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• Published: 13 May 2021

Global prevalence of mental health issues among the general population during the coronavirus disease-2019 pandemic: a systematic review and meta-analysis

• Surapon Nochaiwong   ORCID: orcid.org/0000-0003-1100-7171 1 , 2 ,
• Chidchanok Ruengorn   ORCID: orcid.org/0000-0001-7927-1425 1 , 2 ,
• Kednapa Thavorn   ORCID: orcid.org/0000-0003-4738-8447 2 , 3 , 4 , 5 ,
• Brian Hutton   ORCID: orcid.org/0000-0001-5662-8647 3 , 4 , 5 ,
• Ratanaporn Awiphan   ORCID: orcid.org/0000-0003-3628-0596 1 , 2 ,
• Chabaphai Phosuya 1 ,
• Yongyuth Ruanta   ORCID: orcid.org/0000-0003-4184-0308 1 , 2 ,
• Nahathai Wongpakaran   ORCID: orcid.org/0000-0001-8365-2474 6 &
• Tinakon Wongpakaran   ORCID: orcid.org/0000-0002-9062-3468 6  

Scientific Reports volume  11 , Article number:  10173 ( 2021 ) Cite this article

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• Post-traumatic stress disorder

To provide a contemporary global prevalence of mental health issues among the general population amid the coronavirus disease-2019 (COVID-19) pandemic. We searched electronic databases, preprint databases, grey literature, and unpublished studies from January 1, 2020, to June 16, 2020 (updated on July 11, 2020), with no language restrictions. Observational studies using validated measurement tools and reporting data on mental health issues among the general population were screened to identify all relevant studies. We have included information from 32 different countries and 398,771 participants. The pooled prevalence of mental health issues amid the COVID-19 pandemic varied widely across countries and regions and was higher than previous reports before the COVID-19 outbreak began. The global prevalence estimate was 28.0% for depression; 26.9% for anxiety; 24.1% for post-traumatic stress symptoms; 36.5% for stress; 50.0% for psychological distress; and 27.6% for sleep problems. Data are limited for other aspects of mental health issues. Our findings highlight the disparities between countries in terms of the poverty impacts of COVID-19, preparedness of countries to respond, and economic vulnerabilities that impact the prevalence of mental health problems. Research on the social and economic burden is needed to better manage mental health problems during and after epidemics or pandemics. Systematic review registration : PROSPERO CRD 42020177120.

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Introduction.

After the World Health Organisation (WHO) declared the rapid worldwide spread of coronavirus disease-2019 (COVID-19) to be a pandemic, there has been a dramatic rise in the prevalence of mental health problems both nationally and globally 1 , 2 , 3 . Early international evidence and reviews have reported the psychological effects of the COVID-19 outbreak on patients and healthcare workers, particularly those in direct contact with affected patients 4 , 5 , 6 , 7 , 8 . Besides patients with COVID-19, negative emotions and psychosocial distress may occur among the general population due to the wider social impact and public health and governmental response, including strict infection control, quarantine, physical distancing, and national lockdowns 2 , 9 , 10 .

Amid the COVID-19 pandemic, several mental health and psychosocial problems, for instance, depressive symptoms, anxiety, stress, post-traumatic stress symptoms (PTSS), sleep problems, and other psychological conditions are of increasing concern and likely to be significant 5 , 10 , 11 . Public psychological consequences can arise through direct effects of the COVID-19 pandemic that are sequelae related to fear of contagion and perception of danger 2 . However, financial and economic issues also contribute to mental health problems among the general population in terms of indirect effects 12 , 13 . Indeed, economic shutdowns have disrupted economies worldwide, particularly in countries with larger domestic outbreaks, low health system preparedness, and high economic vulnerability 14 , 15 , 16 .

The COVID-19 pandemic may affect the mental health of the general population differently based on national health and governmental policies implemented and the public resilience and social norms of each country. Unfortunately, little is known about the global prevalence of mental health problems in the general population during the COVID-19 pandemic. Previous systematic reviews have been limited by the number of participants included, and attention has been focussed on particular conditions and countries, with the majority of studies being conducted in mainland China 5 , 8 , 11 , 17 , 18 . To the best of our knowledge, evidence on mental health problems among the general population worldwide has not been comprehensively documented in the current COVID-19 pandemic. Therefore, a systematic review and meta-analysis at a global level is needed to provide robust and contemporary evidence to inform public health policies and long-term responses to the COVID-19 pandemic.

As such, we have performed a rigorous systematic review and meta-analysis of all available observational studies to shed light on the effects of the global COVID-19 pandemic on mental health problems among the general population. We aimed to: (1) summarise the prevalence of mental health problems nationally and globally, and (2) describe the prevalence of mental health problems by each WHO region, World Bank income group, and the global index and economic indices responses to the COVID-19 pandemic.

This systematic review and meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines 19 and reported in line with the Meta-analysis of Observational Studies in Epidemiology statement (Appendix, Table S1 ) 20 . The pre-specified protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42020177120).

Search strategy

We searched electronic databases in collaboration with an experienced medical librarian using an iterative process. PubMed, Medline, Embase, PsycINFO, Web of Science, Scopus, CINAHL, and the Cochrane Library were used to identify all relevant abstracts. As the WHO declared the COVID-19 outbreak to be a public health emergency of international concern on January 30, 2020, we limited the search from January 1, 2020, to June 16, 2020, without any language restrictions. The main keywords used in the search strategy included “coronavirus” or “COVID-19” or “SARS-CoV-2”, AND “mental health” or “psychosocial problems” or “depression” or “anxiety” or “stress” or “distress” or “post-traumatic stress symptoms” or “suicide” or “insomnia” or “sleep problems” (search strategy for each database is provided in the Appendix, Table S2 ). Relevant articles were also identified from the reference lists of the included studies and previous systematic reviews. To updated and provide comprehensive, evidence-based data during the COVID-19 pandemic, grey literature from Google Scholar and the preprint reports from medRxiv, bioRxiv, and PsyArXiv were supplemented to the bibliographic database searches. A targeted manual search of grey literature and unpublished studies was performed through to July 11, 2020.

Study selection and data screening

We included observational studies (cross-sectional, case–control, or cohort) that (1) reported the occurrence or provided sufficient data to estimate the prevalence of mental health problems among the general population, and (2) used validated measurement tools for mental health assessment. The pre-specified protocol was amended to permit the inclusion of studies the recruited participants aged 12 years or older and college students as many colleges and universities were closed due to national lockdowns. We excluded studies that (1) were case series/case reports, reviews, or studies with small sample sizes (less than 50 participants); (2) included participants who had currently confirmed with the COVID-19 infection; and (3) surveyed individuals under hospital-based settings. If studies had overlapping participants and survey periods, then the study with the most detailed and relevant information was used.

Eligible titles and abstracts of articles identified by the literature search were screened independently by two reviewers (SN and CR). Then, potentially relevant full-text articles were assessed against the selection criteria for the final set of included studies. Potentially eligible articles that were not written in English were translated before the full-text appraisal. Any disagreement was resolved by discussion.

The primary outcomes were key parameters that reflect the global mental health status during the COVID-19 pandemic, including depression, anxiety, PTSS, stress, psychological distress, and sleep problems (insomnia or poor sleep). To deliver more evidence regarding the psychological consequences, secondary outcomes of interest included psychological symptoms, suicidal ideation, suicide attempts, loneliness, somatic symptoms, wellbeing, alcohol drinking problems, obsessive–compulsive symptoms, panic disorder, phobia anxiety, and adjustment disorder.

Data extraction and risk of bias assessment

Two reviewers (SN and YR) independently extracted the pre-specified data using a standardised approach to gather information on the study characteristics (the first author’s name, study design [cross-sectional survey, longitudinal survey, case–control, or cohort], study country, article type [published article, short report/letters/correspondence, or preprint reporting data], the data collection period), participant characteristics (mean or median age of the study population, the proportion of females, proportion of unemployment, history of mental illness, financial problems, and quarantine status [never, past, or current]), and predefined outcomes of interest (including assessment outcome definitions, measurement tool, and diagnostic cut-off criteria). For international studies, data were extracted based on the estimates within each country. For studies that had incomplete data or unclear information, the corresponding author was contacted by email for further clarification. The final set of data was cross-checked by the two reviewers (RA and CP), and discrepancies were addressed through a discussion.

Two reviewers (SN and CR) independently assessed and appraised the methodological quality of the included studies using the Hoy and colleagues Risk of Bias Tool-10 items 21 . A score of 1 (no) or 0 (yes) was assigned to each item. The higher the score, the greater the overall risk of bias of the study, with scores ranging from 0 to 10. The included studies were then categorised as having a low (0–3 points), moderate (4–6 points), or high (7 or 10 points) risk of bias. A pair of reviewers (RA and CP) assessed the risk of bias of each study. Any disagreements were resolved by discussion.

Data synthesis and statistical methods

A two-tailed P value of less than 0.05 was considered statistically significant. We used Stata software version 16.0 (StataCorp, College Station, TX, USA) for all analyses and generated forest plots of the summary pooled prevalence. Inter-rater agreements between reviewers for the study selection and risk of bias assessment were tested using the kappa (κ) coefficient of agreement 22 . Based on the crude information data, we recalculated and estimated the unadjusted prevalence of mental health and psychological problems using the crude numerators and denominators reported by each of the included studies. Unadjusted pooled prevalence with corresponding 95% confidence intervals (CIs) was reported for each WHO regions (Africa, America, South-East Asia, Europe, Eastern Mediterranean, and Western Pacific) and World Bank income group (low-, lower-middle-, upper-middle-, and high-income).

We employed the variance of the study-specific prevalence using the Freeman–Tukey double arcsine methods for transforming the crude data before pooling the effect estimates with a random-effect model to account for the effects of studies with extreme (small or large) prevalence estimates 23 . Heterogeneity was evaluated using the Cochran’s Q test, with a p value of less than 0.10 24 . The degree of inconsistency was quantified using I 2 values, in which a value greater than 60–70% indicated the presence of substantial heterogeneity 25 .

Pre-planned subgroup analyses were performed based on the participant (i.e., age, the proportion of female sex, the proportion of unemployment, history of mental illness, financial problems, and quarantine status) and study characteristics (article type, study design, data collection, and sample size). To explore the inequality and poverty impacts across countries, subgroup analyses based on the global index and economic indices responses to the COVID-19 pandemic were performed, including (1) human development index (HDI) 2018 (low, medium, high, and very high) 26 ; (2) gender inequality index 2018 (below vs above world average [0.439]) 27 ; (3) the COVID-19-government response stringency index during the survey (less- [less than 75%], moderate- [75–85%], and very stringent [more than 85%]) according to the Oxford COVID-19 Government Response Tracker reports 28 ; (4) the preparedness of countries in terms of hospital beds per 10,000 people, 2010–2018 (low, medium–low, medium, medium–high, and high) 15 ; (5) the preparedness of countries in terms of current health expenditure (% of gross domestic product [GDP] 2016; low, medium–low, medium, medium–high, and high) 15 ; (6) estimated percent change of real GDP growth based on the International Monetary Fund, April 2020 (below vs above world average [− 3.0]) 29 ; (7) the resilience of countries’ business environment based on the 2020 global resilience index reports (first-, second-, third-, and fourth-quartile) 30 ; and (8) immediate economic vulnerability in terms of inbound tourism expenditure (% of GDP 2016–2018; low, medium–low, medium, medium–high, and high) 15 .

To address the robustness of our findings, we conducted a sensitivity analysis by restricting the analysis to studies with a low risk of bias (Hoy and Colleagues-Tool, 0–3 points). Furthermore, a random-effects univariate meta-regression analysis was used to explore the effect of participant and study characteristics, and the global index and economic indices responses to the COVID-19 pandemic as described above on the prevalence estimates.

The visual inspection of funnel plots was performed when there was sufficient data and tested for asymmetry using the Begg’s and Egger’s tests for each specific. A P value of less than 0.10 was considered to indicate statistical publication bias 31 , 32 . If the publication bias was detected by the Begg’s and Egger’s regression test, the trim and fill method was then performed to calibrate for publication bias 33 .

Initially, the search strategy retrieved 4642 records. From these, 2682 duplicate records were removed, and 1960 records remained. Based on the title and abstract screening, we identified 498 articles that seemed to be relevant to the study question (the κ statistic for agreement between reviewers was 0.81). Of these, 107 studies fulfilled the study selection criteria and were included in the meta-analysis (Appendix, Figure S1 ). The inter-rater agreement between reviewers on the study selection and data extraction was 0.86 and 0.75, respectively. The reference list of all included studies in this review is provided in the Appendix, Table S3 .

Characteristics of included studies

In total, 398,771 participants from 32 different countries were included. The mean age was 33.5 ± 9.5 years, and the proportion of female sex was 60.9% (range, 16.0–51.6%). Table 1 summarises the characteristics of all the included studies according to World Bank income group, the global index of COVID-19 pandemic preparedness, and economic vulnerability indices. The included studies were conducted in the Africa (2 studies 34 , 35 [1.9%], n = 723), America (12 studies 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 [11.2%], n = 18,440), South-East Asia (10 studies 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 [9.4%], n = 11,953), Europe (27 studies 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 [25.2%], n = 148,430), Eastern Mediterranean (12 studies 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 [11.2%], n = 23,396), and Western Pacific WHO regions (44 studies 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 , 140 [41.1%], n = 195,829). Most of the included studies were cross-sectional (96 studies, 89.7%), used an online-based survey (101 studies, 95.3%), conducted in mainland China (34 studies, 31.8%), and were conducted in countries with upper-middle (49 studies, 45.8%) and high-incomes (44 studies, 41.1%). Detailed characteristics of the 107 included studies, measurement tools for evaluating the mental health status and psychological consequences, and the diagnostic cut-off criteria are described in Appendix, Table S4 . Of the 107 included studies, 76 (71.0%) had a low risk, 31 (29.0%) had a moderate risk, and no studies had a high risk of bias (Appendix, Table S5 ).

Global prevalence of mental health issues among the general population amid the COVID-19 pandemic

Table 2 presents a summary of the results of the prevalence of mental health problems among the general population amid the COVID-19 pandemic by WHO region and World Bank country groups. With substantial heterogeneity, the global prevalence was 28.0% (95% CI 25.0–31.2) for depression (75 studies 34 , 35 , 36 , 37 , 38 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 57 , 58 , 60 , 61 , 64 , 66 , 67 , 68 , 69 , 70 , 71 , 73 , 74 , 75 , 76 , 77 , 80 , 81 , 82 , 83 , 87 , 88 , 91 , 93 , 96 , 97 , 99 , 101 , 104 , 105 , 106 , 107 , 108 , 109 , 112 , 113 , 114 , 116 , 117 , 119 , 120 , 122 , 124 , 125 , 126 , 127 , 129 , 130 , 131 , 132 , 133 , 134 , 136 , 138 , 139 , 140 , n = 280,607, Fig.  1 ); 26.9% (95% CI 24.0–30.0) for anxiety (75 studies 35 , 37 , 38 , 40 , 42 , 43 , 44 , 46 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 57 , 58 , 60 , 61 , 64 , 66 , 67 , 68 , 69 , 71 , 73 , 74 , 75 , 76 , 77 , 80 , 81 , 82 , 83 , 87 , 88 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 104 , 105 , 107 , 108 , 109 , 112 , 113 , 114 , 115 , 116 , 117 , 119 , 120 , 122 , 124 , 125 , 126 , 129 , 130 , 131 , 132 , 133 , 134 , 136 , 138 , 139 , 140 , n = 284,813, Fig.  2 ); 24.1% (95% CI 17.0–32.0) for PTSS (28 studies 35 , 44 , 56 , 59 , 62 , 64 , 66 , 69 , 75 , 78 , 80 , 81 , 82 , 89 , 90 , 91 , 106 , 109 , 110 , 111 , 119 , 123 , 124 , 125 , 127 , 131 , 135 , 138 , n = 56,447, Fig.  3 ); 36.5% (95% CI 30.0–43.3) for stress (22 studies 37 , 50 , 51 , 52 , 53 , 54 , 57 , 58 , 71 , 73 , 75 , 76 , 80 , 114 , 117 , 119 , 120 , 122 , 125 , 129 , 131 , 136 , n = 110,849, Fig.  4 ); 50.0% (95% CI 41.8–58.2) for psychological distress (18 studies 39 , 47 , 52 , 59 , 63 , 65 , 70 , 72 , 78 , 79 , 85 , 86 , 88 , 102 , 110 , 118 , 121 , 128 , n = 81,815, Fig.  5 ); and 27.6% (95% CI 19.8–36.1) for sleep problems (15 studies 35 , 53 , 58 , 80 , 84 , 103 , 106 , 107 , 109 , 119 , 120 , 125 , 134 , 136 , 137 , n = 99,534, Fig.  6 ). The prevalence of mental health problems based on different countries varied (Appendix, Table S6 ), from 14.5% (South Africa) to 63.3% (Brazil) for depressive symptoms; from 7.7% (Vietnam) to 49.9% (Mexico) for anxiety; from 10.5% (United Kingdom) to 52.0% (Egypt) for PTSS; from 19.7% (Portugal) to 72.8% (Thailand) for stress; from 23.9% (China) to Jordan (92.9%) for psychological distress; from 9.2% (Italy) to 53.9% (Thailand) for sleep problems.

Pooled prevalence of depression among the general population amid the COVID-19 pandemic. COVID-19 coronavirus disease 2019, CI confidence interval, df degree of freedom, NA not applicable. References are listed according to WHO region in the appendix, Table S3 .

Pooled prevalence of anxiety among the general population amid the COVID-19 pandemic. COVID-19 coronavirus disease 2019, CI confidence interval, df degree of freedom, NA not applicable. References are listed according to WHO region in the appendix, Table S3 .

Pooled prevalence of PTSS among the general population amid the COVID-19 pandemic. COVID-19 coronavirus disease 2019, CI confidence interval, df degree of freedom, NA not applicable, PTSS post-traumatic stress symptoms. References are listed according to WHO region in the appendix, Table S3 .

Pooled prevalence of stress among the general population amid the COVID-19 pandemic. COVID-19 coronavirus disease 2019, CI confidence interval, df degree of freedom, NA not applicable. References are listed according to WHO region in the appendix, Table S3 .

Pooled prevalence of psychological distress among the general population amid the COVID-19 pandemic. COVID-19 coronavirus disease 2019, CI confidence interval, df degree of freedom, NA not applicable. References are listed according to WHO region in the appendix, Table S3 .

Pooled prevalence of sleep problems among the general population amid the COVID-19 pandemic. COVID-19 coronavirus disease 2019, CI confidence interval, df degree of freedom, NA not applicable. References are listed according to WHO region in the appendix, Table S3 .

With respect to the small number of included studies and high degree of heterogeneity, the pooled secondary outcome prevalence estimates are presented in Appendix, Table S7 . The global prevalence was 16.4% (95% CI 4.8–33.1) for suicide ideation (4 studies 36 , 41 , 53 , 124 , n = 17,554); 53.8% (95% CI 42.4–63.2) for loneliness (3 studies 41 , 44 , 45 , n = 2921); 30.7% (95% CI 2.1–73.3) for somatic symptoms (3 studies 53 , 69 , 134 , n = 7230); 28.6% (95% CI 9.2–53.6) for low wellbeing (3 studies 53 , 68 , 97 , n = 15,737); 50.5% (95% CI 49.2–51.7) for alcohol drinking problems (2 studies 97 , 114 , n = 6145); 6.4% (95% CI 5.5–7.4) for obsessive–compulsive symptoms (2 studies 73 , 134 , n = 2535); 25.7% (95% CI 23.7–27.8) for panic disorder (1 study 74 , n = 1753); 2.4% (95% CI 1.6–3.4) for phobia anxiety (1 study 134 , n = 1255); 22.8% (95% CI 22.1–23.4) for adjustment disorder (1 study 80 , n = 18,147); and 1.2% (95% CI 1.0–1.4) for suicide attempts (1 study 36 , n = 10,625).

Subgroup analyses, sensitivity analyses, meta-regression analyses, and publication bias

In the subgroup analyses (Appendix, Table S8 , Table S9 , Table S10 , Table S1 , Table S12 ), the prevalence of mental health problems was higher in countries with a low to medium HDI (for depression, anxiety, PTSS, and psychological distress), high HDI (for sleep problems), high gender inequality index (for depression and PTSS), very stringent government response index (for PTSS and stress), less stringent government response index (for sleep problems), low to medium hospital beds per 10,000 people (for depression, anxiety, PTSS, stress, psychological distress, and sleep problems), low to medium current health expenditure (for depression, PTSS, and psychological distress), estimated percent change of real GDP growth 2020 below − 3.0 (for psychological distress), low resilience (fourth-quartile) of business environment (for depression, anxiety, and PTSS), medium resilience (second-quartile) of business environment (for psychological distress, and sleep problems), high economic vulnerability-inbound tourism expenditure (for psychological distress, sleep problems), article type-short communication/letter/correspondence (for stress), cross-sectional survey (for PTSS and psychological distress), longitudinal survey (for anxiety and stress), non-mainland China (for depression, anxiety, and psychological distress), sample size of less than 1000 (for psychological distress), sample size of more than 5000 (for PTSS), proportion of females more than 60% (for stress and sleep problems), and measurement tools (for depression, anxiety, stress, and sleep problems). However, several pre-planned subgroup analyses based on participant characteristics and secondary outcomes reported could not be performed due to limited data in the included studies.

Findings from the sensitivity analysis were almost identical to the main analysis (Appendix, Table S14 ). The pooled prevalence by restricting the analysis to studies with a low risk of bias was 28.6% (95% CI 25.1–32.3) for depression, 27.4% (95% CI 24.1–30.8) for anxiety, 30.2% (95% CI 20.3–41.1) for PTSS, 40.1% (95% CI 32.5–47.9) for stress, 45.4% (95% CI 32.0–59.2) for psychological distress, and 27.7% (95% CI 19.4–36.9) for sleep problems.

On the basis of univariate meta-regression, the analysis was suitable for the primary outcomes (Appendix, Table S15 ). The increased prevalence of mental health problems was associated with the WHO region (for depression, anxiety, and psychological distress), female gender inequality index (for depression and anxiety), the COVID-19-government response stringency index during the survey (for sleep problems), hospital beds per 10,000 people (for depression and anxiety), immediate economic vulnerability-inbound tourism expenditure (for sleep problems), study design (cross-sectional vs longitudinal survey; for stress), surveyed country (mainland China vs non-mainland China; for depression and psychological distress), and risk of bias (for PTSS).

The visual inspection of the funnel plots, and the p values tested for asymmetry using the Begg’s and Egger’s tests for each prevalence outcome, indicated no evidence of publication bias related to the sample size (Appendix, Table S16 , and Figure S2 ).

This study is, to the best of our knowledge, the first systematic review and meta-analysis on the overall global prevalence of mental health problems and psychosocial consequences among the general population amid the COVID-19 pandemic. Overall, our findings indicate wide variability in the prevalence of mental health problems and psychosocial consequences across countries, particularly in relation to different regions, the global index of COVID-19 pandemic preparedness, inequalities, and economic vulnerabilities indices.

Two reports examined the global prevalence of common mental health disorders among adults prior to the COVID-19 outbreak. The first study was based on 174 surveys across 63 countries from 1980 to 2013. The estimated lifetime prevalence was 29.1% for all mental disorders, 9.6% for mood disorders, 12.9% for anxiety disorders, and 3.4% for substance use disorder 141 . Another report which was conducted as part of the Global Health Estimates by WHO in 2015, showed that the global estimates of depression and anxiety were 4.4% and 3.6% (more common among females than males), respectively 142 . Despite the different methodological methods used, our findings show that the pooled prevalence of mental health problems during the COVID-19 pandemic is higher than before the outbreak.

Previous studies on the prevalence of mental health problems during the COVID-19 pandemic have had substantial heterogeneity. Three systematic reviews reported the prevalence of depression, anxiety, and stress among the general population (mainly in mainland China). The first of these by Salari et al. 11 , was based on 17 included studies (from ten different countries in Asia, Europe, and the Middle East), the pooled prevalence of depression, anxiety, and stress were 33.7% (95% CI 27.5–40.6), 31.9% (95% CI 27.5–36.7), and 29.6% (95% CI 24.3–35.4), respectively. A review by Luo et al. 8 , which included 36 studies from seven different countries, reported a similar overall prevalence of 27% (95% CI 22–33) for depression and 32% (95% CI 25–39) for anxiety. However, a review by Ren et al. 17 , which focussed on only the Chinese population (8 included studies), found that the pooled prevalence was 29% (95% CI 16–42) and 24% (95% CI 16–32), respectively. Nevertheless, previous systematic reviews have been mainly on investigating the prevalence of PTSS, psychological distress, and sleep problems among the patients or healthcare workers that are limited to the general population during the COVID-19 pandemic. With regard to the general population, a review by Cénat et al. 143 , found that the pooled prevalence of PTSS, psychological distress, and insomnia were 22.4% (95% CI 7.6–50.3; 9 included studies), 10.2% (95% CI 4.6–21.0; 10 included studies), and 16.5% (95% CI 8.4–29.7; 8 included studies), respectively.

In this systematic review and meta-analysis, we updated and summarised the global prevalence of mental health problems and psychosocial consequences during the COVID-19 pandemic using information from 32 different countries, and 398,771 participants. A range of problems, including depression, anxiety, PTSS, stress, psychological distress, and sleep problems were reported. The global prevalence of our findings was in line with the previous reviews mentioned above in terms of depression (28.0%; 95% CI 25.0–31.2), anxiety (26.9%; 95% CI 24.0–30.0), and stress (36.5%; 95% CI 30.0–43.3). Interestingly, our findings highlight the poverty impacts of COVID-19 in terms of inequalities, the preparedness of countries to respond, and economic vulnerabilities on the prevalence of mental health problems across countries. For instance, our results suggest that countries with a low or medium HDI had a higher prevalence of depression and anxiety compared to countries with a high or very high HDI (Appendix, Table S8 , and Table S9 ). The prevalence of depression was higher among countries with a gender inequality index of 0.439 or greater (39.6% [95% CI 30.3–49.3] vs 26.2% [95% CI 23.1–29.3]; P  = 0.020; Appendix, Table S8 ). Likewise, the prevalence of depression and anxiety was higher among countries with low hospital beds per 10,000 people (Appendix, Table S8 , and Table S9 ). Our findings suggest that the poverty impacts of COVID-19 are likely to be quite significant and related to the subsequent risk of mental health problems and psychosocial consequences. Although we performed a comprehensive review by incorporating articles published together with preprint reports, there was only limited data available on Africa, low-income groups, and secondary outcomes of interest (psychological distress, suicide ideation, suicide attempts, loneliness, somatic symptoms, wellbeing, alcohol drinking problems, obsessive–compulsive symptoms, panic disorder, phobia anxiety, and adjustment disorder).

Strengths and limitations of this review

From a methodological point of view, we used a rigorous and comprehensive approach to establish an up-to-date overview of the evidence-based information on the global prevalence of mental health problems amid the COVID-19 pandemic, with no language restrictions. The systematic literature search was extensive, comprising published peer-reviewed articles and preprints reporting data to present all relevant literature, minimise bias, and up to date evidence. Our findings expanded and addressed the limitations of the previous systematic reviews, such as having a small sample size and number of included studies, considered more aspects of mental health circumstance, and the generalisability of evidence at a global level 5 , 6 , 11 , 17 , 18 . To address biases from different measurement tools of assessment and the cultural norms across countries, we summarised the prevalence of mental health problems and psychosocial consequences using a random-effects model to estimate the pooled data with a more conservative approach. Lastly, the sensitivity analyses were consistent with the main findings, suggesting the robustness of our findings. As such, our data can be generalised to individuals in the countries where the included studies were conducted.

There were several limitations to this systematic review and meta-analysis. First, despite an advanced comprehensive search approach, data for some geographical regions according to the WHO regions and World Bank income groups, for instance, the Africa region, as well as the countries in the low-income group, were limited. Moreover, the reporting of key specific outcomes, such as suicide attempts and ideation, alcohol drinking or drug-dependence problems, and stigma towards COVID-19 infection were also limited. Second, a subgroup analysis based on participant characteristics (that is, age, sex, unemployment, history of mental illness, financial problems, and quarantine status), could not be performed as not all of the included studies reported this data. Therefore, the global prevalence of mental health problems and psychosocial consequences amid the COVID-19 pandemic cannot be established. Third, it should be noted that different methods, for example, face-to-face interviews or paper-based questionnaires, may lead to different prevalence estimates across the general population. Due to physical distancing, the included studies in this review mostly used online surveys, which can be prone to information bias and might affect the prevalence estimates of our findings. Fourth, a high degree of heterogeneity between the included studies was found in all outcomes of interest. Even though we performed a set of subgroup analyses concerning the participant characteristics, study characteristics, the global index, and economic indices responses to the COVID-19 pandemic, substantial heterogeneity persisted. However, the univariate meta-regression analysis suggested that the WHO region, gender inequality index, COVID-19-government response stringency index during the survey, hospital beds, immediate economic vulnerability (inbound tourism expenditure), study design, surveyed country (mainland China vs non-mainland China), and risk of bias were associated with an increased prevalence of mental health problems and psychosocial consequences amid the COVID-19 pandemic. Finally, we underline that the diagnostic cut-off criteria used were not uniform across the measurement tools in this review, and misclassification remains possible. The genuine variation in global mental health circumstances across countries cannot be explained by our analyses. Indeed, such variation might be predisposed by social and cultural norms, public resilience, education, ethnic differences, and environmental differences among individual study populations.

Implications for public health and research

Despite the limitations of our findings, this review provides the best available evidence that can inform the epidemiology of public mental health, implement targeted initiatives, improving screening, and reduce the long-term consequences of the COVID-19 pandemic, particularly among low-income countries, or those with high inequalities, low preparedness, and high economic vulnerability. Our findings could be improved by further standardised methods and measurement tools of assessment. There is a need for individual country-level data on the mental health problems and psychosocial consequences after the COVID-19 pandemic to track and monitor public health responses. There are a number network longitudinal surveys being conducted in different countries that aim to improve our understanding of the long-term effects of the COVID-19 pandemic 144 . To promote mental wellbeing, such initiatives could also be advocated for by public health officials and governments to increase awareness and provide timely proactive interventions in routine practice.

Conclusions

In conclusion, this systematic review and meta-analysis provides a more comprehensive global overview and evidence of the prevalence of mental health problems among the general population amid the COVID-19 pandemic. The results of this study reveal that the mental health problems and psychosocial consequences amid the COVID-19 pandemic are a global burden, with differences between countries and regions observed. Moreover, equality and poverty impacts were found to be factors in the prevalence of mental health problems. Studies on the long-term effects of the COVID-19 pandemic on the mental health status among the general population at a global level is needed. Given the high burden of mental health problems during the COVID-19 pandemic, an improvement of screening systems and prevention, prompt multidisciplinary management, and research on the social and economic burden of the pandemic, are crucial.

Data sharing

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors thank the research assistances and all staff of Pharmacoepidemiology and Statistics Research Center (PESRC), Chiang Mai, Thailand. This work reported in this manuscript was partially supported by a grant by the Chiang Mai University, Thailand. The funder of the study had no role in the study design collection, analysis, or interpretation of the data, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit it for publication.

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S.N. conceived the study and, together with C.R., K.T., R.A., C.P., and Y.R. developed the protocol. S.N. and C.R. did the literature search, selected the studies. S.N. and Y.R. extracted the relevant information. S.N. synthesised the data. S.N. wrote the first draft of the paper. K.T., B.H., N.W., and T.W. critically revised successive drafts of the paper. All authors approved the final draft of the manuscript. SN is the guarantor of the study.

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

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

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

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

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

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

Conclusions

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

Peer Review reports

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

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

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

Stage 1: identify the research question

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

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

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

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

Stage 2: identify the relevant studies

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

Stage 3: literature selection

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

PRISMA Flow Diagram

Stage 4: charting the data

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

Stage 5: collating, summarizing, and reporting the results

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

Characteristics of included literature

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

Number of sources by characteristics of included literature

Frequency of themes in literature ( n  = 91)

Mental health concerns and their prevalence in the literature

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

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

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

Causes of mental health concerns

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

Effects of mental health concerns on physicians and patients

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

Solutions and interventions

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

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

Barriers to seeking and providing care

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

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

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

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

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

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

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

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

Availability of data and materials

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

Abbreviations

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

United States of America

World Health Organization

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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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Mental well-being and mental distress, measuring mental well-being in people with mental illness, mental well-being and mental health services, mental well-being and mental illness, should mental well-being be used to support the commissioning and delivery of mental health services, conclusions, mental well-being: an important outcome for mental health services.

Published online by Cambridge University Press:  02 January 2018

Mental well-being is being used as an outcome measure in mental health services. The recent Chief Medical Officer's (CMO's) report raised questions about mental well-being in people with mental illness, including how to measure it. We discuss whether mental well-being has prognostic significance or other utility in this context.

The World Health Organization defines mental well-being as an individual's ability to develop their potential, work productively and creatively, build strong and positive relationships with others and contribute to their community. 1 This view distinguishes subjective happiness or life satisfaction (hedonic well-being) from positive psychological functioning (eudaimonic well-being). The mental well-being literature can be confusing as many similar-sounding terms are used interchangeably: social or mental capital, positive mental health, psychological or subjective well-being. The WHO definition of mental well-being is concerned exclusively with positive mental health states, and this approach is also evident in the way that terminology is used in UK policy documents. Nevertheless, it is sometimes unclear whether the term ‘mental well-being’ implies the absence of mental illness or distress. Well-being has been trumpeted as a measure of national prosperity, and linked to improved physical and mental health. It has been identified as a public health target and criterion for commissioning and assessing mental health services. Reference Davies 2 But questions remain about the relationship between mental illness and mental well-being, and about the potential for diverting resources away from evidence-based treatments for mental disorders. These issues were highlighted in the recent Chief Medical Officer (CMO) report on public mental health that challenged the empirical grounds for extending mental well-being into clinical commissioning and argued against mental well-being ‘receiving priority funding over better established fields, including quality of life’. Reference Davies 2

Mental disorders are characterised by psychopathology, distress and impaired functioning. Huppert Reference Huppert 3 and others argued that mental disorders (‘languishing’) and mental well-being (‘flourishing’) were opposite ends of a single dimension. However, further work has shown that, although correlated, mental illness and mental well-being are independent phenomena. Secondary analysis of data on over 7000 adults from the 2007 Adult Psychiatric Morbidity Survey (APMS) demonstrated that associations with well-being scores were not significantly altered by adjusting for comorbid mental disorder. Reference Weich, Brugha, King, McManus, Bebbington and Jenkins 4 These findings were consistent with those from other studies that indicate that mental well-being is more than just the absence of mental illness symptoms and distress, and that (although correlated) mental well-being and mental distress are independent of one another. The APMS findings also showed that at least moderately high levels of well-being may be achieved in the context of mental illness, which is salient when considering whether mental well-being should be a routine outcome measure in mental health services. Reference Weich, Brugha, King, McManus, Bebbington and Jenkins 4 Evidence detailed later in this editorial also supports this conclusion. However, we know less about the determinants and variability of mental well-being among those who experience mental health problems than in the general population. As mental illnesses typically relapse and remit, mental well-being may vary with the phase of illness and the number, frequency or duration of relapses.

Evaluating interventions to improve mental well-being in people with mental illness depends on valid measurement, but there is only limited evidence to guide the assessment of mental well-being in this context. Reference Davies 2 This is a significant barrier to studying mental well-being and its potential determinants in people with mental illness. Reference Davies 2 Since mental well-being is a state of positive mental health, measures should comprise positively phrased items, such as those which make up the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), Reference Tennant, Hiller, Fishwick, Platt, Joseph and Weich 5 WHO-Five Well-Being Index (WHO-5) Reference Bech, Olsen, Kjoller and Rasmussen 6 and the Satisfaction with Life Scale. Reference Kobau, Sniezek, Zack, Lucas and Burns 7

Although generic measures of mental well-being have been used for people with mental illness, their validity in these populations has rarely been evaluated; we do not know whether responses to generic mental well-being items may be biased by the experience of past or current mental illness. Only the WHO-5 has been validated in English in mental illness, specifically in affective and anxiety disorders. Reference Newnham, Hooke and Page 8 The Subjective Well-being under Neuroleptic Treatment Scale (SWN) Reference Vothknecht, Meijer, Zwinderman, Kikkert, Dekker and van Beveren 9 was developed for people with schizophrenia receiving antipsychotics. However, one-half of this scale comprises negatively worded items and it covers domains that are not central to mental well-being, including physical functioning. WEMWBS, despite being recommended by healthcare organisations for measuring mental well-being in the context of mental illness, has only been validated in non-clinical populations in the UK.

The 2011 UK government document No Health without Mental Health emphasised mental well-being as an important service outcome as part of patient-centred, recovery-focused care. 10 However, judging services according to mental well-being outcomes rather than changes in symptoms and disability is not self-evidently consistent with their traditional mission: the consequences of doing so need to be considered carefully. Measuring mental well-being routinely may alter therapeutic relationships in unintended ways. There is a risk that in prioritising mental well-being, professionals might be excused from achieving more challenging outcomes, namely alleviating symptoms and reducing disability. Reference Davies 2

We would argue that two conditions must be met to justify the routine assessment of mental well-being among mental health service users. First, evidence is needed that mental well-being modifies the risk of onset, recovery from or recurrence of episodes of mental illness; in other words that it has prognostic significance in terms of mental health, social functioning or use of healthcare. Second, it must be shown that mental well-being is independent of mental illness and social functioning and therefore unlikely to be captured by measures that assess either of these phenomena.

Although the behavioural and psychosocial determinants of mental well-being may not necessarily resemble those of mental illness, mental well-being is associated with specific forms of psychopathology – examples are discussed below. However, the evidence base is generally limited by substantial methodological variation (including the use of different and often unvalidated measures of mental well-being) and a dearth of longitudinal studies, inhibiting understanding of cause and effect. Reference Davies 2

Anxiety and depression

Maintaining high levels of mental well-being is likely to be difficult in the presence of symptoms of anxiety and depression. However, recent longitudinal data demonstrate that this may be more complicated than (simply) covariance. A recent study of over 1000 Australian in- and day patients with depression or anxiety demonstrated that an intervention (giving feedback during psychological treatment) improved depressive symptoms but not mental well-being, Reference Newnham, Hooke and Page 11 supporting the view that these are independent outcomes.

There is a wealth of cross-sectional evidence linking sleep problems and mental well-being, but less robust evidence of longitudinal associations. A small, prospective study of 75 university students Reference Pilcher, Ginter and Sadowsky 12 found no significant prospective improvements in life satisfaction among those whose sleep increased in duration or quality over 3-month follow-up. Those who reported a reduction in daily sleep quality over 3 months were significantly more likely to report a reduction in life satisfaction ( P <0.01). Reference Pilcher, Ginter and Sadowsky 12 Nonetheless, poor mental well-being in the context of sleep problems may not be associated with greater need for psychiatric care. A cross-sectional general population study of over 8000 Australians found that although the 5% with insomnia were significantly more likely to have poor mental well-being (odds ratio (OR) = 2.34, 95% CI 1.11–4.93) and visited their general practitioner more often (OR = 1.57, 95% CI 1.06–2.33), insomnia was not significantly associated with use of psychotropic medication or hospital admission. Reference Bin, Marshall and Glozier 13

Delusions and hallucinations

Mental well-being is inversely associated with psychotic symptoms. In 83 out-patients with schizophrenia, psychotic symptoms were negatively correlated with quality of life, but interestingly this association was confounded by insight, Reference Rocca, Castagna, Mongini, Montemagni and Bogetto 14 demonstrating the complexity of the relationship between mental well-being and mental illness. Among people with first-episode psychosis, admission to hospital was associated with better quality of life Reference Renwick, Jackson, Foley, Owens, Ramperti and Behan 15 suggesting that illness severity per se may not automatically predict well-being; better mental well-being might also reflect the quality and intensity of care received.

Social functioning and healthcare use

Social functioning is correlated with psychopathology but may be independent of mental well-being. Psychiatric out-patients with serious mental illness in remission demonstrated higher functioning scores but not higher well-being compared with similar patients not in remission, although this used the limited SWN to measure mental well-being. Reference Pinna, Deriu, Lepori, Maccioni, Milia and Sarritzu 16

Healthcare use and mental well-being may also be independent. A 2-year structured rehabilitation programme for those with serious mental illness led to improved quality of life and psychosocial functioning in those who met their rehabilitation goals v. those who had not. However, there were no significant differences in healthcare use between the two groups at 2-year follow-up. Reference Svedberg, Svensson, Hansson and Jormfeldt 17

Valid methods of evaluating healthcare interventions are required to support payment by results, and National Health Service providers are required to collect patient-reported outcomes and experiences in part to prevent ‘gaming’ to maximise income. Mental well-being could serve as a patient-rated outcome measure, but the dearth of validated measures in people with serious mental illness remains a major concern. The CMO has sensibly encouraged policy makers and commissioners to heed the uncertainty surrounding mental well-being, warning that ‘wellbeing policy is running ahead of the evidence’. Reference Davies 2 However, existing evidence suggests that symptomatic and functional outcomes, needs for care and service use appear to be independent of mental well-being to varying degrees. Therefore, mental well-being is not captured completely by existing measures of these states. Mental well-being also has strong conceptual resonances with recovery from mental illness, including notions of hope, purpose and fulfilment, and may be similarly valued by patients. Taken together, these could represent significant arguments for mental well-being as a distinct service outcome in its own right. However, the utility of measuring mental well-being routinely in mental health services has not yet been established. Further research is needed to validate measures of mental well-being in people with serious mental illness, determine the usefulness (and costs) of routinely measuring mental well-being in this population, and to explore the views of patients on the relative importance attached to different service outcomes.

The place of mental well-being in the delivery of mental healthcare remains uncertain and the CMO has stated categorically that this should not be part of current clinical commissioning. Nevertheless, mental well-being is an important public health heuristic and has clear resonances with concepts underpinning recovery from mental illness. The evidence base linking mental well-being and mental illness remains poorly developed, but we believe that two conditions for measuring mental well-being in mental health services have been at least partly met. It appears that mental well-being may be associated with onset, recovery and/or recurrence of episodes of mental illness although the actual detail of these associations is complex; and that it is at least partly independent of symptoms, social functioning or need for mental healthcare. Mental well-being is not fully captured by measures of these phenomena.

However, there are two important caveats. First, it is essential to validate measures of mental well-being in people with serious mental illness, and to know more about the (relative) value that patients place on mental well-being as a service outcome. And second, mental well-being must not be allowed to supersede other outcomes and obscure the imperative to deliver the most effective evidence-based treatments to those with mental illness.

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• Volume 207, Issue 3
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• Role of mental health legislation in patient rights
• Impact of health insurance policies on mental health services
• Mental health in prisons: Policy implications
• The impact of mental health stigma on policy making
• Mental health policies in schools
• Workplace mental health policies
• Mental health parity laws
• Policy implications of mental health in homelessness
• Impact of COVID-19 on mental health policies
• Cognitive-Behavioral Therapy (CBT) in mental health
• Role of medication in mental health treatment
• Efficacy of group therapy in mental health
• Role of art therapy in mental health treatment
• Understanding Electroconvulsive Therapy (ECT)
• The role of lifestyle changes in mental health treatment
• Psychodynamic therapy in mental health
• The use of virtual reality in mental health treatment
• Mindfulness-based therapies in mental health
• Role of family therapy in mental health treatment
• Understanding personality disorders
• The psychopathology of addiction
• Eating disorders: Causes, impacts, and treatments
• Psychopathology of self-harm behaviors
• Understanding anxiety disorders
• The psychopathology of suicidal behavior
• Psychopathology of mood disorders
• Understanding obsessive-compulsive disorder (OCD)
• The psychopathology of paranoia and delusional disorders
• Impact of traumatic experiences on psychopathology
• Impact of job satisfaction on mental health
• Role of organizational culture in employee mental health
• Mental health implications of job burnout
• The role of work-life balance in mental health
• Understanding the concept of ‘Blue Monday’
• Mental health implications of remote work
• The role of employee assistance programs in mental health
• Mental health effects of workplace harassment
• Impact of job insecurity on mental health
• The role of workplace wellness programs in mental health
• Cross-cultural perspectives on mental health
• The impact of cultural stigma on mental health outcomes
• Cultural variations in mental health treatments
• Understanding mental health in indigenous populations
• Mental health impacts of acculturation
• The role of cultural competence in mental health services
• Culture-bound syndromes
• Impact of cultural beliefs on mental health
• Role of language in mental health contexts
• Cross-cultural communication in mental health care
• Role of schools in mental health education
• Impact of mental health literacy on outcomes
• The role of media in mental health education
• Mental health promotion in communities
• Importance of mental health education in medical curricula
• The role of peer educators in mental health promotion
• Impact of stigma reduction campaigns on mental health
• The role of mental health first aid
• The use of technology in mental health education
• Mental health education for parents

As we culminate this extensive list of mental health research paper topics, it is essential to remember that each topic presents a unique chance to broaden our understanding of mental health and contribute to this important field. As aspiring health science students, you have the power to make a difference in enhancing mental health awareness and outcomes. As you traverse this exciting journey, always remember that research is not merely a pursuit of knowledge, but a powerful tool for instigating change. Embrace the opportunity with curiosity, passion, and determination, and let your research pave the way for a mentally healthier world.

Choosing Mental Health Research Paper Topics

Choosing a compelling and relevant mental health research paper topic is crucial for creating a meaningful and impactful study. To assist you in this process, we have gathered expert advice from professionals in the field of mental health research. Consider the following ten tips to guide you in selecting an engaging and significant topic for your research:

• Identify Current Mental Health Issues : Stay updated on the latest developments and trends in mental health research. Explore current issues, emerging challenges, and unanswered questions within the field. This will help you select a topic that is relevant, timely, and has the potential for making a meaningful contribution.
• Reflect on Personal Interests : Consider your own passions and interests within the broad field of mental health. Reflect on the areas that resonate with you the most. Researching a topic that you are genuinely interested in will fuel your motivation and dedication throughout the research process.
• Consult Academic Journals and Publications : Explore reputable academic journals and publications dedicated to mental health research. Reading articles and studies within your area of interest will provide insights into existing research gaps, ongoing debates, and potential areas for further exploration.
• Analyze Existing Literature : Conduct a thorough literature review to identify key themes, theories, and research findings in your chosen area of mental health. Understanding the current body of knowledge will help you narrow down your research focus and identify research gaps that need to be addressed.
• Consider the Population of Interest : Mental health research encompasses various populations, such as children, adolescents, adults, or specific demographic groups. Consider the population you want to focus on and explore their unique mental health challenges, interventions, or outcomes.
• Examine Cultural and Social Factors : Mental health is influenced by cultural and social factors. Investigate how cultural norms, societal expectations, or environmental contexts impact mental health outcomes. Understanding these factors will add depth and richness to your research.
• Think Interdisciplinary : Mental health is a multidisciplinary field that intersects with psychology, sociology, neuroscience, public health, and more. Consider integrating perspectives from other disciplines to gain a comprehensive understanding of mental health issues and approaches to addressing them.
• Explore Innovative Interventions and Technologies : Investigate novel interventions, therapies, or technologies that are emerging in the field of mental health. Exploring innovative approaches can lead to exciting research opportunities and contribute to advancements in mental health care.
• Address Stigmatized or Understudied Topics : Mental health encompasses a wide range of conditions and experiences, some of which may be stigmatized or underrepresented in research. Consider topics that address the mental health needs of marginalized populations or shed light on less-discussed mental health conditions.
• Seek Guidance and Collaboration : Consult with your professors, mentors, or peers who specialize in mental health research. Seek their guidance in selecting a research topic and consider opportunities for collaboration. Collaborative research can provide valuable insights and support throughout the research process.

By incorporating these expert tips into your topic selection process, you can choose a mental health research paper topic that is not only academically rigorous but also personally meaningful. Remember to strike a balance between your interests, the existing body of knowledge, and the potential for making a significant impact in the field of mental health research. With a well-chosen topic, you will embark on a rewarding research journey that contributes to the understanding and well-being of individuals with mental health concerns.

How to Write a Mental Health Research Paper

Writing a mental health research paper requires careful planning, critical thinking, and effective communication of your findings. To help you navigate this process successfully, we have compiled ten essential tips to guide you in crafting a well-structured and impactful paper:

• Define Your Research Question : Begin by clearly defining your research question or objective. This will serve as the foundation for your paper, guiding your literature review, methodology, and analysis.
• Conduct a Thorough Literature Review : Familiarize yourself with existing research and theories related to your topic through a comprehensive literature review. This will help you identify gaps in the literature, build on existing knowledge, and situate your research within the broader context of mental health.
• Select an Appropriate Methodology : Choose a research methodology that aligns with your research question and objectives. Consider whether qualitative, quantitative, or mixed-method approaches are best suited for your study. Justify your choice and outline your methodology clearly.
• Ethical Considerations : Ensure that your research adheres to ethical guidelines and protects the rights and well-being of participants. Obtain necessary approvals from ethical review boards and maintain confidentiality and anonymity when reporting your findings.
• Collect and Analyze Data : Collect data using appropriate methods, whether through surveys, interviews, observations, or existing datasets. Analyze your data using sound statistical techniques or qualitative analysis methods, depending on your research design.
• Structure Your Paper : Organize your mental health research paper into sections, including an introduction, literature review, methodology, results, discussion, and conclusion. Use headings and subheadings to clearly delineate each section and guide the reader through your paper.
• Craft a Compelling Introduction : Begin your paper with an engaging introduction that captures the reader’s attention and provides the necessary background information. Clearly state your research question, the significance of your study, and the gaps you aim to address.
• Interpret Your Findings : In the results section, present your findings objectively and concisely. Use tables, graphs, or figures to enhance clarity and provide a comprehensive overview of your results. Interpret your findings in light of your research question and existing literature.
• Engage in a Thoughtful Discussion : In the discussion section, critically analyze and interpret your results, discussing their implications for theory, practice, and future research. Compare your findings with previous studies and identify areas of agreement or divergence.
• Conclude with Key Takeaways : Summarize your main findings, restate the significance of your study, and discuss potential avenues for further research. Highlight the contributions your research makes to the field of mental health and offer practical implications for mental health professionals or policymakers.

Additional Tips:

• Use clear and concise language, avoiding jargon whenever possible. Define any technical terms or acronyms for clarity.
• Properly cite all sources using a recognized citation style, such as APA, MLA, Chicago/Turabian, or Harvard, to give credit to the original authors and avoid plagiarism.
• Seek feedback from professors, mentors, or peers to refine your writing and ensure the clarity and coherence of your paper.
• Revise and edit your paper multiple times to polish your arguments, improve sentence structure, and eliminate grammatical errors.

By following these tips, you can confidently navigate the process of writing a mental health research paper. Remember to maintain a logical flow, support your arguments with evidence, and engage in critical analysis to contribute to the understanding and advancement of mental health research.

iResearchNet’s Custom Writing Services

At iResearchNet, we understand the unique challenges that students face when writing a mental health research paper. We are dedicated to providing comprehensive writing services that cater specifically to the needs of health sciences students like you. Here are thirteen features that set us apart and ensure your research paper’s success:

• Expert Degree-Holding Writers : Our team of writers consists of highly qualified professionals with advanced degrees in mental health and related fields. They have the expertise and knowledge necessary to tackle complex research topics and produce high-quality papers.
• Custom Written Works : We believe in originality and customization. Each mental health research paper we deliver is custom-written from scratch to meet your specific requirements and adhere to your instructions. We guarantee plagiarism-free and unique content.
• In-Depth Research : Our writers conduct thorough and in-depth research on your chosen mental health topic to ensure the accuracy, relevance, and comprehensiveness of your paper. They have access to a vast array of scholarly resources and stay updated on the latest research in the field.
• Custom Formatting : We understand the importance of following specific formatting styles. Whether you require APA, MLA, Chicago/Turabian, or Harvard formatting, our writers are well-versed in these styles and will ensure that your paper meets the required standards.
• Top Quality Assurance : We have a stringent quality assurance process in place to guarantee the highest standards of excellence. Our dedicated team of editors and proofreaders carefully review each mental health research paper for grammar, clarity, coherence, and adherence to academic standards.
• Customized Solutions : We recognize that every mental health research paper is unique. Our services are tailored to your specific needs, ensuring that we address your research question, objectives, and desired outcomes. We work closely with you to customize our approach and deliver a paper that aligns with your academic goals.
• Flexible Pricing : We understand the financial constraints that students face. Our pricing options are designed to be flexible and affordable while maintaining the quality of our services. We offer competitive rates and transparent pricing, ensuring that you receive value for your investment.
• Short Deadlines : We are equipped to handle urgent requests and short deadlines. If you require your mental health research paper in a tight timeframe, we can accommodate deadlines as short as three hours without compromising on quality or accuracy.
• Timely Delivery : We recognize the importance of meeting deadlines. Our writers and support staff are committed to delivering your mental health research paper on time, allowing you sufficient time for review and any necessary revisions.
• 24/7 Support : We provide round-the-clock customer support to address any inquiries, concerns, or issues you may have. Our dedicated support team is available to assist you at any stage of the writing process, ensuring a seamless and positive experience.
• Absolute Privacy : We prioritize the confidentiality and privacy of our clients. Rest assured that any personal information shared with us will be handled with the utmost care and will remain strictly confidential.
• Easy Order Tracking : Our user-friendly platform allows you to easily track the progress of your mental health research paper. You can communicate directly with your assigned writer, exchange messages, provide additional instructions, and stay informed about the status of your order.
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With iResearchNet’s writing services, you can trust that your mental health research paper is in capable hands. Our team of experts is dedicated to delivering custom-written papers that meet your academic requirements and exceed your expectations. Let us be your partner in achieving excellence in your mental health research endeavors.

Unlock Your Research Potential with iResearchNet

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By choosing iResearchNet, you gain access to a team of highly qualified writers who specialize in mental health and related disciplines. Our writers possess extensive knowledge and experience in the field, ensuring that your research paper is crafted with precision, accuracy, and a deep understanding of the subject matter. We are committed to delivering custom-written papers that reflect your unique research objectives and contribute to the advancement of mental health knowledge.

With iResearchNet, you can expect a seamless and enriching experience throughout your research journey. Our user-friendly platform enables you to easily communicate with your assigned writer, providing an opportunity for collaboration and ensuring that your paper is tailored to your specific requirements. Our dedicated customer support team is available 24/7 to address any inquiries or concerns you may have, providing you with the guidance and assistance you need at every step.

At iResearchNet, we take pride in our commitment to excellence. We strive to exceed your expectations by delivering high-quality, custom-written mental health research papers that showcase your academic prowess. Our writers conduct in-depth research, adhere to strict academic standards, and ensure that your paper is free from plagiarism. We offer timely delivery, flexible pricing options, and a money-back guarantee to provide you with peace of mind.

Choose iResearchNet as your trusted partner in your mental health research journey. Our writing services will empower you to produce a research paper that stands out, contributes to the field of mental health, and earns you the recognition you deserve. Take the next step towards academic success and unlock your research potential by placing your trust in iResearchNet. Together, let’s make a difference in the field of mental health research.

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Post-Pandemic Depression, Anxiety, and Stress: A Look at the Mental Health of Nursing and Administrative Staff

14 Pages Posted: 25 Jun 2024

Pacheco-Flores Laura Iraís

Universidad de las Americas Puebla

Pineda-Téllez Magno

affiliation not provided to SSRN

Erika Ramos-Tovar

Some research has shown how mental health was affected during the COVID-19 pandemic in hospital staff worldwide. However, there is little evidence of the physiological status of healthcare and administrative workers at the first level of medical care. Therefore, it is necessary to identify mental health problems among hospital staff once this pandemic has passed. This study aims to determine the prevalence of depression, anxiety, and post-pandemic stress in personnel in the medical and administrative workers.This research is an observational and cross-sectional study of the medical and administrative workers of the clinic who participated voluntarily through the application of the DASS-21 questionnaire to determine the prevalence and severity of depression, anxiety, and stress. The 190 participants had a mean age of 49 ± 11 years. The prevalence of depression was 20% with a predominantly moderate severity index (38.46%), 33% of anxiety with a predominant extremely severe index (36.51%), and 30% of stress with a predominantly moderate severity index (36.84%), related to the healthcare personnel and particularly in the nursing staff and administrative area. In conclusion, it was identified that post-pandemic depression, anxiety, and stress in the population studied, nursing staff showed an intensity of extremely severe anxiety, the administrative area had depression with severe stress, and workers with different responsibilities but focused on the operation of the hospital. However, additional studies are required to evaluate appropriate management strategies to diagnose, treat, and prevent mental health disorders among hospital staff.

Note: Funding Information: None declared. Declaration of Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Ethics Approval Statement: This study did not represent a bioethical risk and was carried out with the approval of the unit authorities after evaluation and ruling by the Research and Research Ethics Committee of the ISSSTE Puebla Regional Hospital, with registration number 490.2023. Written informed consent was obtained.

Keywords: Depression, anxiety, stress, medical area, administrative area, nursing staff

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Universidad de las Americas Puebla ( email )

Affiliation not provided to ssrn ( email ).

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Erika Ramos-Tovar (Contact Author)

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60 popular mental health research paper topics.

The best way to write a good mental health research paper is to select a topic that you will enjoy working on. If you are looking for some interesting mental health research paper topics to work on, here is a list of 60 ideas to choose from.

Perfect for students as well as experts these topics have ample scope to experiment, share ideas and arguments on, and find substantial evidence to support your view. Take a look –

Mental Health Topics for Research Paper

When you are writing a paper for a graded assignment, it is important to have some great research paper topics about mental health to pick from. Here are some to consider –

• Mental traumas from physical injuries and how to help recover
• Resilience building – why is it important for children?
• Friendships in men and how they contribute to mental health?
• The role of parenting in building good mental health in children
• What is normal emotional health and mental functioning?
• Anti-depressants and their side effects.
• Indicators suggesting medication for depression can be stopped
• Effects of colors on mental health
• How and why does lack of sleep effect emotional mental health?
• Effect of exercise on a patient’s mental health
• Effective methods to boost brain health and emotional quotient as we age
• Mental health developmental stages in children from birth to 5 years of age
• Why is play important for mental health in children
• Obsessive Compulsive Disorder – what causes it and how to manage?
• ADHD — how to identify if someone has it?

Critical Analysis Research Paper Topics in Mental Health

For psychology students looking for effective research paper topics mental health offers many arenas for critical analysis. Here are some good topics to pick from –

• Relevance of Freud in modern day psychiatry
• Abortion care – the ethics and the procedures to facilitate emotional wellbeing
• Are women facing more mental health issues than men?
• Suicide – The reasons, trauma, and dealing with it
• How does peer pressure change mental wellness and how to deal with it?
• Effect of child abuse on toddlers’ mental health and resilience
• Does Obesity affect mental health?
• Is the damage on mental health caused by sexual abuse permanent?
• Hormonal imbalances and their effect on women’s mental health
• How to identify signs of mental illness in a loved one?

Music Therapy Research Paper Topics Mental Health

Music plays a significant role in enhancing mental health. Here are some mental health research paper topics on the role of music therapy in the field of mental health and treatments:

• Music therapy a complimentary approach to biomedicine
• Does music therapy facilitate enhanced healing?
• Efficacy of music therapy for older adults
• The role of music therapy in rehabilitation of mental health patients
• Music based interventions and the effects of music therapy
• Eating disorders and can music therapy help?
• Can music therapy help with mental health during menopause?
• Music therapy and its role in PTSD

Mental Health Nursing Research Paper Topics

If you are a nursing student you will certainly find these research paper topics for mental health useful for your assignment –

• Psychiatric care in adult patients of mental health disorders
• Non-chemical practices in bipolar disorder
• Mental health care for patients dealing with alcohol addiction
• Managing PTSD in armed forces veterans
• Ethics to deal with psychiatric patients
• Postpartum depression and how to identify and assist in early stages
• Identifying the signs and managing patients with eating disorder
• Mental illnesses common in soldiers returning from war
• Signs of mental illness that must never be ignored
• How to manage self-destructive mental health patients?

Controversial Research Paper Topics About Mental Health

Some mental health topics are controversial, but also well scoring if handled well. Take a look at some such topics worth considering –

• Do natural alternatives to anti-depressants work?
• Extreme postpartum depression leading to child harming tendencies
• Infertility and its effects on mental health of the couple
• Are more women suicidal than men?
• Effect of teen relationship problems on mental health
• The relationship between mental health and child abusers
• Physical abuse in marriage and its effect on mental health
• Rape and managing the emotional scars for effective healing
• Self-destructive tendencies in children – causes and cures
• Is it possible that there are people without conscience?
• Are video games making children violent and aggressive?
• Should criminals facing trial be subjected to genetic testing for impulse control?
• Mental health in teenagers and why they cut themselves
• Phobias – some of the most common and unusual fears people have
• Divorce and how it affects the mental health of children
• Is mental illness genetic
• Does discovery of being adopted affect mental health of a child?

If you are a college student wondering what is the best way to write a research paper or how to write an effective submission that will get you good grades, you can get in touch with us for writing help. Our team offers fast and cheap assistance with writing papers that are appropriate for your level of education.

School Closures and Parental Mental Health

Schools enhance the lives of families in various ways, and one potential consequence of their closures is worsened parental well-being. We study the effects of COVID-19 pandemic school closures on parental mental health by measuring consumption of products that are often used to cope with increased stress and depression. Using a cohort based difference in difference (DID) design and commercial claims data, we find an increase in maternal anti-depressant use by 1.5%, in zip codes with above median school closures; there are no statistically significant effects for paternal antidepressant use, and we are able to rule out fairly small values. Some parents may "self-medicate" as a coping mechanism rather than seek formal medical care. Using a county based DID design and retail scanner data, we find alcohol sales increased by 2% in counties with above median school closures. Both anti-depressant prescriptions and alcohol sales returned to base line levels as in-person schooling resumed. We explore whether the burdens of school closures were disparately concentrated in minoritized communities, and find that anti-depressant and alcohol use increases were concentrated in zip codes with above median Black and Asian populations, but not in zip codes with a predominantly White or Hispanic population. Overall, these results suggest that the school system plays an important role in maintaining population mental well-being outcomes and in helping families cope with stress.

We thank Emily Lawler, Kandice Kapinos and the participants of the 2023 American Society of Health Economists conference, the 2023 Association for Public Policy Analysis and Management conference and the 2024 O’Neill School Research Workshop participants at Indiana University for valuable comments and suggestions. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

MARC RIS BibTeΧ

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A hybrid predictive and prescriptive modelling framework for long-term mental healthcare workforce planning

• Chamara Hewage, Harsha
• Rostami-Tabar, Bahman

Over the past decade, there has been a severe staffing shortage in mental healthcare, exacerbated by increased demand for mental health services due to COVID-19. This demand is projected to increase over the next decade or so, necessitating proactive workforce planning to ensure sufficient staffing for ongoing service delivery. Despite the subject's critical significance, the present literature lacks thorough research dedicated to developing a model that addresses the long-term workforce needs required for efficient mental healthcare planning. Furthermore, our interactions with mental health practitioners within the United Kingdom's National Health Service (NHS) revealed the practical need for such a model. To address this gap, we aim to develop a hybrid predictive and prescriptive modelling framework, which combines long-term probabilistic forecasting with an analytical stock-flow model, designed specifically for mental health workforce planning. Given the vital role of nurses, who account for one-third of the total mental health workforce, we focus on modelling the headcount of nurses, but the proposed model can be generalised to other types of workforce planning in the healthcare sector. Using statistical and machine learning approaches and real-world data from NHS, we first identify factors contributing to variations in workforce requirements, then develop a long-term forecasting model to estimate future workforce needs, and finally integrate it into an analytical stock-flow method to provide policy analysis. Our findings highlight the unsustainable nature of present staffing plans, showing a growing nursing shortage. Furthermore, the policy analysis demonstrates the ineffectiveness of blanket remedies, highlighting the need for regional-level policy developments.

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NCA4 indicates Fourth National Climate Assessment.

Incidence rate ratio of emergency department visits with increasing temperature compared with optimal temperature. Main model adjusted for relative humidity and day of the week. Shading represents the 95% CI. The optimal temperature is the first percentile of the county-specific temperature distribution, at which minimum morbidity occurs. The additional temperatures shown on the x-axis represent the 25th, 50th, 75th, and 100th percentiles of the county-specific temperature distribution, converted to the equivalent actual temperature across all counties in the study area.

Incidence rate ratio of emergency department visits with increasing temperature compared with optimal temperature. Main model adjusted for relative humidity and day of the week. Shading indicates the 95% CI. The optimal temperature is the first percentile of the county-specific temperature distribution, at which minimum morbidity occurs. The additional temperatures shown on the x-axis represent the 25th, 50th, 75th, and 100th percentiles of the county-specific temperature distribution, converted to the equivalent actual temperature across all counties in the study area.

eTable. CCS Codes and Corresponding ICD-9/ICD-10 Codes.

eFigure 1. Time Course for Extreme Heat Exposure Response Curve.

eFigure 2. Sensitivity Analysis Results and Time Course for Composite Mental Health End Point.

eFigure 3. Time Course for Cause-Specific Mental Health Emergency Department Visits.

eFigure 4. Incidence Rate Ratio of Emergency Department Visits for 95th Percentile of Temperature vs Optimal Temperature Among Subgroups, and Heterogeneity Tests.

eAppendix. Sample R Code for Analysis.

• Association Between the 2021 Heat Wave in the Pacific Northwest and Emergency Department Visits JAMA Research Letter December 20, 2022 This study used a health care claims data set of enrollees in commercial and Medicare Advantage insurance plans to assess the association between the June 2021 heat wave and the rates of emergency department visits in Portland, Oregon, and Seattle, Washington. Amruta Nori-Sarma, PhD; Chad Milando, PhD; Kate R. Weinberger, PhD; Jeremy J. Hess, MD; Nicole A. Errett, PhD; Gregory A. Wellenius, ScD
• Identifying and Preparing for the Mental Health Burden of Climate Change JAMA Psychiatry Editorial April 1, 2022 Nick Obradovich, PhD; Kelton Minor, MS

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Nori-Sarma A , Sun S , Sun Y, et al. Association Between Ambient Heat and Risk of Emergency Department Visits for Mental Health Among US Adults, 2010 to 2019. JAMA Psychiatry. 2022;79(4):341–349. doi:10.1001/jamapsychiatry.2021.4369

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Association Between Ambient Heat and Risk of Emergency Department Visits for Mental Health Among US Adults, 2010 to 2019

• 1 Department of Environmental Health, Boston University School of Public Health, Boston, Massachusetts
• 2 OptumLabs Visiting Scholar, Eden Prairie, Minnesota
• 3 Department of Psychiatry, Boston Medical Center, Boston, Massachusetts
• 4 Boston University School of Public Health, Boston, Massachusetts
• 5 Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
• Editorial Identifying and Preparing for the Mental Health Burden of Climate Change Nick Obradovich, PhD; Kelton Minor, MS JAMA Psychiatry
• Research Letter Association Between the 2021 Heat Wave in the Pacific Northwest and Emergency Department Visits Amruta Nori-Sarma, PhD; Chad Milando, PhD; Kate R. Weinberger, PhD; Jeremy J. Hess, MD; Nicole A. Errett, PhD; Gregory A. Wellenius, ScD JAMA

Question   Are periods of higher ambient temperature associated with an increase in emergency department (ED) visits for mental health conditions among US adults with health insurance?

Findings   In this case-crossover study of 3 496 762 ED visits among 2 243 395 unique individuals, higher warm-season temperatures were associated with an increased risk of ED visits for any mental health condition and for specific mental health conditions.

Meaning   This information could aid clinicians providing services for mental health in preparing for increased stress on individuals and the health care system during times when extreme heat is anticipated.

Importance   The implications of extreme heat for physical health outcomes have been well documented. However, the association between elevated ambient temperature and specific mental health conditions remains poorly understood.

Objective   To investigate the association between ambient heat and mental health–related emergency department (ED) visits in the contiguous US among adults overall and among potentially sensitive subgroups.

Design, Setting, and Participants   This case-crossover study used medical claims data obtained from OptumLabs Data Warehouse (OLDW) to identify claims for ED visits with a primary or secondary discharge psychiatric diagnosis during warm-season months (May to September) from 2010 through 2019. Claims for adults aged 18 years or older with commercial or Medicare Advantage health insurance who were living in 2775 US counties were included in the analysis. Emergency department visits were excluded if the Clinical Classifications Software code indicated that the visits were for screening for mental health outcomes and impulse control disorders.

Exposures   County-specific daily maximum ambient temperature on a continuous scale was estimated using the Parameter-Elevation Relationships on Independent Slopes model. Extreme heat was defined as the 95th percentile of the county-specific warm-season temperature distribution.

Main Outcomes and Measures   The daily incidence rate of cause-specific mental health diagnoses and a composite end point of any mental health diagnosis were assessed by identifying ED visit claims using primary and secondary discharge diagnosis International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Conditional logistic regression models were used to estimate the incidence rate ratio (IRR) and 95% CIs for the association between daily temperature and incidence rates of ED visits.

Results   Data from 3 496 762 ED visits among 2 243 395 unique individuals were identified (56.8% [1 274 456] women; mean [SD] age, 51.0 [18.8] years); of these individuals, 14.3% were aged 18 to 26 years, 25.6% were aged 27 to 44 years, 33.3% were aged 45 to 64 years, and 26.8% were aged 65 years or older. Days of extreme heat were associated with an IRR of 1.08 (95% CI, 1.07-1.09) for ED visits for any mental health condition. Associations between extreme heat and ED visits were found for specific mental health conditions, including substance use disorders (IRR, 1.08; 95% CI, 1.07-1.10); anxiety, stress-related, and somatoform disorders (IRR, 1.07; 95% CI, 1.05-1.09); mood disorders (IRR, 1.07; 95% CI, 1.05-1.09); schizophrenia, schizotypal, and delusional disorders (IRR, 1.05; 95% CI, 1.03-1.07); self-harm (IRR, 1.06; 95% CI, 1.01-1.12); and childhood-onset behavioral disorders (IRR, 1.11; 95% CI, 1.05-1.18). In addition, associations were higher among men (IRR, 1.10; 95% CI, 1.08-1.12) and in the US Northeast (IRR, 1.10; 95% CI, 1.07-1.13), Midwest (IRR, 1.11; 95% CI, 1.09-1.13), and Northwest (IRR, 1.12; 95% CI, 1.03-1.21) regions.

Conclusions and Relevance   In this case-crossover study of a large population of US adults with health insurance, days of extreme heat were associated with higher rates of mental health–related ED visits. This finding may be informative for clinicians providing mental health services during periods of extreme heat to prepare for increases in health service needs when times of extreme heat are anticipated.

Exposure to high ambient temperatures (ie, heat) is a recognized threat to public health and has been documented to be associated with excess morbidity 1 and mortality. 2 - 4 Seven of the warmest years on record for the contiguous US have occurred since 2014, with 2016 reaching the greatest temperatures and 2020 now ranked as the second warmest year in the available 141-year record. 5 As climate change leads to more days with extreme temperatures, and particularly, higher summertime temperatures, the burden of disease associated with ambient heat is expected to increase. Heat stress is known to trigger adverse physiological responses in the human body, ranging from heat rash and muscle cramps or fatigue to broad consequences for a range of human organ systems and heat stroke, which can be fatal. 6

In addition to the association between extreme heat and physical health, a growing number of studies have reported on the potential adverse effects of heat on mental health. Ambient temperature has been previously associated with exacerbation of symptoms for many mental and behavioral disorders, including self-reported adverse mental health outcomes, 7 - 9 and elevated risk of emergency department (ED) visits for any mental health cause, 9 mood-anxiety disorders, substance use, and schizophrenia 10 , 11 as well as higher suicide risk. 9 , 12 , 13 However, existing studies have been limited by small sample sizes, specific populations or geographic areas, or reliance on self-reported mental health symptoms. Thus, the association between heat and mental health remains incompletely quantified, and little is known about whether certain population subgroups have increased risk factors for visiting the ED for mental health diagnoses because of exposure to higher ambient temperature.

Mental health consequences of elevated ambient temperature can arise during both warm- and cool-temperature seasons. However, the underlying processes that lead to elevated adverse mental health outcomes may be different by season. For example, cold temperatures may affect health on a different time scale, with substantially longer lag effects during cold periods compared with hot periods. 14 - 16 In addition, virtually all extreme heat events in the US occur during the warm season. Therefore, although it is important to assess the association between temperature and mental health across the entire year, the proposed statistical method in the current analysis is better suited to a warm-season-only model. The aim of this study was to investigate the association between warm-season (May through September) temperatures between 2010 and 2019 and rates of ED visits for a broad range of mental health outcomes among adults with commercial and Medicare Advantage health insurance living in the contiguous US. We focus on ED visits, which represent the most severe presentations of mental health exacerbations both from a clinical perspective and in terms of stress on health systems to provide care. We further investigated whether observed associations differed across strata defined by age, sex, and geographic region and explored the time course of the observed association.

In this case-crossover study, we obtained medical claims between January 1, 2010, and December 31, 2019, from the OptumLabs Data Warehouse (OLDW), which contains deidentified, longitudinal health information on enrollees and patients, representing a diverse mixture of ages, ethnicities, and geographies throughout the contiguous US. 17 We identified claims for ED visits related to mental health ( Figure 1 A) based on the International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) code, revenue code, Current Procedural Terminology code, and place of service code. For each claim, we then extracted information on the age, sex, and county of residence of the individual as well as the admission date and principal diagnosis code (based on ICD-9 until 2015 or ICD-10 after 2015) for each ED visit. Information on race and ethnicity was unavailable in these data sets. We limited our analysis to ED visits occurring among individuals aged 18 years or older. The institutional review board of Boston University deemed the study exempt from review and waived the requirement for informed consent because the study involved analysis of deidentified data. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We applied the Agency for Healthcare Research and Quality’s Clinical Classifications Software scheme 18 to ICD-9 and ICD-10 principal diagnosis codes at discharge, including primary discharge diagnosis and secondary diagnoses, to classify ED visits into clinically meaningful and mutually exclusive disease groups. The Clinical Classifications Software scheme is a comprehensive classification tool for clustering diagnoses into a manageable number of categories based on disease characteristics and treatment protocol and is widely used to analyze disease-specific conditions. We identified the disease groups for relevant mental health outcomes 19 as specified in Table 1 . We excluded the Clinical Classifications Software codes for screening for mental health outcomes because the data-generation process is different than for a diagnosis and may lead to inaccuracies in the data. We further excluded ED visits for impulse control disorders, which are uncommon in this data set.

We obtained daily maximum ambient temperature data from the Parameter-Elevation Regressions on Independent Slopes (PRISM) model from the PRISM Climate Group, 20 which is a validated spatiotemporal model with approximately 4-km horizontal grid spacing. 21 To represent population exposure to temperature, we calculated a population-weighted mean daily maximum temperature provided by the PRISM model for each day in each county, as described previously in the literature. 22 We limited the study period to the warm-season months (May through September; henceforth referred to as the warm season for simplicity) to represent heat exposure. We estimated extreme temperature as days with a daily maximum ambient temperature greater than or equal to the 95th percentile of county-specific temperature ( Figure 1 B). For sensitivity analyses, we also estimated a population-weighted mean daily ambient temperature based on PRISM data.

We used a case-crossover study 23 , 24 to estimate the association between daily maximum temperature and the incidence rate per county-day of ED visits with a diagnosis for a composite end point of any mental health condition and ED visits for specific mental health conditions. In this study design, participants serve as their own control, and the inference is based on the comparison of exposures over time within the same individual. This design has the advantage of controlling for all known and unknown potential confounders that are time invariant or vary relatively slowly over long periods of time (eg, socioeconomic status, age, and sex). We used a time-stratified approach to select control periods such that ambient temperature during the case period was compared with ambient temperature on other days of the same year, month, and day of the week as the case day. 25 , 26 This approach to selecting control periods serves to minimize confounding by seasonal and long-term time patterns as well as day of the week. 25 In addition, we adjusted for relative humidity (natural spline with 3 df ) and federal holidays.

In the primary analysis, we applied a well-established distributed lag nonlinear modeling framework to allow for both nonlinear exposure-response functions and nonlinear lag-response functions. 27 , 28 We modeled exposure-response functions using a quadratic B-spline, with 1 internal knot placed at the 50th percentile of county-specific warm-season months’ temperature distribution. For the lag-response function, we used a natural cubic B-spline with 2 knots placed at equal intervals on the log scale of lags up to 5 days. We used conditional logistic regression models to estimate the incidence rate ratio (IRR) and 95% CIs for the association between daily temperature and incidence rates of ED visits, comparing ED visits associated with ambient temperature with ED visits associated with the optimal temperature. The optimal temperature was estimated as the temperature percentile with minimum ED visits across the county-specific temperature distribution. Extreme heat was defined as ambient temperature at the 95th percentile of the county-specific temperature distribution. We first considered the association between temperature and the IRR of ED visits associated with a composite end point of any mental health condition. We subsequently considered the association between temperature and the IRR of ED visits for specific mental health conditions.

We performed a series of sensitivity analyses using the composite mental health end point to assess the robustness of our findings. First, we varied the key modeling parameters to estimate the association between ambient heat and ED visits for the composite mental health end point. This sensitivity analysis included exposure-response functions using a quadratic B-spline with 2 and 3 internal knots. We modeled the lag-response function using a natural cubic B-spline with 3 knots placed at equal intervals on the log scale of lags up to 5 days. Second, because there is no consensus on which exposure metrics should be used to examine the impact of heat, we used daily mean temperature in the sensitivity analysis.

To examine differences in the rate of ED visits for population subgroups, we evaluated whether the association between warm-season heat and incidence of ED visits varied across strata defined by age, sex, and region in the US (defined using the Fourth National Climate Assessment 29 regions). We used the Wald test to assess whether the associations were homogeneous across strata. 30

We conducted all analyses in R software, version 3.6.3 (R Foundation for Statistical Computing), with the survival package, version 3.2-7, for the conditional logistic regression and the dlnm package, version 2.4.2, for the distributed lag nonlinear model.

Between 2010 and 2019, we identified 3 496 762 claims for ED visits occurring among 2 243 395 unique individuals (56.8% [1 274 456] women and 43.2% [968 939] men; mean [SD] age, 51.0 [18.8] years); of these individuals, 14.3% were aged 18 to 26 years, 25.6% were aged 27 to 44 years, 33.3% were aged 45 to 64 years, and 26.8% were aged 65 years or older. This sample represented claims for mental health conditions among 21 048 502 individuals (approximately 6.8% of the 2015 US population) enrolled in commercial or Medicare Advantage health insurance plans. Emergency department visits for substance use disorders were most common, followed by ED visits for anxiety, stress-related, and somatoform disorders and for mood disorders ( Table 1 ). The individuals included in this analysis resided in 1 of 2775 US counties; these counties are the most populated areas within the contiguous US, accounting for locations where approximately 97.6% of the 2020 US population (331 449 281 people) resided.

Overall, higher warm-season temperatures were associated with monotonically higher rates of ED visits for any mental health condition ( Figure 2 ). Specifically, days of extreme heat had an IRR of 1.08 (95% CI, 1.07-1.09) for ED visits for any mental health condition compared with days of optimal temperature. The increase in IRR was highest on the same day (lag 0), with some evidence of continued higher IRR 2 to 4 days later (eFigure 1 and eAppendix in the Supplement ). This result was robust to sensitivity analysis incorporating various modeling parameters (eFigure 2 in the Supplement ). Days of extreme heat were also associated with higher rates of ED visits for specific mental health conditions, including substance use disorders (IRR, 1.08; 95% CI, 1.07-1.10); anxiety, stress-related, and somatoform disorders (IRR, 1.07; 95% CI, 1.05-1.09); mood disorders (IRR, 1.07; 95% CI, 1.05-1.09); schizophrenia, schizotypal, and delusional disorders (IRR, 1.05; 95% CI, 1.03-1.07); self-harm (IRR, 1.06; 95% CI, 1.01-1.12); and childhood-onset behavioral disorders (IRR, 1.11; 95% CI, 1.05-1.18) ( Table 2 ). The association between higher temperatures and mental health was less evident for other specific mental health conditions, including adult personality and behavior disorders and other miscellaneous disorders that are not otherwise classified ( Figure 3 ). There was no evidence of lag effects of temperature for specific causes (eFigure 3 in the Supplement ). We evaluated how the observed associations between higher temperature and ED visits for any mental health condition varied by age, sex, and geographic region within the US (eFigure 4 in the Supplement ). We found no evidence of heterogeneity across age groups but found elevated rates of ED visits for mental health among men (IRR, 1.10; 95% CI, 1.08-1.12) compared with women (IRR, 1.06; 95% CI, 1.05-1.08). We also found that IRRs were higher in the Northeast (IRR, 1.10; 95% CI, 1.07-1.13), Midwest (IRR, 1.11; 95% CI, 1.09-1.13), and Northwest (IRR, 1.12; 95% CI, 1.03-1.21) US.

In this nationwide study of ED visits among adults with commercial and Medicare Advantage health insurance in the contiguous US, we found that days of extreme heat were associated with higher rates of ED visits for a composite measure of mental health diagnoses and ED visits associated with specific mental health conditions, including substance use disorders; anxiety, stress-related, and somatoform disorders; mood disorders; schizophrenia, schizotypal, and delusional disorders; self-harm; and childhood-onset behavioral disorders.

Relatively few studies have examined the association between heat and ED visits for mental health. Regional studies conducted in many cities and countries, including in California, 9 , 31 Southern California, 32 and New York 10 in the US; Adelaide, Australia 10 ; Paris, France 33 ; Tel Aviv, Israel 34 ; the Baix Camp and Tarragona region of Spain 35 ; and Canada, 36 have found an increasing number of ED visits for a variety of mental health conditions associated with increasing temperatures. Another study based in Barcelona, Spain, found no association between heat and ED visits in the general population but did find elevated risk factors among patients with psychiatric histories, as well as more alcohol and drug misuse, during an extreme heat wave in 2003. 37 However, these studies often rely on data from local hospitals or regional health care utilization data, potentially limiting the generalizability of results. By comparison, our findings extend the previous work by examining the implications of temperature for ED utilization for mental health conditions among adults with health insurance across the entire contiguous US.

In addition, we examined the potential for elevated rates of ED visits associated with any mental health diagnosis among different age groups as well as among men vs women and within different US regions. We found no evidence of differential associations between temperature and mental health stratified by age groups, which stands in contrast to previous findings. 10 We also found that the rate of ED visits on days of extreme heat was higher among men vs women, a different result from past work. 31 We also found higher rates of ED visits in the US Northwest, Northeast, and Midwest, a regional analysis that has not been previously conducted for mental health outcomes in the US. This finding may suggest that there is an increased risk of adverse mental health outcomes in regions of the US that are less well adapted to heat (ie, where adaptive measures such as air conditioning may be less prevalent compared with areas, such as the Southeastern and Southwestern US, that have historically experienced higher temperatures 38 ).

There are several potential pathways by which heat may exacerbate mental health conditions. Exogenous stressors are well known to exacerbate existing mental health conditions. Our finding that heat was associated with a similar increase in the rate of ED visits for a variety of different mental health conditions is consistent with the hypothesis that heat is an external stressor that is not specific to any given mental health condition. One etiological mechanism may be disrupted sleep during periods of high ambient temperature, which may be associated with adverse mental health outcomes. 39 Daytime discomfort or irritation owing to elevated temperature may be a stressor that exacerbates preexisting conditions. Another biological pathway may be the increase in hopelessness, maladaptive anxiety, and stress attributable to the anticipation of climate change and associated extreme events. 40 - 43 In addition, on warmer days, patients may visit the ED to seek relief from high temperatures. Heat could also affect opening hours of other health care facilities, which could be associated with an increase in ED visits. These and other social and health care system factors might explain elevated ED visits on days of extreme temperature.

This study has strengths. To our knowledge, it is the largest and most comprehensive analysis of daily ambient temperature associated with ED visits for mental health diagnoses among adults aged 18 years or older across the contiguous US. Because we focused on ED visits, which represent clinically meaningful exacerbations of mental health conditions, we were able to assess the costliest interactions between temperature and mental health both at the individual level and from the perspective of the health care system. With such a large data set, we were able to explore the consequences of temperature on a wide range of illnesses associated with adverse mental health outcomes, filling an important gap in the existing literature. The current analysis focused on the warm season; future work is needed to further characterize the implications of temperature for mental health outcomes during cold seasons. We were also able to identify some strata of the population that may have more risk factors for adverse mental health outcomes owing to extreme heat. Additional studies are needed to identify other populations that may be at greater risk for adverse outcomes and to gain insights into the pathophysiologic mechanisms underlying the observed associations in an effort to identify effective strategies to prevent adverse mental health outcomes.

The association between elevated ambient temperature and an increased rate of ED visits for specific mental health conditions, such as substance use disorders, may be of particular relevance to mental health practitioners and public health officials during periods of extreme heat. It is possible that the association between extreme heat and exacerbation of symptoms for many mental and behavioral disorders is not limited to ED visits but may also include a broader group of people with mental health conditions that may not require emergency care. During and following periods of high temperature, mental health and emergency care practitioners may consider increasing capacity to provide necessary mental health services. This consideration is particularly important given the potential for climate change to increase both the frequency and severity of extreme temperatures, 29 which may further increase demand for clinical services related to mental health and may also lead to increased direct emotional responses such as anxiety. 40

This study also has limitations. First, although our use of the case-crossover study presented some advantages, there are some limitations to causal interpretation of the effect size estimates. This study design is appropriate when exposure is intermittent, the implications for the risk of outcome are immediate, and the outcome itself is abrupt—a series of general criteria that suit our study. 23 , 24 We estimate that potential causes of bias within our study design would bias the results toward the null. For example, we used the population-weighted mean daily maximum temperature as a proxy for personal heat exposure, potentially leading to some exposure misclassification. However, we expect that this exposure misclassification would be nondifferential and on average tend to bias our results toward the null. In addition, there may be unmeasured time-varying confounders, including time spent outdoors and activity levels, which we anticipate would be nondifferential and on average bias our results toward the null.

Second, we did not consider other meteorological characteristics, such as precipitation or cloud cover, either of which may alter mental health. 44 , 45 However, given that warm-season days with precipitation or substantial cloud cover are generally cooler than what would be observed under equivalent clear-sky conditions, we expect that any confounding by these elements (if present) would have biased our estimates toward the null hypothesis of no association between extreme heat and an increase in ED visits for mental health conditions.

Third, our study is based on health care utilization data, and given that it specifically focused on ED visits, we anticipate that the mental health diagnoses included in this study likely represent the most severe presentations. The less severe outcomes associated with increasing temperature are an area for future research.

Fourth, use of deidentified medical claims data limits the information available on individual-level characteristics; data on race and ethnicity, individual markers of socioeconomic means, occupation, and time-activity patterns were not available. Although these factors cannot confound the results because of the use of the study’s design, we were not able to comprehensively assess individual-level risk factors.

Fifth, our data are limited to individuals with commercial health insurance or Medicare Advantage (ie, data do not include recipients of Medicaid health coverage for individuals with a low income or Medicare without supplemental plans, hence likely skewing of the sample toward wealthier socioeconomic status), potentially limiting the generalizability of our results.

Results of this case-crossover study suggest that there was an association between elevated ambient temperature and ED visits for any mental health condition and for specific mental health diagnoses. This finding could aid clinicians who provide mental health services in preparing for increases in health service needs when high ambient temperature is anticipated. Further research could investigate the implications of sustained periods of extreme heat (heat waves) for health outcomes and continue to investigate the association among different populations. In addition, future work could characterize the implications of elevated temperatures during cold periods for mental health outcomes and the consequences of additional meteorological characteristics and multiple extreme weather events that may occur with elevated ambient temperature or may be triggered by periods of extreme heat.

Accepted for Publication: November 30, 2021.

Published Online: February 23, 2022. doi:10.1001/jamapsychiatry.2021.4369

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2022 Nori-Sarma A et al. JAMA Psychiatry .

Corresponding Authors: Amruta Nori-Sarma, PhD, MPH ( [email protected] ), and Shengzhi Sun, PhD ( [email protected] ), Department of Environmental Health, Boston University School of Public Health, 715 Albany St, Talbot 4W, Boston, MA 02118.

Author Contributions: Drs Nori-Sarma and S. Sun had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Nori-Sarma, S. Sun, Galea, Wellenius.

Acquisition, analysis, or interpretation of data: Nori-Sarma, S. Sun, Y. Sun, Spangler, Oblath, Gradus, Wellenius.

Drafting of the manuscript: Nori-Sarma, Y. Sun, Gradus.

Critical revision of the manuscript for important intellectual content: Nori-Sarma, S. Sun, Spangler, Oblath, Galea, Gradus, Wellenius.

Statistical analysis: Nori-Sarma, S. Sun, Y. Sun.

Obtained funding: Wellenius.

Administrative, technical, or material support: Spangler, Oblath, Galea.

Supervision: Gradus, Wellenius.

Conflict of Interest Disclosures: Dr Galea reported receiving personal fees from Sharecare outside the submitted work. Dr Wellenius reported receiving grants from the National Institutes of Health’s National Institute of Environmental Health Sciences and the Wellcome Trust during the conduct of the study and serving as a consultant for the Health Effects Institute and Google. No other disclosures were reported.

Funding/Support: This study was supported by grant R01-ES029950 from the National Institutes of Health’s National Institute of Environmental Health Sciences (Drs Nori-Sarma, S. Sun, Spangler, and Wellenius and Mr Y. Sun) and grant 216033-Z-19-Z from the Wellcome Trust (Drs Nori-Sarma, S. Sun, Spangler, and Wellenius and Mr Y. Sun).

Role of the Funder/Sponsor: The National Institute of Environmental Health Sciences and the Wellcome Trust had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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• DOI: 10.36330/kmj.v20i1.13900
• Corpus ID: 270543758

Impact of Internet and Social Media on Academic Performance, Social Interaction, and Mental Health among a Sample of Iraqi University Students

• Taqi Mohammed Jwad Taher , Diana Mazlum Ali
• Published in Kufa Medical Journal 15 June 2024
• Education, Psychology

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Impact of COVID-19 pandemic on mental health in the general population: A systematic review

Jiaqi xiong.

a Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON

Orly Lipsitz

c Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, Ontario

Flora Nasri

Leanna m.w. lui, hartej gill, david chen-li, michelle iacobucci.

e Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

f Institute for Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore

Amna Majeed

Roger s. mcintyre.

b Department of Psychiatry, University of Toronto, Toronto, Ontario

d Brain and Cognition Discovery Foundation, Toronto, ON

Associated Data

As a major virus outbreak in the 21st century, the Coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented hazards to mental health globally. While psychological support is being provided to patients and healthcare workers, the general public's mental health requires significant attention as well. This systematic review aims to synthesize extant literature that reports on the effects of COVID-19 on psychological outcomes of the general population and its associated risk factors.

A systematic search was conducted on PubMed, Embase, Medline, Web of Science, and Scopus from inception to 17 May 2020 following the PRISMA guidelines. A manual search on Google Scholar was performed to identify additional relevant studies. Articles were selected based on the predetermined eligibility criteria.

Results: Relatively high rates of symptoms of anxiety (6.33% to 50.9%), depression (14.6% to 48.3%), post-traumatic stress disorder (7% to 53.8%), psychological distress (34.43% to 38%), and stress (8.1% to 81.9%) are reported in the general population during the COVID-19 pandemic in China, Spain, Italy, Iran, the US, Turkey, Nepal, and Denmark. Risk factors associated with distress measures include female gender, younger age group (≤40 years), presence of chronic/psychiatric illnesses, unemployment, student status, and frequent exposure to social media/news concerning COVID-19.

Limitations

A significant degree of heterogeneity was noted across studies.

Conclusions

The COVID-19 pandemic is associated with highly significant levels of psychological distress that, in many cases, would meet the threshold for clinical relevance. Mitigating the hazardous effects of COVID-19 on mental health is an international public health priority.

1. Introduction

In December 2019, a cluster of atypical cases of pneumonia was reported in Wuhan, China, which was later designated as Coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO) on 11 Feb 2020 ( Anand et al., 2020 ). The causative virus, SARS-CoV-2, was identified as a novel strain of coronaviruses that shares 79% genetic similarity with SARS-CoV from the 2003 SARS outbreak ( Anand et al., 2020 ). On 11 Mar 2020, the WHO declared the outbreak a global pandemic ( Anand et al., 2020 ).

The rapidly evolving situation has drastically altered people's lives, as well as multiple aspects of the global, public, and private economy. Declines in tourism, aviation, agriculture, and the finance industry owing to the COVID-19 outbreak are reported as massive reductions in both supply and demand aspects of the economy were mandated by governments internationally ( Nicola et al., 2020 ). The uncertainties and fears associated with the virus outbreak, along with mass lockdowns and economic recession are predicted to lead to increases in suicide as well as mental disorders associated with suicide. For example, McIntyre and Lee (2020b) have reported a projected increase in suicide from 418 to 2114 in Canadian suicide cases associated with joblessness. The foregoing result (i.e., rising trajectory of suicide) was also reported in the USA, Pakistan, India, France, Germany, and Italy ( Mamun and Ullah, 2020 ; Thakur and Jain, 2020 ). Separate lines of research have also reported an increase in psychological distress in the general population, persons with pre-existing mental disorders, as well as in healthcare workers ( Hao et al., 2020 ; Tan et al., 2020 ; Wang et al., 2020b ). Taken together, there is an urgent call for more attention given to public mental health and policies to assist people through this challenging time.

The objective of this systematic review is to summarize extant literature that reported on the prevalence of symptoms of depression, anxiety, PTSD, and other forms of psychological distress in the general population during the COVID-19 pandemic. An additional objective was to identify factors that are associated with psychological distress.

Methods and results were formated based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( Moher et al., 2010 ).

2.1. Search strategy

A systematic search following the PRISMA 2009 flow diagram ( Fig. 1 ) was conducted on PubMed, Medline, Embase, Scopus, and Web of Science from inception to 17 May 2020. A manual search on Google Scholar was performed to identify additional relevant studies. The search terms that were used were: (COVID-19 OR SARS-CoV-2 OR Severe acute respiratory syndrome coronavirus 2 OR 2019nCoV OR HCoV-19) AND (Mental health OR Psychological health OR Depression OR Anxiety OR PTSD OR PTSS OR Post-traumatic stress disorder OR Post-traumatic stress symptoms) AND (General population OR general public OR Public OR community). An example of search procedure was included as a supplementary file.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) study selection flow diagram. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

2.2. Study selection and eligibility criteria

Titles and abstracts of each publication were screened for relevance. Full-text articles were accessed for eligibility after the initial screening. Studies were eligible for inclusion if they: 1) followed cross-sectional study design; 2) assessed the mental health status of the general population/public during the COVID-19 pandemic and its associated risk factors; 3) utilized standardized and validated scales for measurement. Studies were excluded if they: 1) were not written in English or Chinese; 2) focused on particular subgroups of the population (e.g., healthcare workers, college students, or pregnant women); 3) were not peer-reviewed; 4) did not have full-text availability.

2.3. Data extraction

A data extraction form was used to include relevant data: (1) Lead author and year of publication, (2) Country/region of the population studied, (3) Study design, (4) Sample size, (5) Sample characteristics, (6) Assessment tools, (7) Prevalence of symptoms of depression/anxiety/ PTSD/psychological distress/stress, (8) Associated risk factors.

2.4 Quality appraisal

The Newcastle-Ottawa Scale (NOS) adapted for cross-sectional studies was used for study quality appraisal, which was modified accordingly from the scale used in Epstein et al. (2018) . The scale consists of three dimensions: Selection, Comparability, and Outcome. There are seven categories in total, which assess the representativeness of the sample, sample size justification, comparability between respondents and non-respondents, ascertainments of exposure, comparability based on study design or analysis, assessment of the outcome, and appropriateness of statistical analysis. A list of specific questions was attached as a supplementary file. A total of nine stars can be awarded if the study meets certain criteria, with a maximum of four stars assigned for the selection dimension, a maximum of two stars assigned for the comparability dimension, and a maximum of three stars assigned for the outcome dimension.

3.1. Search results

In total, 648 publications were identified. Of those, 264 were removed after initial screening due to duplication. 343 articles were excluded based on the screening of titles and abstracts. 41 full-text articles were assessed for eligibility. There were 12 articles excluded for studying specific subgroups of the population, five articles excluded for not having a standardized/ appropriate measure, three articles excluded for being review papers, and two articles excluded for being duplicates. Following the full-text screening, 19 studies met the inclusion criteria.

3.2. Study characteristics

Study characteristics and primary study findings are summarized in Table 1 . The sample size of the 19 studies ranged from 263 to 52,730 participants, with a total of 93,569 participants. A majority of study participants were over 18 years old. Female participants ( n  = 60,006) made up 64.1% of the total sample. All studies followed a cross-sectional study design. The 19 studies were conducted in eight different countries, including China ( n  = 10), Spain ( n  = 2), Italy ( n  = 2), Iran ( n  = 1), the US ( n  = 1), Turkey ( n  = 1), Nepal ( n  = 1), and Denmark ( n  = 1). The primary outcomes chosen in the included studies varied across studies. Twelve studies included measures of depressive symptoms while eleven studies included measures of anxiety. Symptoms of PTSD/psychological impact of events were evaluated in four studies while three studies assessed psychological distress. It was additionally observed that four studies contained general measures of stress. Three studies did not explicitly report the overall prevalence rates of symptoms; notwithstanding the associated risk factors were identified and discussed.

Summary of study sample characteristics, study design, assessment tools used, prevalence rates and associated risk factors.

3.3. Quality appraisal

The result of the study quality appraisal is presented in Table 2 . The overall quality of the included studies is moderate, with total stars awarded varying from four to eight. There were two studies with four stars, two studies with five stars, seven studies with six stars, seven studies with seven stars, and one study with eight stars.

Results of study quality appraisal of the included studies.

3.4. Measurement tools

A variety of scales were used in the studies ( n  = 19) for assessing different adverse psychological outcomes. The Beck Depression Inventory-II (BDI-II), Patient Health Questionnaire-9/2 (PHQ-9/2), Self-rating Depression Scales (SDS), The World Health Organization-Five Well-Being Index (WHO-5), and Center for Epidemiologic Studies Depression Scale (CES-D) were used for measuring depressive symptoms. The Beck Anxiety Inventory (BAI), Generalized Anxiety Disorder 7/2-item (GAD-7/2), and Self-rating Anxiety Scale (SAS) were used to evaluate symptoms of anxiety. The Depression, Anxiety, and Stress Scale- 21 items (DASS-21) was used for the evaluation of depression, anxiety, and stress symptoms. The Hospital Anxiety and Depression Scale (HADS) was used for assessing anxiety and depressive symptoms. Psychological distress was measured by The Peritraumatic Distress Inventory (CPDI) and the Kessler Psychological Distress Scale (K6/10). Symptoms of PTSD were assessed by The Impact of Event Scale-(Revised) (IES(-R)), PTSD Checklist (PCL-(C)-2/5). Chinese Perceived Stress Scale (CPSS-10) was used in one study to evaluate symptoms of stress.

3.5. Symptoms of depression and associated risk factors

Symptoms of depression were assessed in 12 out of the 19 studies ( Ahmed et al., 2020 ; Gao et al., 2020 ; González-Sanguino et al., 2020 ; Huang and Zhao, 2020 ; Lei et al., 2020 ; Mazza et al., 2020 ; Olagoke et al., 2020 ; Ozamiz-Etxebarria et al., 2020 ; Özdin and S.B. Özdin, 2020 ; Sønderskov et al., 2020 ; Wang et al., 2020a ; Wang et al., 2020b ). The prevalence of depressive symptoms ranged from 14.6% to 48.3%. Although the reported rates are higher than previously estimated one-year prevalence (3.6% and 7.2%) of depression among the population prior to the pandemic ( Huang et al., 2019 ; Lim et al., 2018 ), it is important to note that presence of depressive symptoms does not reflect a clinical diagnosis of depression.

Many risk factors were identified to be associated with symptoms of depression amongst the COVID-19 pandemic. Females were reported as are generally more likely to develop depressive symptoms when compared to their male counterparts ( Lei et al., 2020 ; Mazza et al., 2020 ; Sønderskov et al., 2020 ; Wang et al., 2020a ). Participants from the younger age group (≤40 years) presented with more depressive symptoms ( Ahmed et al., 2020 ; Gao et al., 2020 ; Huang and Zhao, 2020 ; Lei et al., 2020 ; Olagoke et al., 2020 ; Ozamiz-Etxebarria et al., 2020 ;). Student status was also found to be a significant risk factor for developing more depressive symptoms as compared to other occupational statuses (i.e. employment or retirement) ( González et al., 2020 ; Lei et al., 2020 ; Olagoke et al., 2020 ). Four studies also identified lower education levels as an associated factor with greater depressive symptoms ( Gao et al., 2020 ; Mazza et al., 2020 ; Olagoke et al., 2020 ; Wang et al., 2020a ). A single study by Wang et al., 2020b reported that people with higher education and professional jobs exhibited more depressive symptoms in comparison to less educated individuals and those in service or enterprise industries.

Other predictive factors for symptoms of depression included living in urban areas, poor self-rated health, high loneliness, being divorced/widowed, being single, lower household income, quarantine status, worry about being infected, property damage, unemployment, not having a child, a past history of mental stress or medical problems, having an acquaintance infected with COVID-19, perceived risks of unemployment, exposure to COVID-19 related news, higher perceived vulnerability, lower self-efficacy to protect themselves, the presence of chronic diseases, and the presence of specific physical symptoms ( Gao et al., 2020 ; González-Sanguino et al., 2020 ; Lei et al., 2020 ; Mazza et al., 2020 ; Olagoke et al., 2020 ; Ozamiz-Etxebarria et al., 2020 ; Özdin and Özdin, 2020 ; Wang et al., 2020a ).

3.6. Symptoms of anxiety and associated risk factors

Anxiety symptoms were assessed in 11 out of the 19 studies, with a noticeable variation in the prevalence of anxiety symptoms ranging from 6.33% to 50.9% ( Ahmed et al., 2020 ; Gao et al., 2020 ; González-Sanguino et al., 2020 ; Huang and Zhao, 2020 ; Lei et al., 2020 ; Mazza et al., 2020 ; Moghanibashi-Mansourieh, 2020 ; Ozamiz-Etxebarria et al., 2020 ; Özdin and Özdin, 2020 ; Wang et al., 2020a ; Wang et al., 2020b ).

Anxiety is often comorbid with depression ( Choi et al., 2020 ). Some predictive factors for depressive symptoms also apply to symptoms of anxiety, including a younger age group (≤40 years), lower education levels, poor self-rated health, high loneliness, female gender, divorced/widowed status, quarantine status, worry about being infected, property damage, history of mental health issue/medical problems, presence of chronic illness, living in urban areas, and the presence of specific physical symptoms ( Ahmed et al., 2020 ; Gao et al., 2020 ; González-Sanguino et al., 2020 ; Huang and Zhao, 2020 ; Lei et al., 2020 ; Mazza et al., 2020 ;  Moghanibashi-Mansourieh, 2020 ; Ozamiz-Etxebarria et al., 2020 ; Ozamiz-Etxebarria et al., 2020 ; Wang et al., 2020a ; Wang et al., 2020b ).

Additionally, social media exposure or frequent exposure to news/information concerning COVID-19 was positively associated with symptoms of anxiety ( Gao et al., 2020 ; Moghanibashi-Mansourieh, 2020 ). With respect to marital status, one study reported that married participants had higher levels of anxiety when compared to unmarried participants ( Gao et al., 2020 ). On the other hand, Lei et al. (2020) found that divorced/widowed participants developed more anxiety symptoms than single or married individuals. A prolonged period of quarantine was also correlated with higher risks of anxiety symptoms. Intuitively, contact history with COVID-positive patients or objects may lead to more anxiety symptoms, which is noted in one study ( Moghanibashi-Mansourieh, 2020 ).

3.7. Symptoms of PTSD/ psychological distress/stress and associated risk factors

With respect to PTSD symptoms, similar prevalence rates were reported by Zhang and Ma (2020) and N. Liu et al. (2020) at 7.6% and 7%, respectively. Despite using the same measurement scale as Zhang and Ma (2020) (i.e., IES), Wang et al. (2020a) noted a remarkably different result, with 53.8% of the participants reporting moderate-to-severe psychological impact. González et al. ( González-Sanguino et al., 2020 ) noted 15.8% of participants with PTSD symptoms. Three out of the four studies that measured the traumatic effects of COVID-19 reported that the female gender was more susceptible to develop symptoms of PTSD. In contrast, the research conducted by Zhang and Ma (2020) found no significant difference in IES scores between females and males. Other risk factors included loneliness, individuals currently residing in Wuhan or those who have been to Wuhan in the past several weeks (the hardest-hit city in China), individuals with higher susceptibility to the virus, poor sleep quality, student status, poor self-rated health, and the presence of specific physical symptoms. Besides sex, Zhang and Ma (2020) found that age, BMI, and education levels are also not correlated with IES-scores.

Non-specific psychological distress was also assessed in three studies. One study reported a prevalence rate of symptoms of psychological distress at 38% ( Moccia et al., 2020 ), while another study from Qiu et al. (2020) reported a prevalence of 34.43%. The study from Wang et al. (2020) did not explicitly state the prevalence rates, but the associated risk factors for higher psychological distress symptoms were reported (i.e., younger age groups and female gender are more likely to develop psychological distress) ( Qiu et al., 2020 ; Wang et al., 2020 ). Other predictive factors included being migrant workers, profound regional severity of the outbreak, unmarried status, the history of visiting Wuhan in the past month, higher self-perceived impacts of the epidemic ( Qiu et al., 2020 ; Wang et al., 2020 ). Interestingly, researchers have identified personality traits to be predictive of psychological distresses. For example, persons with negative coping styles, cyclothymic, depressive, and anxious temperaments exhibit greater susceptibility to psychological outcomes ( Wang et al., 2020 ; Moccia et al., 2020 ).

The intensity of overall stress was evaluated and reported in four studies. The prevalence of overall stress was variably reported between 8.1% to over 81.9% ( Wang et al., 2020a ; Samadarshi et al., 2020 ; Mazza et al., 2020 ). Females and the younger age group are often associated with higher stress levels as compared to males and the elderly. Other predictive factors of higher stress levels include student status, a higher number of lockdown days, unemployment, having to go out to work, having an acquaintance infected with the virus, presence of chronic illnesses, poor self-rated health, and presence of specific physical symptoms ( Wang et al., 2020a ; Samadarshi et al., 2020 ; Mazza et al., 2020 ).

3.8. A separate analysis of negative psychological outcomes

Out of the nineteen included studies, five studies appeared to be more representative of the general population based on the results of study quality appraisal ( Table 1 ). A separate analysis was conducted for a more generalizable conclusion. According to the results of these studies, the rates of negative psychological outcomes were moderate but higher than usual, with anxiety symptoms ranging from 6.33% to 18.7%, depressive symptoms ranging from 14.6% to 32.8%, stress symptoms being 27.2%, and symptoms of PTSD being approximately 7% ( Lei et al., 2020 ; Liu et al., 2020 ; Mazza et al., 2020 ; Wang et al., 2020b ; Zhang et al., 2020 ). In these studies, female gender, younger age group (≤40 years), and student population were repetitively reported to exhibit more adverse psychiatric symptoms.

3.9. Protective factors against symptoms of mental disorders

In addition to associated risk factors, a few studies also identified factors that protect individuals against symptoms of psychological illnesses during the pandemic. Timely dissemination of updated and accurate COVID-19 related health information from authorities was found to be associated with lower levels of anxiety, stress, and depressive symptoms in the general public ( Wang et al., 2020a ). Additionally, actively carrying out precautionary measures that lower the risk of infection, such as frequent handwashing, mask-wearing, and less contact with people also predicted lower psychological distress levels during the pandemic ( Wang et al., 2020a ). Some personality traits were shown to correlate with positive psychological outcomes. Individuals with positive coping styles, secure and avoidant attachment styles usually presented fewer symptoms of anxiety and stress ( Wang et al., 2020 ; Moccia et al., 2020 ). ( Zhang et al. 2020 ) also found that participants with more social support and time to rest during the pandemic exhibited lower stress levels.

4. Discussion

Our review explored the mental health status of the general population and its predictive factors amid the COVID-19 pandemic. Generally, there is a higher prevalence of symptoms of adverse psychiatric outcomes among the public when compared to the prevalence before the pandemic ( Huang et al., 2019 ; Lim et al., 2018 ). Variations in prevalence rates across studies were noticed, which could have resulted from various measurement scales, differential reporting patterns, and possibly international/cultural differences. For example, some studies reported any participants with scores above the cut-off point (mild-to-severe symptoms), while others only included participants with moderate-to-severe symptoms ( Moghanibashi-Mansourieh, 2020 ; Wang et al., 2020a ). Regional differences existed with respect to the general public's psychological health during a massive disease outbreak due to varying degrees of outbreak severity, national economy, government preparedness, availability of medical supplies/ facilities, and proper dissemination of COVID-related information. Additionally, the stage of the outbreak in each region also affected the psychological responses of the public. Symptoms of adverse psychological outcomes were more commonly seen at the beginning of the outbreak when individuals were challenged by mandatory quarantine, unexpected unemployment, and uncertainty associated with the outbreak ( Ho et al., 2020 ). When evaluating the psychological impacts incurred by the coronavirus outbreak, the duration of psychiatric symptoms should also be taken into consideration since acute psychological responses to stressful or traumatic events are sometimes protective and of evolutionary importance ( Yaribeygi et al., 2017 ; Brosschot et al., 2016 ; Gilbert, 2006 ). Being anxious and stressed about the outbreak mobilizes people and forces them to implement preventative measures to protect themselves. Follow-up studies after the pandemic may be needed to assess the long-term psychological impacts of the COVID-19 pandemic.

4.1. Populations with greater susceptibility

Several predictive factors were identified from the studies. For example, females tended to be more vulnerable to develop the symptoms of various forms of mental disorders during the pandemic, including depression, anxiety, PTSD, and stress, as reported in our included studies ( Ahmed et al., 2020 ; Gao et al., 2020 ; Lei et al., 2020 ). Greater psychological distress arose in women partially because they represent a higher percentage of the workforce that may be negatively affected by COVID-19, such as retail, service industry, and healthcare. In addition to the disproportionate effects that disruption in the employment sector has had on women, several lines of research also indicate that women exhibit differential neurobiological responses when exposed to stressors, perhaps providing the basis for the overall higher rate of select mental disorders in women ( Goel et al., 2014 ; Eid et al., 2019 ).

Individuals under 40 years old also exhibited more adverse psychological symptoms during the pandemic ( Ahmed et al., 2020 ; Gao et al., 2020 ; Huang and Zhao, 2020 ). This finding may in part be due to their caregiving role in families (i.e., especially women), who provide financial and emotional support to children or the elderly. Job loss and unpredictability caused by the COVID-19 pandemic among this age group could be particularly stressful. Also, a large proportion of individuals under 40 years old consists of students who may also experience more emotional distress due to school closures, cancelation of social events, lower study efficiency with remote online courses, and postponements of exams ( Cao et al., 2020 ). This is consistent with our findings that student status was associated with higher levels of depressive symptoms and PTSD symptoms during the COVID-19 outbreak ( Lei et al., 2020 ; Olagoke et al., 2020 , Wang et al., 2020a ; Samadarshi et al., 2020 ).

People with chronic diseases and a history of medical/ psychiatric illnesses showed more symptoms of anxiety and stress ( Mazza et al., 2020 ; Ozamiz-Etxebarria et al., 2020 ; Özdin and Özdin, 2020 ). The anxiety and distress of chronic disease sufferers towards the coronavirus infection partly stem from their compromised immunity caused by pre-existing conditions, which renders them susceptible to the infection and a higher risk of mortality, such as those with systemic lupus erythematosus ( Sawalha et al., 2020 ). Several reports also suggested that a substantially higher death rate was noted in patients with diabetes, hypertension and other coronary heart diseases, yet the exact causes remain unknown ( Guo et al., 2020 ; Emami et al., 2020 ), leaving those with these common chronic conditions in fear and uncertainty. Additionally, another practical aspect of concern for patients with pre-existing conditions would be postponement and inaccessibility to medical services and treatment as a result of the COVID-19 pandemic. For example, as a rapidly growing number of COVID-19 patients were utilizing hospital and medical resources, primary, secondary, and tertiary prevention of other diseases may have unintentionally been affected. Individuals with a history of mental disorders or current diagnoses of psychiatric illnesses are also generally more sensitive to external stressors, such as social isolation associated with the pandemic ( Ho et al., 2020 ).

4.2. COVID-19 related psychological stressors

Several studies identified frequent exposure to social media/news relating to COVID-19 as a cause of anxiety and stress symptoms ( Gao et al., 2020 ; Moghanibashi-Mansourieh, 2020 ). Frequent social media use exposes oneself to potential fake news/reports/disinformation and the possibility for amplified anxiety. With the unpredictable situation and a lot of unknowns about the novel coronavirus, misinformation and fake news are being easily spread via social media platforms ( Erku et al., 2020 ), creating unnecessary fears and anxiety. Sadness and anxious feelings could also arise when constantly seeing members of the community suffering from the pandemic via social media platforms or news reports ( Li et al., 2020 ).

Reports also suggested that poor economic status, lower education level, and unemployment are significant risk factors for developing symptoms of mental disorders, especially depressive symptoms during the pandemic period ( Gao et al., 2020 ; Lei et al., 2020 ; Mazza et al., 2020 ; Olagoke et al., 2020 ;). The coronavirus outbreak has led to strictly imposed stay-home-order and a decrease in demands for services and goods ( Nicola et al., 2020 ), which has adversely influenced local businesses and industries worldwide. Surges in unemployment rates were noted in many countries ( Statistics Canada, 2020 ; Statista, 2020 ). A decrease in quality of life and uncertainty as a result of financial hardship can put individuals into greater risks for developing adverse psychological symptoms ( Ng et al., 2013 ).

4.3. Efforts to reduce symptoms of mental disorders

4.3.1. policymaking.

The associated risk and protective factors shed light on policy enactment in an attempt to relieve the psychological impacts of the COVID-19 pandemic on the general public. Firstly, more attention and assistance should be prioritized to the aforementioned vulnerable groups of the population, such as the female gender, people from age group ≤40, college students, and those suffering from chronic/psychiatric illnesses. Secondly, governments must ensure the proper and timely dissemination of COVID-19 related information. For example, validation of news/reports concerning the pandemic is essential to prevent panic from rumours and false information. Information about preventative measures should also be continuously updated by health authorities to reassure those who are afraid of being infected ( Tran, et al., 2020a ). Thirdly, easily accessible mental health services are critical during the period of prolonged quarantine, especially for those who are in urgent need of psychological support and individuals who reside in rural areas ( Tran et al., 2020b ). Since in-person health services are limited and delayed as a result of COVID-19 pandemic, remote mental health services can be delivered in the form of online consultation and hotlines ( Liu et al., 2020 ; Pisciotta et al., 2019 ). Last but not least, monetary support (e.g. beneficial funds, wage subsidy) and new employment opportunities could be provided to people who are experiencing financial hardship or loss of jobs owing to the pandemic. Government intervention in the form of financial provisions, housing support, access to psychiatric first aid, and encouragement at the individual level of healthy lifestyle behavior has been shown effective in alleviating suicide cases associated with economic recession ( McIntyre and Lee, 2020a ). For instance, declines in suicide incidence were observed to be associated with government expenses in Japan during the 2008 economic depression ( McIntyre and Lee, 2020a ).

4.3.2. Individual efforts

Individuals can also take initiatives to relieve their symptoms of psychological distress. For instance, exercising regularly and maintaining a healthy diet pattern have been demonstrated to effectively ease and prevent symptoms of depression or stress ( Carek et al., 2011 ; Molendijk et al., 2018 ; Lassale et al., 2019 ). With respect to pandemic-induced symptoms of anxiety, it is also recommended to distract oneself from checking COVID-19 related news to avoid potential false reports and contagious negativity. It is also essential to obtain COVID-19 related information from authorized news agencies and organizations and to seek medical advice only from properly trained healthcare professionals. Keeping in touch with friends and family by phone calls or video calls during quarantine can ease the distress from social isolation ( Hwang et al., 2020 ).

4.4. Strengths

Our paper is the first systematic review that examines and summarizes existing literature with relevance to the psychological health of the general population during the COVID-19 outbreak and highlights important associated risk factors to provide suggestions for addressing the mental health crisis amid the global pandemic.

4.5. Limitations

Certain limitations apply to this review. Firstly, the description of the study findings was qualitative and narrative. A more objective systematic review could not be conducted to examine the prevalence of each psychological outcome due to a high heterogeneity across studies in the assessment tools used and primary outcomes measured. Secondly, all included studies followed a cross-sectional study design and, as such, causal inferences could not be made. Additionally, all studies were conducted via online questionnaires independently by the study participants, which raises two concerns: 1] Individual responses in self-assessment vary in objectivity when supervision from a professional psychiatrist/ interviewer is absent, 2] People with poor internet accessibility were likely not included in the study, creating a selection bias in the population studied. Another concern is the over-representation of females in most studies. Selection bias and over-representation of particular groups indicate that most studies may not be representative of the true population. Importantly, studies in inclusion were conducted in a limited number of countries. Thus generalizations of mental health among the general population at a global level should be made cautiously.

5. Conclusion

This systematic review examined the psychological status of the general public during the COVID-19 pandemic and stressed the associated risk factors. A high prevalence of adverse psychiatric symptoms was reported in most studies. The COVID-19 pandemic represents an unprecedented threat to mental health in high, middle, and low-income countries. In addition to flattening the curve of viral transmission, priority needs to be given to the prevention of mental disorders (e.g. major depressive disorder, PTSD, as well as suicide). A combination of government policy that integrates viral risk mitigation with provisions to alleviate hazards to mental health is urgently needed.

Authorship contribution statement

JX contributed to the overall design, article selection , review, and manuscript preparation. LL and JX contributed to study quality appraisal. All other authors contributed to review, editing, and submission.

Declaration of Competing Interest

Acknowledgements.

RSM has received research grant support from the Stanley Medical Research Institute and the Canadian Institutes of Health Research/Global Alliance for Chronic Diseases/National Natural Science Foundation of China and speaker/consultation fees from Lundbeck, Janssen, Shire, Purdue, Pfizer, Otsuka, Allergan, Takeda, Neurocrine, Sunovion, and Minerva.

Supplementary material associated with this article can be found, in the online version, at doi: 10.1016/j.jad.2020.08.001 .

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Understanding evacuation behavior for effective disaster preparedness: a hybrid machine learning approach

• Letter to the Editor
• Published: 27 June 2024

Cite this article

• Evangelos Karampotsis   ORCID: orcid.org/0000-0002-6041-2301 1 ,
• Kitty Kioskli 2 , 3 ,
• Athina Tsirimpa 2 , 4 ,
• Georgios Dounias 1 &
• Amalia Polydoropoulou 2  

This paper delves into the pivotal role of machine learning in responding to natural disasters and understanding human behavior during crises. Natural disasters, from earthquakes to floods, have profound consequences for both the environment and society, impacting health, the economy, and mental well-being. Prevention and preparedness are key components of disaster management, yet the psychological challenges faced by affected individuals are equally significant. Psychosocial support and educational programs play a vital role in aiding individuals in their recovery. Machine learning, in this context, offers the ability to predict the evolution of natural disasters, providing early warnings that can save lives and reduce losses. It further extends to analyzing data related to human behavior during disasters, enhancing readiness for future calamities. This study specifically addresses the challenge of understanding human behavior during a snowstorm that struck Greece in 2023, employing artificial intelligence techniques to develop classification models categorizing individuals into three distinct groups based on socio-economic characteristics and is one of the few machine learning approaches that have been performed to date on data derived from corresponding questionnaire surveys. Artificial intelligence methodologies were harnessed to construct these classification models, with a focus on categorizing individuals into three specific classes: "Did not travel at all", "Traveled only as necessary", or “Did not limit travel”. The dataset employed in this study was collected through a survey conducted within the framework of the AEGIS+ research project, concentrating on assessing the mental health of individuals impacted by natural disasters. The goal was to generalize the optimal classification model and extract knowledge applicable in natural disaster scenarios. Three methodological frameworks for data analysis were proposed, incorporating combinations of Simple Logistic Regression and Inductive Decision Trees with the SMOTE data balancing method and a new data balancing method called LCC (Leveling of Cases per Class), within the context of validation procedures like “Use Train Set,” “10-fold Cross Validation,” and “Hold Out.” This paper’s contribution lies in the development of hybrid classification models, highlighting the significance of data balancing with LCC method throughout the modeling process. The results were deemed satisfactory, with the inductive decision tree method demonstrating superior performance (Classification accuracy near to 90%). This approach, offering strong classification rules, holds potential for knowledge application in natural disaster risk management. Knowledge Mining and Metadata Analysis further revealed the socio-economic characteristics influencing the decision to move during a natural disaster, including age, education, work-status, and workstyle. Crucially, this work, in addition to providing knowledge through the data mining process that can be used to estimate evacuation probability, develop targeted emergency information messages, and improve evacuation planning, is also used as a catalyst for future research efforts. It encourages the collection of relevant data, the exploration of new challenges in data analysis related to natural disasters and mental health, and the development of new data balancing methods and hybrid data analysis methodological frameworks.

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Acknowledgements

The authors would like to extend their sincere gratitude to the participants for their valuable time and cooperation. They would also like to express their appreciation to The American College of Greece for their support and approval of the ethical procedures. The research described in this paper was funded by the Greek national project "Development of the 'Coastal Environmental Observatory and Crisis Management in Island Areas' Infrastructure (AEGIS+)" conducted at the University of the Aegean. Additionally, the second author (KK) would like to acknowledge the financial support provided for the following projects: ‘Collaborative, Multi- modal and Agile Professional Cybersecurity Training Program for a Skilled Workforce In the European Digital Single Market and Industries’ (CyberSecPro) project, which has received funding from the European Union’s Digital Europe Programme (DEP) programme under grant agreement No 101083594. The ‘Human-centered Trustworthiness Optimisation in Hybrid Decision Support’ (THEMIS 5.0) project, which has received funding from the European Union’s Horizon Programme under grant agreement No 101121042. The ‘advaNced cybErsecurity awaReness ecOsystem for SMEs’ (NERO) project, which has received funding from the European Union’s DEP programme under grant agreement No 101127411. And ‘Fostering Artificial Intelligence Trust for Humans towards the optimization of trustworthiness through large-scale pilots in critical domains’ (FAITH) project, which has received funding from the European Union’s Horizon Programme under grant agreement No 101135932. It is important to note that the views expressed in this paper solely represent the opinions of the authors and not those of the University of the Aegean, the American College of Greece, trustilio B.V., the European Commission, or the partners involved in the mentioned projects. Finally, the authors declare that there are no conflicts of interest, including any financial or personal relationships, that could be perceived as potential conflicts.

The authors have not disclosed any funding.

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Department of Financial and Management Engineering, University of the Aegean, Chios, Greece

Evangelos Karampotsis & Georgios Dounias

Department of Shipping, Trade and Transport, University of the Aegean, Chios, Greece

Kitty Kioskli, Athina Tsirimpa & Amalia Polydoropoulou

Trustilio B.V., Amsterdam, The Netherlands

Kitty Kioskli

Department of Maritime Transport and Logistics, The American College of Greece, Athens, Greece

Athina Tsirimpa

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Contributions

The authors confirm contribution to the paper as follows: study conception and design: AP, AT, KK, EK; data collection, recruitment process and ethics approval: AP, AT, KK; data analysis and production of the first draft of the manuscript: EK, GD. Discussion and conclusions: AP, EK, KK, AT, GD. All authors reviewed the results and approved the final version of the manuscript.

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Correspondence to Evangelos Karampotsis .

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The authors have not disclosed any competing interests.

Ethical approval

The study received ethical clearance from the Institutional Review Board of the American College of Greece (reference number: 202212333). As the survey was carried out anonymously, direct assistance was not feasible for participants who obtained high scores on the psychometric tests and displayed potential indications of clinical problems. To tackle this concern, the information sheet included contact details for accessible support services.

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Karampotsis, E., Kioskli, K., Tsirimpa, A. et al. Understanding evacuation behavior for effective disaster preparedness: a hybrid machine learning approach. Nat Hazards (2024). https://doi.org/10.1007/s11069-024-06759-y

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Received : 17 November 2023

Accepted : 21 June 2024

Published : 27 June 2024

DOI : https://doi.org/10.1007/s11069-024-06759-y

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