’. 24 Lamptey recorded no cases of depression, however it is possible these may have been missed due to the prominence of somatic symptoms such as palpitations, burning sensations and insomnia. In another study of 94 patients referred to a psychiatric out-patient clinic at KBTH the majority were diagnosed with affective (23) and neurotic/stress related disorders (11). 25

To address the lack of cross-cultural data on depression in the early 1980s the World Health Organization sponsored a study utilising the Standardized Assessment for Depressive Disorders (SADD). Fifty patients were assessed using SADD, Thirty-three were female. Anxiety and tension were the core symptoms expressed, with 35% reporting feelings of guilt and self-reproach. Feelings of sadness and loss of interest and enjoyment were commonly reported. Forty reported somatic symptoms including headaches, bodily heat, and generalised body pain. 26

The authors argue that there has been a change in the presentation of depression in Africa compared to earlier data. However, whilst the population of Ghana is more widely educated than in the 1950s, the study recruited a highly selective English-speaking sample who had already interpreted their symptoms in such as way as to approach psychiatric hospital. Indeed Turkson and Dua's study with a larger, less well-educated sample produced contrasting results. They studied 131 female outpatients with a diagnosis of depression using the Montgomery-Asberg Depressive Rating Scale (MADRS). They noted a high degree of somatic symptoms, in particular headaches (77.86%) and sleeplessness (68.7%). In contrast to the SADD study, there were fewer reported psychological symptoms such as pessimistic thoughts (20.61%) and sadness (12.97%). Only 10 (7.3%) reported suicidal thoughts. 27 However the MADRS has fewer psychological items than the SADD and therefore elicits different symptoms, highlighting one of the limitations of standardised instruments, particularly where they have not been validated with the local population.

Osei explored the incidence of depression among 17 self-confessed ‘witches’ at three shrines in the Ashanti region of Ghana. All were diagnosed with depression according to ICD-10. Three also had serious physical health problems. As in the previous studies, many described physical complaints such as a burning sensation or persistent headaches. The women also expressed ideas of guilt relating to having harmed someone in the family through the use of witchcraft. 28 Like Field, Osei suggests that guilt feelings arising from depression might prompt women to confess to witchcraft.

Such research raises interesting issues for the study of mental illness within the context of widespread belief in witchcraft and other supernatural phenomena in Ghana.

Turkson and Dua hypothesise on a link between socioeconomic status and depression, however without a control group and with inadequate numbers they could provide little substantive evidence. A qualitative study of 75 women in the Volta region is highly suggestive of a link between social factors and psychological distress. 29 – 31 Whilst this study did not set out specifically to research mental disorders, almost three quarters of the women interviewed described ‘thinking too much’ or ‘worrying too much’. Importantly, such symptoms were more prominent in women's accounts of their health than physical health problems.

Most participants complained of stresses arising from multiple responsibilities in the arenas of family and work, as well as financial hardship. 30 Headaches, bodily aches and pains, and sleep disturbance were commonly reported. A similar link between such experiences of poverty and possible symptoms of mental illness such as excessive thinking, worry and anxiety, as well as persistent physical symptoms such as headaches, has been made in a study of migrant squatters in Accra. 32 It is probable that some of these women may have met the criteria for a psychiatric diagnosis of depression.

The prominence of somatic symptoms among Ghanaian women diagnosed with depression is notable. Turkson notes that in 1988 32% of all new patients at APH presented with primarily somatic symptoms such as headaches, burning sensations, tiredness and bodily weakness with the majority diagnosed with anxiety, depression and somatisation disorders. 25 This highlights the importance of screening measures which have been locally validated and can identify somatic and non-somatic symptoms. A study of depression and life satisfaction among Nigerian, Australian, Northern Irish, Swazi and Ghanaian college students utilising the Beck Depression Inventory (BDI) for example, found that Ghanaians had significantly lower depression scores than other groups. 33

Aside from sleeplessness and loss of appetite, the BDI items are mostly concerned with psychological aspects of depression such as worthlessness and guilt. In a study of the comparative validity of screening scales for post-natal common mental disorders Weobong provides evidence for the cross-cultural validity and reliability of a Twi version of the Patient Health Questionnaire (PHQ-9). 34

Significantly the study showed that a mixture of somatic and cognitive symptoms best discriminated between cases and non-cases for all scales evaluated.

Given the high birth rate in Ghana, Weobong's study of post-natal depression will provide much-needed data on a condition which has been little researched. The only previous study identified described four cases of psychiatric disorders associated with childbirth treated at APH, including post-partum psychosis and manic-depressive psychosis. The author observed that few cases were referred to the psychiatric hospital and queried whether post-partum mental disorders were being recognised within antenatal wards. He also noted the influence of social factors such as marital problems and financial difficulties. 35

The literature reveals that women are generally underrepresented in psychiatric hospitals in Ghana. In Forster's study of APH inpatient admissions between 1951–1971 males consistently outnumbered females by about 3:1. 15 It has been suggested that when men become acutely mentally unwell they may be more difficult to manage at home, and so are more likely to be brought to the psychiatric hospitals for treatment. 16 18 36 37 Women in Ghana appear to be underserved by mental health services and the majority of women suffering from mental disorders, particularly depression, remain untreated or under the care of churches and shrines. Research at facilities such as polyclinics, shrines and churches may provide a more accurate picture of the numbers of women with mental disorders and their clinical presentation.

Suicide and self-harm

There is very little research on self-harm in Ghana. Roberts and Nkum examined the case notes of 53 patients admitted to Komfo Anokye Teaching Hospital (KATH) over a 5 year period. 38 The most common means of self-harm was ingestion of pesticides (22), and other harmful substances. 10 used ‘physical methods’ including self-stabbing (4). 6 cases were diagnosed with psychosis and 28 with acute reactions to social stresses such as marital and financial problems. The authors found an increase in deliberate self-harm during the five year period compared to an earlier study 39 from 0.3 cases per 1,000 admissions between 1965–1971 to 1.32 cases per 1,000 admissions in 1987. Based on their findings the authors estimated a crude annual incidence of 2.93 per 100,000. However this figure is likely to be an underestimate given that some cases may not reach medical services.

A number of studies comparing suicidal ideation among Ghanaian and Caucasian students in the USA showed significantly lower rates of self-reported suicidal ideation among the Ghanaian sample, as well as more negative attitudes towards suicide. 40 41 A larger survey compared 570 Ghanaian students with students from Uganda and Norway utilising the Attitudes Toward Suicide Questionnaire. Thirty (5.4%) of the Ghanaian sample reported making suicide attempts, significantly lower than either Uganda or Norway. Nine of the respondents reported a completed suicide in the family, and 91 among non-family members, again markedly lower than those reported by the Ugandan and Norwegian respondents. 42

Though these studies seem to suggest a low rate of suicidal ideation in Ghana, generalisation is cautioned since all the studies were conducted with young, urbanised, highly-educated participants. There is also no published research on completed suicides in Ghana. It is possible that the lower reported rates of suicidal ideation or suicide attempts may in part reflect likelihood that Ghanaian students would be less likely to report suicidal ideation due to negative attitudes towards suicide. This is supported by the finding of Hjelmeland et al that 31% of their sample felt that suicide should not be talked about. 42

However these studies also point to possible factors in Ghanaian society which could be employed in suicide prevention including family support, religious belief, and an emphasis on the value of the group. Qualitative studies related to beliefs and attitudes towards suicide, as well as risk factors, would greatly enhance the quantitative data and enable an exploration of some of the correlations observed. 41 There is one recent study on anorexia nervosa among female secondary school students in North East Ghana, a condition which has been considered rare in non-Western cultures.

The researchers completed a clinical examination of physical and mental health, two standard measures of eating behaviour and attitudes, and a depression screen. Of 666 students, 29 were pathologically underweight of which 10 were diagnosed with morbid self-starvation based on clinically significant indicators such as denial of hunger, self-punishment and perfectionist traits. The majority of the participants, both Christian and Muslim, reported regularly engaging in religious fasting. For the 10 engaged in morbid self-starvation, this fasting was particularly frequent, at least once a week, and associated with feelings of self-control and self-punishment. Since self-starvation was not associated with a desire to be thin or a morbid fear of fatness, a diagnosis of anorexia nervosa according to DSM-IV or ICD-10 criteria could not be made.

However the authors suggest that in Ghana fasting rather than dieting may provide the cultural context within which morbid self-starvation occurs. 43 As suggested by the role of somatic symptoms in the presentation of depression in Ghana, this study has important implications regarding the limitations of standardised psychiatric diagnoses and the need to recognise cultural influences on the presentation of mental illness.

Substance misuse

It is notable that the highest number of published papers in this review concerns substance abuse. 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 This may reflect more on the interests of researchers than the severity of the problem. In his sociological study Affinnih claims there has been an increase in the use of drugs such as cocaine and heroin in Accra and other urban centres. 45 , 46 However data from the psychiatric hospitals suggests that cannabis and alcohol are the most frequently used substances and may be a risk factor for the development of psychosis amongst young men. 23 , 25 , 54 , 53

There is limited research on the mental health implications of substance use in Ghana. A study of substance abusers admitted to a private clinic in Accra excluded those with co-morbid mental illness. 49 Importantly only two papers were identified which were primarily concerned with alcohol misuse, one of which is a social history of alcohol use in Ghana. 44 The only epidemiological study of alcohol misuse was conducted with 350 psychiatric outpatients in Kumasi using the WHO Alcohol Use Disorders Identification Test (AUDIT).

The researchers found a prevalence of only 8.6% for hazardous drinking, significantly lower than comparable studies in the West. 53 The link between substance misuse and mental disorders may be exaggerated in the public imagination and the media and there is a tendency to make speculative assertions based on limited evidence. Affinnih for example quotes a minister of health as saying that ‘drugs are responsible for 70% of the cases in local psychiatric hospitals’ (p.397), 45 a figure which is not substantiated by hospital records. More research is needed in this area from a specifically mental health perspective.

Help-seeking

The popularity of traditional healers in the treatment of mental illness has been noted since the earliest studies of mental illness in Ghana and continues to the present day. 55 A study of 194 people attending three shrines in the Ashanti region stated that 100 (51.55%) of these were suffering from a mental illness, the majority (64 (32.99%)) with depression. Another 14 were diagnosed with somatisation, and 19 with psychotic illness, including 6 with schizophrenia, 4 with acute psychosis and 3 with cannabis-induced psychosis. 28 36

Though data is limited, two papers suggest a change in the pattern of help-seeking over the last thirty years, with a greater role for Christian healers. In 1973 a study of 105 patients at APH diagnosed with psychosis showed that almost all (97(92%)) had sought another form of treatment before attending the psychiatric hospital. 67 (64%) patients had consulted a herbalist, 28 (26%) a healing church, and only 2 a fetish priest. 56

A study in 2004 of the use of traditional healers and pastors by 303 new patients attending state and private psychiatric services in Kumasi found that a smaller proportion of patients had consulted other forms of treatment and a greater number reported consulting a pastor than a traditional healer (43 (14.2%) and 18 (5.9%) respectively). There also appeared to be more use of medical facilities in the treatment of mental illness. 14 patients had seen a family doctor and 6 had visited another psychiatric hospital. Nearly a quarter (24.4%) had previously attended one of the other mental health centres in Kumasi. 57

Limited research has been conducted on beliefs and attitudes towards mental illness in Ghana which may influence help-seeking behaviour, though there is much speculation on the spiritual attribution of mental illness amongst the general population. 7 Two studies conducted in the early 1990s suggest a more varied and complex picture. A quantitative survey of 1000 women in Accra found that most (88%) said they would seek help from the psychiatric hospitals and only a minority (8.2%) said they would consult traditional healers.

The most important socio-demographic factors influencing the orientation towards help-seeking were area of residence, ethnicity, migration status, and prior use of medical services. Women who perceived the cause of psychosis to be natural or stress-related were more likely to seek help from mental hospitals than those who identified supernatural causation. 58 Similarly, a study of the effect of social change on causal beliefs of mental disorders and treatment preferences among teachers in Accra found that rather than emphasising spiritual causation for mental illness in Ghana, respondents attributed multiple causal factors to mental illness drawn from biological, social and spiritual models.

The authors attributed this in part to ‘acculturation’ but cautioned that participants may have wished to present themselves as educated and therefore have been less willing to disclose supernatural beliefs.

They also hypothesised that such beliefs may only come into play as an ‘indirect attribution’. 59 In both studies participants were urban residents and most were educated. Using semi-structured interviews with 80 relatives of people with mental illness, and 10 service providers, Quinn explored beliefs about mental illness in Accra and Kumasi, and two rural areas in the Ashanti and Northern regions and how these influenced family responses to mental illness.

In line with the urban ‘acculturation’ thesis, 2 , 17 Quinn reported that in urban areas most respondents attributed mental illness to ‘natural’ causes such as work stress. In the Northern region however, spiritual attributions were more common. The Northern samples were also significantly less educated with 14 out of 19 respondents having no education. Caution should be exercised in generalising these results as the sample size in each area was small. There were also many ‘don't knows’ - 22 out of 80. 60 This may be a reflection of more complex aetiological beliefs and uncertainty around the cause of mental illness than reflected in a binary spiritual/natural schema, as earlier studies have suggested. 37 , 59

Quinn's study claims that there was greater reliance on traditional healing in the North due to beliefs in a spiritual origin of mental illness; however it does not explore these issues in sufficient depth to support this assertion. The lower education of those in the Northern sample as well as their long distance from the psychiatric hospitals was other factors which may have influenced help-seeking. The study also reports that respondents in the Northern Region described greater acceptance of people with mental illness by families and communities with little evidence of stigma, echoing earlier reports. 2 , 17 Quinn's finding however is based on only 19 respondents, 17 of which were male. Since mothers are likely to provide most of the caring role they might have provided differing opinions on the impact of the illness. 60

None of these studies allow for in-depth exploration of possible influences on help-seeking behaviour for mental illness. However they suggest some interesting hypotheses regarding the reputation of traditional healers in treating mental illness, the stigma attached to mental illness and psychiatric hospitals, and the scarcity of psychiatric services.

In common with other mental health researchers and professionals in Africa, these studies recommend collaboration with traditional and faith healers in the treatment of mental illness, such as training healers in recognising severe mental illness, and referring patients to psychiatric services. However traditional healers and pastors may be unwilling to pass on their customers to biomedical practitioners or admit to failings in their intervention. Claims for the efficacy of traditional healers also tend to be anecdotal and speculative and are seldom based on rigorous longitudinal data. Most authors highlight the role of traditional healers in addressing the psychosocial aspects of mental illness and their resonance with cultural beliefs. 37 , 56 , 61 , 62 , 63

Whilst some present a rather idealised picture, 61 others note the inhumane treatment of people with mental illness by traditional healers. 4 , 36 , 62 One paper points to the role of the family in caring for patients within traditional shrines and churches, and shows how this model was replicated within psychiatric facilities by enabling family members to stay with the patient in hospital. 64 Further research is needed on the practices of traditional and faith healers to inform interventions to address the maltreatment of people with mental illness, and ensure that those with mental illness receive the best quality treatment from both psychiatric facilities and informal services.

This review shows that mental health research in Ghana remains limited in both quantity and quality. In the absence of comprehensive research, much is assumed based on scant evidence, and services are heavily influenced by the results of research conducted elsewhere, most often in high-income settings. Whilst researchers have used their findings to argue for more resources for mental health, such pleas would be more forcefully made were there more accurate epidemiological data. It is difficult to estimate the true prevalence of mental disorder and plan effectively for mental health promotion and treatment without more rigorous, large-scale population-based studies. However the published research on mental disorders such as psychosis, depression, substance misuse and self-harm provides insights for future research on the cultural context of these disorders in Ghana, including risk factors, with important implications for clinical intervention and mental health promotion.

A major omission in the literature regards studies of the practice and efficacy of psychiatric treatment in Ghana. Given the scarcity of psychosocial interventions, psychotropic medication is the mainstay of treatment and has been the topic of four papers. 65 , 66 , 67 One study reports that adherence to medication is poor among many patients 68 suggesting the need for further research into the reasons for this, and methods by which to improve both access and adherence.

Most research in Ghana has been conducted by psychiatrists and there is very little published research by psychologists, psychiatric nurses and social workers. The only published study identified on counselling argued for consideration of notions of self-identity, as well as the influence of the multi-lingual post-colonial environment when importing talking therapies, 69 a topic which would benefit from further research. Multidisciplinary research is also needed on the particular social and psychological factors which play an important part in the aetiology and course of mental disorders within Ghana and how these might be addressed.

Research on beliefs and attitudes towards mental illness suggests that these influence not only help-seeking behaviour but also stigma, care-giving and social inclusion. Research in this area may not only point to the roots of stigma, social exclusion and human rights abuse, but also to potential resources for the support and social integration of those with mental disorders. Most importantly research on mental health in Ghana needs to focus on experiences of the mentally ill and their caregivers. Existing research suggests a high social, financial and psychological burden for patients and carers, 4 , 30 , 31 , 60 and further research in this area could provide a powerful tool to argue for greater attention to mental illness as a neglected public health concern.

The studies reviewed have been small in scale and of limited generalizability. Nonetheless, they provide important insights into the development of mental health care in Ghana, and suggest directions for future research. Based on this review we suggest the following priorities for mental health research in Ghana:

  • Population-based epidemiological studies of mental disorders - including attention to shrines and churches.
  • Research on mental disorders, in particular psychosis, substance use, depression, somatisation, and self-harm including risk factors, clinical picture, course and outcome.
  • Outcome studies of interventions within psychiatric services, primary care and other service providers e.g. NGOs
  • Experiences of people with mental illness and their family members, including the psychosocial and financial impact, help-seeking and treatment experiences.
  • The practices of traditional and religious healers and potential for collaboration.

Evidently these topics call for both quantitative and qualitative methodologies across disciplines in both medicine and social science. However an important caveat remains as to who will conduct this research given the pressures on clinicians and the limited research expertise. For too long mental health research has been dominated by experts in high-income countries with the consequent risk of cultural bias.

There remains a need for capacity building among clinicians across all disciplines to conduct clinically-based research, and for researchers trained in psychiatric epidemiological methods. Collaboration with mental health researchers in Africa and elsewhere, including the Ghanaian diaspora is one suggestion. 70 Above all high quality large-scale research requires funding. Given the burden of mental illness suggested by existing research in Ghana and elsewhere in the region, there is a strong case for international funding for mental health research to provide an evidence-based foundation for targeted and culturally relevant interventions.

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  1. A scoping review of the literature on the current mental health status

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    concluded that suicide prevention and so-called "mental health literacy" campaigns can make short-term improvements in mental health and suicide related knowledge and attitudes, for example, increased recognition of depression. However, most studies show limited effects on behaviors when communications are used alone (Goldney et al., 2008).

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  26. Mental Health Research in Ghana: A Literature Review

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