example research paper on mental health

ORIGINAL RESEARCH article

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

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

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

Introduction

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

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

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

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

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

Perspectives on Mental Health and Mental Illness

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

Disciplinary Approaches to the Conceptualization of Mental Health/Illness

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

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

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

The Importance of the Context in Mental Health

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

Prioritizing Positive Mental Health: The Science of Well-Being

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

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

Integrating Mental Health, Mental Illness, and Well-Being

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

The Present Study

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

Materials and Methods

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

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

Figure 1. Methodological framework.

Search Strategy

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

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

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

Data Analysis Procedures

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

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

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

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

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

Findings and Discussion

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

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

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

Productivity I: Core Journals and Research Areas

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

Table 1. Core journals ranked by number of records.

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

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

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

Productivity II: Leading Authors and Countries/Territories

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

Table 3. Leading authors ranked by number of records.

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

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

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

Social Structure: Networks of Scientific Collaboration

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

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

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

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

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

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

Intellectual Structure: Disciplines Underlying the Foundations of the Field

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

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

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

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

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

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

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

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

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

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

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

Data Availability Statement

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

Author Contributions

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

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

Conflict of Interest

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

• ^ www.vosviewer.com

Abramo, G., D’Angelo, C. A., and Di Costa, F. (2009). Research collaboration and productivity: Is there correlation? High. Educ. 57, 155–171. doi: 10.1007/s10734-008-9139-z

CrossRef Full Text | Google Scholar

Antaramian, S. (2015). Assessing psychological symptoms and well-being: application of a dual-factor mental health model to understand college student performance. J. Psychoeduc. Assess. 33, 419–429. doi: 10.1177/0734282914557727

Auerbach, R. P., Mortier, P., Bruffaerts, R., Alonso, J., Benjet, C., Cuijpers, P., et al. (2018). WHO world mental health surveys international college student project: prevalence and distribution of mental disorders. J. Abnorm. Psychol. 127, 623–638. doi: 10.1037/abn0000362

PubMed Abstract | CrossRef Full Text | Google Scholar

Bailey, D. (2012). Interdisciplinary Working in Mental Health. Basingstoke: Palgrave Macmillan.

Google Scholar

Bewick, B. M., Koutsopoulou, G., Miles, J., Slaa, E., and Barkham, M. (2010). Changes in undergraduate students’ psychological wellbeing as they progress through university. Stud. High. Educ. 35, 633–645. doi: 10.1080/03075070903216643

Bhugra, D., Till, A., and Sartorius, N. (2013). What is mental health? Int. J. Soc. Psychiatr. 59, 3–4. doi: 10.1177/0020764012463315

Blanco, C., Okuda, M., Wright, C., Hasin, D. S., Grant, B. F., Liu, S. M., et al. (2008). Mental health of college students and their non-college-attending peers: results from the national epidemiologic study on alcohol and related conditions. Arch. Gen. Psychiatry 65, 1429–1437. doi: 10.1001/archpsyc.65.12.1429

Buckton, A. (2015). Conversations between anthropology and psychiatry: drawing out the best from interdisciplinarity in global mental health. Australas. Psychiatry 23, 3–5. doi: 10.1177/1039856215608291

Cleary, M., Walter, G., and Jackson, D. (2011). Not always smooth sailing: mental health issues associated with the transition from high school to college. Issues Ment. Health Nurs. 32, 250–254. doi: 10.3109/01612840.2010.548906

Coccia, M., and Bozeman, B. (2016). Allometric models to measure and analyze the evolution of international research collaboration. Scientometrics 108, 1065–1084. doi: 10.1007/s11192-016-2027-x

Coccia, M., and Wang, L. (2016). Evolution and convergence of the patterns of international scientific collaboration. Proc. Natl. Acad. Sci. U.S.A. 113, 2057–2061. doi: 10.1073/pnas.1510820113

Compton, M. T., and Shim, R. S. (2015). The social determinants of mental health. Focus 13, 419–425. doi: 10.1176/appi.focus.20150017

Cooke, R., Bewick, B. M., Barkham, M., Bradley, M., and Audin, K. (2006). Measuring, monitoring and managing the psychological well-being of first year university students. Br. J. Guid. Couns. 34, 505–517. doi: 10.1080/03069880600942624

Cuijpers, P., Auerbach, R. P., Benjet, C., Bruffaerts, R., Ebert, D., Karyotaki, E., et al. (2019). The world health organization world mental health international college student initiative: an overview. Int. J. Methods Psychiatr. Res. 28:e1762. doi: 10.1002/mpr.1761

Davy, C., Dobson, A., Lawrence-Wood, E., Lorimer, M., Moores, K., Lawrence, A., et al. (2012). The Middle East Area of Operations (MEAO) Health Study: Prospective Study Report. Adelaide: University of Adelaide.

Deci, E. L., and Ryan, R. M. (2008). Self-determination theory: a macrotheory of human motivation, development, and health. Can. Psychol. 49, 182–185. doi: 10.1037/a0012801

Dekker, J., Stauder, A., and Penedo, F. J. (2017). Proposal for an update of the definition and scope of behavioral medicine. Int. J. Behav. Med. 24, 1–4. doi: 10.1007/s12529-016-9610-7

Diener, E. (2012). New findings and future directions for subjective well-being research. Am. Psychol. 67, 590–597. doi: 10.1037/a0029541

Eisenberg, D., Downs, M. F., Golberstein, E., and Zivin, K. (2009). Stigma and help seeking for mental health among college students. Med. Care Res. Rev. 66, 522–541. doi: 10.1177/1077558709335173

Eisenberg, D., Hunt, J., Speer, N., and Zivin, K. (2011). Mental health service utilization among college students in the United States. J. Nerv. Ment. Dis. 199, 301–308. doi: 10.1097/NMD.0b013e3182175123

Eshun, S., and Gurung, A. R. (2009). “Introduction to culture and psychopathology,” in Culture and Mental Health: Sociocultural Influences, Theory, and Practice , eds S. Eshun and R. A. R. Gurung (Hoboken, NJ: Wiley and Sons), 3–18.

Evans, T. M., Bira, L., Gastelum, J. B., Weiss, L. T., and Vanderford, N. L. (2018). Evidence for a mental health crisis in graduate education. Nat. Biotechnol. 36, 282–284. doi: 10.1038/nbt.4089

Falagas, M. E., Pitsouni, E. I., Malietzis, G. A., and Pappas, G. (2008). Comparison of PubMed, Scopus, web of science, and Google scholar: strengths and weaknesses. FASEB J. 22, 338–342. doi: 10.1096/fj.07-9492LSF

Fergusson, D. M., Boden, J. M., and Horwood, L. J. (2007). Recurrence of major depression in adolescence and early adulthood, and later mental health, educational and economic outcomes. Br. J. Psychiatry 191, 335–342. doi: 10.1192/bjp.bp.107.036079

Fernando, S. (2019). Developing mental health services in the global south. Int. J. Ment. Health 48, 338–345. doi: 10.1080/00207411.2019.1706237

Foster, G. M. (1975). Medical anthropology: some contrasts with medical sociology. Soc. Sci. Med. 9, 427–432. doi: 10.1016/0037-7856(75)90070-0

Freshwater, D., Sherwood, G., and Drury, V. (2006). International research collaboration: issues, benefits and challenges of the global network. J. Res. Nurs. 11, 295–303. doi: 10.1177/1744987106066304

Galderisi, S., Heinz, A., Kastrup, M., Beezhold, J., and Sartorius, N. (2015). Toward a new definition of mental health. World Psychiatry 14, 231–233. doi: 10.1002/wps.20231

Gazni, A., Sugimoto, C. R., and Didegah, F. (2012). Mapping world scientific collaboration: authors, institutions, and countries. J. Am. Soc. Inf. Sci. Technol. 63, 323–335. doi: 10.1002/asi.21688

Gopalkrishnan, N. (2018). Cultural diversity and mental health: considerations for policy and practice. Front. Public Health 6:179. doi: 10.3389/fpubh.2018.00179

Gulliver, A., Griffiths, K. M., and Christensen, H. (2010). Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review. BMC Psychiatry 10:113. doi: 10.1186/1471-244X-10-113

Haslam, N., and Lusher, D. (2011). The structure of mental health research: networks of influence among psychiatry and clinical psychology journals. Psychol. Med. 41, 2661–2668. doi: 10.1017/S0033291711000821

Hooper, T. I., Smith, T. C., Gray, G. C., Al Qahtani, M. S., Memish, Z. A., Barrett, D. H., et al. (2005). Saudi Arabia–United States collaboration in health research: a formula for success. Am. J. Infect. Control 33, 192–196. doi: 10.1016/j.ajic.2005.01.006

Horwitz, A. V. (2010). “An overview of sociological perspectives on the definitions, causes, and responses to mental health and illness,” in A Handbook for the Study of Mental Health: Social Contexts, Theories and Systems , eds T. L. Scheid and T. N. Brown (Cambridge: Cambridge University Press), 6–19. doi: 10.1017/9781316471289.004

Hunt, J., and Eisenberg, D. (2010). Mental health problems and help-seeking behaviors among college students. J. Adolesc. Health 46, 3–10. doi: 10.1016/j.jadohealth.2009.08.008

Insel, T. R., and Wang, P. S. (2010). Rethinking mental illness. JAMA 303, 1970–1971.

Kadison, R., and DiGeronimo, T. F. (2004). College of the Overwhelmed: The Campus Mental Health Crisis and What to do About It. San-Francisco, CA: Jossey-Bass.

Kerr, D. C., and Capaldi, D. M. (2011). Young men’s intimate partner violence and relationship functioning: long-term outcomes associated with suicide attempt and aggression in adolescence. Psychol. Med. 41, 759–769. doi: 10.1017/S0033291710001182

Kessler, R. C., Amminger, G. P., Aguilar-Gaxiola, S., Alonso, J., Lee, S., and Ustun, T. B. (2007). Age of onset of mental disorders: a review of recent literature. Curr. Opin. Psychiatr. 20, 359–364. doi: 10.1097/YCO.0b013e32816ebc8c

Keyes, C. L. (2005). Mental illness and/or mental health? Investigating axioms of the complete state model of health. J. Consult. Clin. Psychol. 73, 539–548. doi: 10.1037/0022-006X.73.3.539

Keyes, C. L. (2007). Promoting and protecting mental health as flourishing: a complementary strategy for improving national mental health. Am. Psychol. 62, 95–108. doi: 10.1037/0003-066X.62.2.95

Keyes, C. L., and Lopez, S. J. (2002). “Toward a science of mental health,” in Handbook of Positive Psychology , eds C. R. Synder and S. J. Lopez (Oxford: Oxford University Press), 45–62.

Keyes, C. L. M., and Michalec, B. (2010). “Viewing mental health from the complete state paradigm,” in A Handbook for the Study of Mental Health: Social Contexts, Theories and Systems , eds T. L. Scheid and T. N. Brown (Cambridge: Cambridge University Press), 125–134. doi: 10.1017/cbo9780511984945.010

Kim, K. W. (2006). Measuring international research collaboration of peripheral countries: taking the context into consideration. Scientometrics 66, 231–240. doi: 10.1007/s11192-006-0017-0

King, K. M., Meehan, B. T., Trim, R. S., and Chassin, L. (2006). Marker or mediator? The effects of adolescent substance use on young adult educational attainment. Addiction 101, 1730–1740. doi: 10.1111/j.1360-0443.2006.01507.x

Kobau, R., Seligman, M. E., Peterson, C., Diener, E., Zack, M. M., Chapman, D., et al. (2011). Mental health promotion in public health: perspectives and strategies from positive psychology. Am. J. Public Health 101, e1–e9. doi: 10.2105/AJPH.2010.300083

Larivière, V., Diepeveen, S., Chonaill, S. N., Macaluso, B., Pollitt, A., and Grant, J. (2013). International comparative performance of mental health research, 1980–2011. Eur. Neuropsychopharm. 23, 1340–1347. doi: 10.1016/j.euroneuro.2013.01.006

LeViness, P., Bershad, C., Gorman, K., Braun, L., and Murray, T. (2018). The Association for University and College Counseling Center Directors Annual Survey. Available online at: https://www.aucccd.org/assets/documents/Survey/2018%20AUCCCD%20Survey-Public-June%2012-FINAL.pdf (accessed February 24, 2020).

Li, J., Burnham, J. F., Lemley, T., and Britton, R. M. (2010). Citation analysis: comparison of Web of Science, Scopus, SciFinder, and Google Scholar. J. Electron. Resour. Med. Lib. 7, 196–217. doi: 10.1080/15424065.2010.505518

Lipson, S. K., Lattie, E. G., and Eisenberg, D. (2019). Increased rates of mental health service utilization by US college students: 10-year population-level trends (2007–2017). Psychiatr. Serv. 70, 60–63. doi: 10.1176/appi.ps.201800332

Mabry, P. L., Olster, D. H., Morgan, G. D., and Abrams, D. B. (2008). Interdisciplinarity and systems science to improve population health: a view from the NIH Office of Behavioral and Social Sciences Research. Am. J. Prev. Med. 35, S211–S224. doi: 10.1016/j.amepre.2008.05.018

Macaskill, A. (2013). The mental health of university students in the United Kingdom. Br. J. Guid. Couns. 41, 426–441. doi: 10.1080/03069885.2012.743110

Manwell, L. A., Barbic, S. P., Roberts, K., Durisko, Z., Lee, C., Ware, E., et al. (2015). What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey. BMJ Open 5, 1–11. doi: 10.1136/bmjopen-2014-007079

McAvoy, J. (2014). “Psy disciplines,” in Encyclopedia of Critical Psychology , ed. T. Teo (New York, NY: Springer), 1527–1529. doi: 10.1007/978-1-4614-5583-7_611

McVeigh, M. (2009). “Citation indexes and the Web of Science,” in Encyclopedia of Library and Information Sciences , 3rd Edn, eds M. J. Bates and M. N. Maack (Cambridge: Chandos Publishing), 1027–1037. doi: 10.1081/e-elis3-120044569

Meho, L. I., and Yang, K. (2007). Impact of data sources on citation counts and rankings of LIS faculty: web of science versus Scopus and Google scholar. J. Am. Soc. Inf. Sci. Technol. 58, 2105–2125. doi: 10.1002/asi.20677

Mey, S. C., and Yin, C. J. (2015). Mental health and wellbeing of the undergraduate students in a research university: a Malaysian experience. Soc. Indic. Res. 122, 539–551. doi: 10.1007/s11205-014-0704-9

Mitchell, S. L., Oakley, D. R., and Dunkle, J. H. (2019). White paper: a multidimensional understanding of effective university and college counseling center organizational structures. J. Coll. Stud. Psychother. 33, 89–106. doi: 10.1080/87568225.2019.1578941

Mongeon, P., and Paul-Hus, A. (2016). The journal coverage of Web of Science and Scopus: a comparative analysis. Scientometrics 106, 213–228. doi: 10.1007/s11192-015-1765-5

Naveed, S., Waqas, A., Majeed, S., Zeshan, M., Jahan, N., and Sheikh, M. H. (2017). Child psychiatry: a scientometric analysis 1980-2016. F1000Res . 6:1293. doi: 10.12688/f1000research.12069.1

Pellmar, T. C., and Eisenberg, L. (2000). Bridging Disciplines in the Brain, Behavioral, and Clinical Sciences. Washington, DC: IOM.

Peterson, P. (2010). “Psychological approaches to mental illness,” in A Handbook for the Study of Mental Health: Social Contexts, Theories and Systems , eds T. L. Scheid and T. N. Brown (Cambridge: Cambridge University Press), 106–124.

Rolfe, M. K., Bryar, R. M., Hjelm, K., Apelquist, J., Fletcher, M., and Anderson, B. L. (2004). International collaborations to address common problems in healthcare: processes practicalities and power. Int. Nurs. Rev. 51, 140–148. doi: 10.1111/j.1466-7657.2004.00237.x

Ryff, C. D. (1989). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. J. Pers. Soc. Psychol. 57, 1069–1081. doi: 10.1037/0022-3514.57.6.1069

Ryff, C. D., and Singer, B. H. (2008). Know thyself and become what you are: a eudaimonic approach to psychological well-being. J. Happiness Stud. 9, 13–39. doi: 10.1007/s10902-006-9019-0

Sánchez Moreno, E., and Barrón López de Roda, A. (2003). Social psychology of mental health: the social structure and personality perspective. Span. J. Psychol. 6, 3–11. doi: 10.1017/s1138741600005163

Scheid, T. L., and Brown, T. N. (2010). A Handbook for the Study of Mental Health: Social Contexts, Theories and Systems. Cambridge: Cambridge University Press.

Schumann, G., Binder, E., Holte, A., de Kloet, E. R., Odegaard, K. J., Robbins, T. W., et al. (2014). Stratified medicine for mental disorders. Eur. Neuropsychopharm. 24, 5–50. doi: 10.1016/j.euroneuro.2013.09.010

Schwartz, S., and Corcoran, C. (2010). “Biological theories of psychiatric disorders: a sociological approach,” in A Handbook for the Study of Mental Health: Social Contexts, Theories and Systems , eds T. L. Scheid and T. N. Brown (Cambridge: Cambridge University Press), 64–88. doi: 10.1017/cbo9780511984945.007

Sharp, J., and Theiler, S. (2018). A review of psychological distress among university students: pervasiveness, implications and potential points of intervention. Int. J. Adv. Couns. 40, 193–212. doi: 10.1007/s10447-018-9321-7

Skute, I., Zalewska-Kurek, K., Hatak, I., and de Weerd-Nederhof, P. (2019). Mapping the field: a bibliometric analysis of the literature on university-industry collaborations. J. Technol. Transfer 44, 916–947. doi: 10.1007/s10961-017-9637-1

Slade, M. (2010). Mental illness and well-being: the central importance of positive psychology and recovery approaches. BMC Health Serv. Res. 10:26. doi: 10.1186/1472-6963-10-26

Summerfield, D. (2013). Global mental health is an oxymoron and medical imperialism. Br. Med. J. 346:f3509. doi: 10.1136/bmj.f3509

Timimi, S. (2010). The McDonaldization of childhood: children’s mental health in neo-liberal market cultures. Transcult. Psychiatry 47, 686–706. doi: 10.1177/1363461510381158

Vaillant, G. E. (2012). Positive mental health: Is there a cross-cultural definition? World Psychiatry 11, 93–99. doi: 10.1016/j.wpsyc.2012.05.006

Van Eck, N. J., and Waltman, L. (2014). “Visualizing bibliometric networks,” in Measuring Scholarly Impact: Methods and Practice , eds Y. Ding, R. Rousseau, and D. Wolfram (Cham: Springer), 285–320. doi: 10.1007/978-3-319-10377-8_13

Van Eck, N. J., Waltman, L., Noyons, E. C. M., and Buter, R. K. (2010). Automatic term identification for bibliometric mapping. Scientometrics 82, 581–596. doi: 10.1007/s11192-010-0173-0

Van Raan, A. F. (2014). “Advances in bibliometric analysis: research performance assessment and science mapping,” in Bibliometrics: Use and Abuse in the Review of Research Performance , Vol. 3, eds W. Blockmans, L. Engwall, and D. Weaire (London: Portland Press Ltd), 17–28.

Verger, P., Guagliardo, V., Gilbert, F., Rouillon, F., and Kovess-Masfety, V. (2010). Psychiatric disorders in students in six French universities: 12-month prevalence, comorbidity, impairment and help-seeking. Soc. Psychiatry Psychiatr. Epidemiol. 45, 189–199. doi: 10.1007/s00127-009-0055-z

Wagner, C. S., Park, H. W., and Leydesdorff, L. (2015). The continuing growth of global cooperation networks in research: a conundrum for national governments. PLoS One 10:e0131816. doi: 10.1371/journal.pone.0131816

Wang, Q., and Waltman, L. (2016). Large-scale analysis of the accuracy of the journal classification systems of Web of Science and Scopus. J. Informetr. 10, 347–364. doi: 10.1016/j.joi.2016.02.003

White, R., Jain, S., and Giurgi-Oncu, C. (2014). Counterflows for mental well-being: what high-income countries can learn from low and middle-income countries. Int. Rev. Psychiatr. 26, 602–606. doi: 10.3109/09540261.2014.939578

Wittchen, H. U., Knappe, S., Andersson, G., Araya, R., Banos Rivera, R. M., Barkham, M., et al. (2014a). The need for a behavioural science focus in research on mental health and mental disorders. Int. J. Methods Psychiatr. Res. 23, 28–40.

Wittchen, H. U., Knappe, S., and Schumann, G. (2014b). The psychological perspective on mental health and mental disorder research: introduction to the ROAMER work package 5 consensus document. Int. J. Methods Psychiatr. Res. 23, 15–27. doi: 10.1002/mpr.1408

Wong, J. G., Cheung, E. P., Chan, K. K., Ma, K. K., and Wa Tang, S. (2006). Web-based survey of depression, anxiety and stress in first-year tertiary education students in Hong Kong. Aust. N. Z. J. Psychiatry 40, 777–782. doi: 10.1080/j.1440-1614.2006.01883.x

World Health Organization (2004). Promoting Mental Health: Concepts, Emerging Evidence, Practice (Summary Report). Geneva: World Health Organization.

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

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

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

Reviewed by:

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

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

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

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Peer-reviewed

Research Article

Impact of COVID-19 pandemic on mental health: An international study

Roles Conceptualization, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

¶ ‡ ATG, MK and AK designed and implemented the study together. AK and MK should be considered joint senior authors.

Affiliation Division of Clinical Psychology & Intervention Science, Department of Psychology, University of Basel, Basel, Switzerland

Roles Data curation, Formal analysis, Writing – original draft, Writing – review & editing

Affiliation Department of Health Sciences, European University Cyprus, Nicosia, Cyprus

Roles Investigation, Resources, Writing – review & editing

Affiliation Psychological Laboratory, Faculty of Public Health and Social Welfare, Riga Stradiņš University, Riga, Latvia

Affiliation Kore University Behavioral Lab (KUBeLab), Faculty of Human and Social Sciences, Kore University of Enna, Enna, Italy

Affiliation Department of Social Sciences, School of Humanities and Social Sciences, University of Nicosia, Nicosia, Cyprus

Affiliation Department of Nursing, Cyprus University of Technology, Limassol, Cyprus

Affiliation Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus

Affiliation Department of Psychological Counseling and Guidance, Faculty of Education, Hasan Kalyoncu University, Gaziantep, Turkey

Affiliation The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong

Affiliation Department of Psychology, Fundación Universitaria Konrad Lorenz, Bogotà, Columbia

Roles Conceptualization, Investigation, Resources, Writing – review & editing

Affiliation Faculty of Psychology, University of La Sabana, Chía, Columbia

Affiliation School of Applied Psychology, University College Cork, Cork, Ireland

Affiliation School of Psychology, University College Dublin, Dublin, Ireland

Affiliation Medical University Innsbruck, Innsbruck, Austria

Affiliation Department of Psychology, Babeş-Bolyai University (UBB), Cluj-Napoca, Romania

Affiliation Instituto Superior de Psicologia Aplicada (ISPA), Instituto Universitário; APPsyCI—Applied Psychology Research Center Capabilities & Inclusion, Lisboa, Portugal

Affiliation Faculdade de Psicologia, Alameda da Universidade, Universidade de Lisboa, Lisboa, Portugal

Affiliation LIP/PC2S, Université Grenoble Alpes, Grenoble, France

Affiliation Department of Biomedicine, Biotechnology and Public Health, University of Cadiz, Cadiz, Spain

Affiliation Instituto ACT, Madrid, Spain

Affiliation Department of Psychology, European University of Madrid, Madrid, Spain

Affiliation Department of Psychology and Sociology, University of Zaragoza, Zaragoza, Spain

Affiliation Vadaskert Child and Adolescent Psychiatric Hospital, Budapest, Hungary

Affiliation Private Pratice, Poland

Affiliation Department of Psychology, University of Jyväskylä, Jyväskylä, Finland

Affiliation Clinic for Psychiatry, Clinical Center of Montenegro, Podgorica, Montenegro

Affiliation Ljubljana University Medical Centre, Ljubljana, Slovania

Affiliation Département de Psychologie, Université du Québec à Trois-Rivières, Trois-Rivières, Canada

Affiliation Department of Psychiatry and Behavioral Science, Duke University, Durham, North Carolina, United States of America

Roles Conceptualization, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

Affiliation Department of Psychology, University of Cyprus, Nicosia, Cyprus

•  [ ... ],
• [ view all ]
• [ view less ]
• Andrew T. Gloster, 
• Demetris Lamnisos, 
• Jelena Lubenko, 
• Giovambattista Presti, 
• Valeria Squatrito, 
• Marios Constantinou, 
• Christiana Nicolaou, 
• Savvas Papacostas, 
• Gökçen Aydın, 

• Published: December 31, 2020
• https://doi.org/10.1371/journal.pone.0244809
• Reader Comments

The COVID-19 pandemic triggered vast governmental lockdowns. The impact of these lockdowns on mental health is inadequately understood. On the one hand such drastic changes in daily routines could be detrimental to mental health. On the other hand, it might not be experienced negatively, especially because the entire population was affected.

The aim of this study was to determine mental health outcomes during pandemic induced lockdowns and to examine known predictors of mental health outcomes. We therefore surveyed n = 9,565 people from 78 countries and 18 languages. Outcomes assessed were stress, depression, affect, and wellbeing. Predictors included country, sociodemographic factors, lockdown characteristics, social factors, and psychological factors.

Results indicated that on average about 10% of the sample was languishing from low levels of mental health and about 50% had only moderate mental health. Importantly, three consistent predictors of mental health emerged: social support, education level, and psychologically flexible (vs. rigid) responding. Poorer outcomes were most strongly predicted by a worsening of finances and not having access to basic supplies.

Conclusions

These results suggest that on whole, respondents were moderately mentally healthy at the time of a population-wide lockdown. The highest level of mental health difficulties were found in approximately 10% of the population. Findings suggest that public health initiatives should target people without social support and those whose finances worsen as a result of the lockdown. Interventions that promote psychological flexibility may mitigate the impact of the pandemic.

Citation: Gloster AT, Lamnisos D, Lubenko J, Presti G, Squatrito V, Constantinou M, et al. (2020) Impact of COVID-19 pandemic on mental health: An international study. PLoS ONE 15(12): e0244809. https://doi.org/10.1371/journal.pone.0244809

Editor: Joel Msafiri Francis, University of the Witwatersrand, SOUTH AFRICA

Received: October 3, 2020; Accepted: December 16, 2020; Published: December 31, 2020

Copyright: © 2020 Gloster et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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

Funding: This work was supported by grants from the Swiss National Science Foundation awarded to Andrew T. Gloster (PP00P1_ 163716/1 & PP00P1_190082). The funder provided support in the form of salaries for authors [ATG], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section. One of the authors is employed by a commercial affiliation: Private Pratice, Poland. This affiliation provided support in the form of salaries for authors [BK], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: One of the authors is employed by a commercial affiliation: Private Pratice, Poland. This affiliation provided support in the form of salaries for author BK, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. This does not alter our adherence to PLOS ONE policies on sharing data and materials. No other authors have competing interests to declare.

Introduction

The COVID-19 global pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) virus triggered governmentally mandated lockdowns, social distancing, quarantines and other measures in the interest of public health. The mandated lockdowns abruptly and dramatically altered people’s daily routines, work, travel, and leisure activities to a degree unexperienced by most people living outside of war zones. Simultaneously, the highly contagious, yet invisible virus transformed previously neutral situations to perceived potentially dangerous ones: social interaction, touching one’s face, going to a concert, shaking someone’s hand, and even hugging grandparents. Given these changes and looming threat, increases in anxiety and depression can be expected [ 1 ]. Indeed, common psychological reactions to previous quarantines include post-traumatic symptoms, confusion, and anger [ 2 ], though these data stem from quarantines of specific regions or a subgroup of exposed people, such as medical professionals. It therefore remains an empirical question whether such patterns are consistent when entire populations across the globe are simultaneously affected.

For most people, it stands to reason that governmentally mandated lockdowns decrease their activity levels and the number of stimuli experienced compared to pre-lockdown levels. The impact of reducing activities, stimuli and routines on the population is unknown, but various analogue situations can be used to make predictions, like death of a spouse [ 3 ]; hearing loss [ 4 ]; job loss [ 5 ]; long duration expeditions [ 6 ]; poor acculturation [ 7 ]; and even ageing when combined with loneliness [ 8 ]. Each of these situations is associated with increases in psychological distress. This reduction of stimulations may lead to boredom and reductions in reinforcement, which has been associated with depression [ 9 ]. The sum total of these literatures, and some evidence from country specific studies on COVID-19 suggests that for some people, the mental distress in the form of stress, depression, and negative affect are likely reactions to the lockdown; therefore, people’s wellbeing is likely to suffer. Indeed, increased loneliness, social isolation, and living alone are associated with increased mortality [ 10 ]–the exact effect that mandated lockdown and social distancing rules aimed to counteract.

Alternately, the planned slowing down of daily routines can be beneficial. For example, vacations and weekends are highly sought-after–if not always achieved–periods of relaxation and stress reduction [ 11 ]. Likewise, some religious and spiritual traditions encourage simplicity, mindfulness, and solitude with the goal of increasing wellbeing [ 12 ]. It is therefore conceivable that for some people the lockdown could offer a reprieve from daily hassles and stress and even lead to increases in wellbeing. It is therefore equally important to identify protective factors that can buffer against the negative effects of the lockdown.

Although nearly all people around the globe have been subject to some form of lockdown measures to contain the COVID-19 response, variations exist with respect to how each person is confined, even within a single country. For instance, during the COVID-19 pandemic some people were allowed to go to work, whereas others were required to work exclusively from home. For various reasons, some people had difficulty obtaining some basic supplies. Further, some were thrust into the situation of taking care of others (e.g., children, due to closing of schools). Finally, some people lost income as a result of the lockdown, and this is a known risk-factor for poor mental health [ 13 , 14 ]. Finally, a lockdown may be experienced differently the longer it continues and potentially when in confined spaces [ 2 ]. All of these lockdown-specific features may have an impact on one’s mental health, but to date it remains inadequately explored.

As the risk of the pandemic continues, it is important to understand to what degree the virus-induced uncertainty and the lockdown-induced changes in daily routines impact stress, depression, affect, and wellbeing. Towards this end, it is important to identify factors that can mitigate potential negative psychological effects of pandemics and lockdowns. Various social and psychological factors have been identified in other contexts that may also help build resilience in large-scale pandemics such as COVID-19. On the social level, one such candidate is social support, which has repeatedly been found to positively impact mental health and wellbeing [ 15 – 18 ]. Another social factor is the family climate and family functioning, which clearly impacts people’s mental health [ 19 , 20 ]. Psychological factors such as mindfulness and psychologically flexible response styles (as opposed to rigid and avoidant response styles) are behavioral repertoires that have previously been shown to buffer the impact of stress and facilitate wellbeing [ 21 – 24 ].

Given the scope of the COVID-19 pandemic, it is crucial to better understand how a pandemic and associated lockdowns impact on mental health. Thus, the aim of this study was to determine mental health outcomes and to examine known predictors of outcomes to identify psychological processes and contextual factors that can be used in developing public health interventions. It can be assumed, but remains untested, that those with risks in social-demographic factors, living conditions, social factors and psychological factors have more severe reactions to the lockdown. We therefore tested whether outcomes of stress, depression, affect, and wellbeing were predicted by country of residence, social demographic characteristics, COVID-19 lockdown related predictors, social predictors, and psychological predictors.

Participants

The inclusion criteria were ≥18 years of age and ability to read one of the 18 languages (English, Greek, German, French, Spanish, Turkish, Dutch, Latvian, Italian, Portuguese, Finnish, Slovenian, Polish, Romanian, Hong Kong, Hungarian, Montenegrin, & Persian.). There were no exclusion criteria. People from all countries were eligible to participate.

Ethics approval was obtained from the Cyprus National Bioethics Committee (ref.: EEBK EΠ 2020.01.60) followed by site approvals from different research teams involved in data collection. All participants provided written informed consent prior to completing the survey (computer-based, e.g., by clicking “yes”).

A population based cross-sectional study was conducted in order to explore how people across the world reacted to the COVID-19. The anonymous online survey was distributed using a range of methods. Universities emailed the online survey to students and academic staff and also posted the survey link to their websites. In addition, and in order to broaden the sample to older age groups and to those with different socio-demographic characteristics, the survey was disseminated in local press (e.g., newspapers, newsletters, radio stations), in social media (e.g., Facebook, Twitter, etc.), in professional networks, local hospitals and health centers and professional groups’ email lists (e.g., medical doctors, teachers, engineers, psychologists, government workers), and to social institutions in the countries (e.g., churches, schools, cities/townships, clubs, etc.).

Data were collected for two months between 07th April and 07th June 2020. The majority of countries where data were collected had declared a state of emergency for COVID-19 during this time.

Well validated and established measures were used to assess constructs. When measures did not already exist in a language, they were subject to forward and backward translation procedures. Well-validated measures of predictors and outcomes and items measuring COVID-19 related characteristics were selected after a consensus agreement among the members of this study.

Respondents’ countries were coded and entered as predictors.

Socio-demographic status.

Participants responded to questions related to their socio-demographic characteristics including their age, gender, country of residence, marital status, employment status, educational level, whether they have children as well as their living situation.

Lockdown variables.

Participants responded to questions related to lockdown including length of lockdown, whether they need to leave home for work, any change in their finances, whether they were able to obtain basic supplies, the amount of their living space confined in during the lockdown. They were also asked whether they, their partner, or a significant other was diagnosed with COVID-19.

Social factors.

Social factors were measured using the Brief Assessment of Family Functioning Scale (BAFFS; [ 25 ]) and the Oslo Social Support Scale (OSSS; [ 26 ]). The BAFFS items are summed to produce a single score with higher scores indicating worse family functioning. The OSSS items are summed up and provide three levels types of social support: low (scored 3–8), moderate (scored 9–11) and high (scored 12–14).

Psychological factors.

Psychological factors including mindfulness and psychological flexibility. Mindfulness was measured using the Cognitive Affective Mindfulness Scale (CAMS; [ 27 ]). The CAMS produces a single score with higher scores indicating better mindfulness qualities. Psychological flexibility (e.g., hold one’s thoughts lightly, be accepting of one’s experiences, engage in what is important to them despite challenging situations) was measured using the Psyflex scale [ 28 ]. The Psyflex produces a single score with higher scores indicating better psychological flexibility qualities.

Stress was measured using the Perceived Stress Scale (PSS; [ 29 ]). The PSS assesses an individual’s appraisal of how stressful situations in their life are. Items ask about people’s feelings and thoughts during the last month. A total score is produced, with higher scores indicating greater overall distress.

Depression.

Depressive symptomatology was assessed using two items from the disengagement subscale of the Multidimensional State Boredom Scale (MSBS; [ 30 ]). These items assessed wanting to do pleasurable things but not finding anything appealing (i.e., boredom), as well as wasting time. Based on concepts of reinforcement deprivation (i.e., lack of access to or engagement with positive stimuli) that is known to contribute to depression, we added an item that measured how rewarding or pleasurable people found the activities that they were engaging in (i.e., reinforcement). Higher scores indicated higher depressive symptomatology.

Positive affect/ negative affect.

The Positive And Negative Affect Scale (PANAS) was used to measure affect [ 31 ]. The original version of the questionnaire was used with five additional items: bored, confused, angry, frustrated and lonely. All items were scored on a 5-point Likert type scale, ranging from 1 = very little/not at all to 5 = extremely and summed up so that higher scores in the positive-related items indicating higher positive affect and higher scores in the negative-related items indicating higher negative affect. In order to capture additional dimensions of negative affect believed to be relevant to the COVID-19 lockdowns, we additionally added five items: bored, confused, angry, frustrated, lonely.

Wellbeing was assessed using the Mental Health Continuum Short Form (MHC-SF; [ 32 ]); which assesses three aspects of wellbeing: emotional, psychological, and social. The MHC-SF produces a total score and scores for each of the three aspects of wellbeing. The MHC-SF can also be scored to produce categories of languishing (i.e., low levels of emotional, psychological, and social well-being), flourishing (i.e., high levels of emotional psychological and social well-being almost every day), and moderately mentally healthy (in between languishing and flourishing).

Statistical analysis

The mean and standard deviation was calculated for dependent variables that follow the normal distribution while the median and interquartile range (IQR) were computed for non-normally distributed data. Bivariable association between an outcome variable and each predictor was investigated with ANOVA test for categorical predictor and univariable linear regression for numerical predictor. Linear mixed-effect model with random effect for country was performed to consider simultaneously several predictors in the same model and to account for the variation in outcome variable between countries. Four separate linear mixed-effect models were used for each outcome variable, one for each set of socio-demographic, lockdown, social and psychosocial predictors and multicollinearity for each set of predictors was investigated with the variation inflation criterion (VIF). Standardized regression coefficients were computed as effect size indices to measure the strength of the association between predictor variables and outcome variables. The comparison between the country mean and overall mean for each outcome variable was estimated though a linear regression model with dependent variable the mean centering outcome and predictor the country. Cohen’s d effect size of the standardize difference between country mean and the overall mean was computed as a measure of the magnitude of the difference between the two means.

The whole sample was used in linear mixed-effect models while for the comparison of country mean to the overall mean was used the sample from countries with sample size ≥100. The R packages lme4 and effect sizes were used for fitting the linear mixed effect model and to compute the standardized regression coefficients of the linear mixed effect models [ 33 ]. Significance test and confidence intervals were calculated at a significance level of 0.05. The following cut-off values were used for the evaluation of the effect sizes: ‘tiny’ ≤0.05, ‘very small’ from 0.05 to ≤0.10, ‘small’ from 0.10 to ≤ 0.20, ‘medium’ from 0.20 to ≤ 0.30, ‘large’ from 0.30 to ≤ 0.40 and ‘very large’ > 0.40 [ 34 ].

Descriptive

Participants were n = 9,565 people from 78 countries. See supporting information for a participation flowchart ( S1 Appendix ). The countries with the largest samples were: Latvia (n = 1285), Italy (n = 962), Cyprus (n = 957), Turkey (n = 702), Switzerland (n = 550), Hong Kong (n = 516), Colombia (n = 485), Ireland (n = 414), Austria (n = 368), Romania (n = 339), Portugal (n = 334), France (n = 313), Spain (n = 296), Germany (n = 279), Hungary (n = 273), Greece (n = 270), USA (n = 268), Finland (n = 157), Montenegro (n = 147), Poland (n = 135), United Kingdom (n = 100), Slovenia (n = 77), and Canada (n = 60). The remaining countries are listed in the supporting information ( S1 Table ).

Outcome variables

The means, standard deviations, and where appropriate percentage of participants within categories of the five outcome variables can be seen in Table 1 .

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0244809.t001

Predictor variables

A full list of countries can be found in the supporting information ( S1 Table ).

The mean age was 36.9 (13.3) years. A majority of participants were female (77.7%), approximately a fifth male (22.0%), and small minority identified as other (0.3%). More than half of the respondents were either in a relationship (25.7%) or married (36.1%), almost a third were single (30.8%), and the rest were either divorced (5%), widower (1.1%) or other (1.3%). Participants indicated that they lived: alone (14.6%), with both parents (20.8%), one parent (5.1%), with their own family including partner and children (54.1%), or with friends or roommates (5.5%). Less than half of respondents had children (40.8%). Approximately half of the participants were working full time (53.4%), almost a fifth were working part-time (17.5%), 23.2% were unemployed and a small minority were either on parental leave (2.2%) or retired (3.7%).

COVID-19 lockdown variables.

At the time of responding, participants were in lockdown or self-isolation for a median of 5.0 (3.0 IQR) weeks. Most people indicated that they had not been infected with COVID-19 (88.0%), a small minority indicated they had been infected (1.4%) and the rest had symptoms but were unsure (10.6%). Similar patterns were seen with reported infection rates of partners (no: 92.2%, yes: 0.7%, unsure: 7.1%) and of people close to them (no: 86.0%; yes: 5.6%; unsure: 8.4%). With respect to leaving the house for work, almost half (47.7%) indicated that this never occurred, 7.7% indicated leaving only once, whereas an almost equal number indicated leaving a couple times per week (23.7%) or more than three times per week (21.0%). Nearly all participants indicated they were able to obtain all the basic supplies they needed (93.5%). Participants reported having a median inner living space of 90.0 square meters (80.0 IQR) and median outdoor space of 20.0 square meters (192.1 IQR). Finally, with respect to finances, more than half indicated that their financial situation remained about the same (57.9%), a minority indicated it improved (8.9%), and a third reported that their finances had gotten worse (33.3%).

Social and psychological predictors.

Mean values of the other predictors (i.e., social predictors and psychological predictors) can be seen in Table 1 .

Multivariate analyses

Results of multivariate analyses for the outcome of stress can be seen in Table 2 . The largest protective factor against stress was social support (high support vs low support (-3.35, 95%CI, -3.39 to -2.92), with a very large effect size). Positive predictors of stress with large effect sizes were being female (2.42, 95%CI, 2.07 to 2.77) and worsening of finances (2.32, 95%CI, 1.68 to 2.96), whereas psychological flexibility buffered this response (-0.65, 95%CI, -0.69 to -0.62). Higher education levels were also associated with lower levels of stress, with a large effect size (see Table 2 ). Moderate effect sizes for predictors associated with less stress were older age (-0.13, 95%CI, -0.14, -0.11) and mindfulness (-0.69, 95%CI, -0.74, -0.64). Moderate effect sizes of predictors associated with more stress were worse family functioning (0.98, 95%CI, 0.90, 1.06) and not being able to obtain all basic supplies (1.82 95%CI, 1.12, 2.52).

https://doi.org/10.1371/journal.pone.0244809.t002

Differences in reported levels of stress across countries were largely negligible, with the exception of two countries that reported higher levels of stress (Hong Kong (2.85, 95%CI, 2.22, 3.49) and Turkey (2.47, 95%CI, 1.93, 3.02)) and two that reported lower levels of stress (Portugal (-2.50, 95%CI, -3.29, -1.71) and Montenegro (-3.30, 95%CI, -4.49, -2.11)) than the average stress level across all countries. See supporting information for information on each country ( S2 – S6 Tables).

Results of multivariate analyses for the outcome of depression can be seen in Table 3 . The strongest predictor of depression was social support, such that high (-1.30, 95%CI, -1.44, -1.16) and medium levels (-0.73, 95%CI, -0.85, -0.62) of social support were protective against depression (relative to low levels) with a very large and large effect sizes, respectively. The only other large effect size was for psychological flexibility, which also served in a protective manner (-0.20, 95%CI, -0.22, -0.19). Moderate effect sizes of predictors associated with less depression symptoms were also observed for higher education levels (see Table 3 ). Moderate effect sizes of predictors associated with more depression were worse family functioning (0.29, 95%CI, 0.27, 0.32) and not being able to obtain all basic supplies (0.49, 95%CI, 0.27, 0.70).

https://doi.org/10.1371/journal.pone.0244809.t003

The amount of depression symptoms reported on average within countries was similar for most countries with the exception of one country with lower reported levels than average with a large effect size (Austria (-0.71, 95%CI, -0.95, -0.47)) and one with higher levels than average with a large effect size (USA (0.85, 95%CI, 0.58, 1.13)). See supporting information for information on each country ( S2 – S6 Tables).

Results of multivariate analyses for the outcome of affect can be seen in Table 4 . With respect to positive affect, social support (high support vs low support (5.69, 95%CI, 5.23, 6.16) and psychological flexibility (0.77, 95%CI, 0.74, 0.81) were both predictors with very large effect sizes. Interestingly, those who left their house more than three times per week had higher levels of positive affect than those that did not leave their house for work (1.68, 95%CI, 1.18, 2.17), with a medium effect size. Higher education levels were associated with higher levels of positive affect with a medium to large effect size (see Table 4 , PANAS-Positive).

https://doi.org/10.1371/journal.pone.0244809.t004

The amount of positive affect reported on average within countries was similar for most countries with the exception of one country with lower reported levels than average with a large effect size (Finland (-2.96, 95%CI, -4.19, -1.73)) and one with higher reported levels than average with a large effect size (Portugal (2.96, 95%CI, 2.12, 3.80)). See supporting information for information on each country ( S2 – S6 Tables).

With respect to negative affect, social support (high support vs low support (-2.74, 95%CI, -3.2, -2.29) and psychological flexibility (-0.62, 95%CI, -0.66, -0.58) were again the strongest associated predictors, with large effects. Higher education levels were also associated with lower levels of negative affect, with a medium effect (see Table 4 , PANAS-Negative). Higher levels of negative affect were noted, with medium effect sizes, for the predictors: worsening of finances (1.75, 95%CI, 1.10, 2.40) and not being able to obtain all basic supplies (1.6, 95%CI, 0.89, 2.31).

The amount of negative affect reported on average within countries was similar for most countries with the exception of few countries with lower reported negative affect levels than average with a very large effect sizes (Switzerland (-4.96, 95%CI, -5.91, -4.01), Germany (-4.70, 95%CI, -6.03, -3.37) & Austria (-6.49, 95%CI, -7.65, -5.33)) and one with a large effect size (Montenegro (-3.56, 95%CI, -5.39, -1.73). The average amount of negative affect was higher than average in two countries, with very large effects size (Turkey (5.75, 95%CI, 4.92, 6.59) & Finland (7.57, 95%CI, 5.80, 9.34)). See supporting information for information on each country ( S2 – S6 Tables).

Results of multivariate analyses for the outcome of wellbeing can be seen in Table 5 . Once again, social support (high support vs low support (13.20, 95%CI, 12.39, 14.01)) and psychological flexibility (1.42, 95%CI, 1.34, 1.49) were the predictors with the largest effect sizes (very large) on wellbeing. Higher education levels were associated with higher levels of wellbeing with a medium to large effect sizes (see Table 5 ). Medium negative effect sizes were noted for family functioning (-1.98, 95%CI, -2.12, -1.83) and inability to obtain all basic supplies (-3.27, 95%CI, -4.67, -1.87). Two medium positive effect sizes were observed: mindfulness (0.95, 95%CI, 0.86–1.04) and living with friends/roommates ((3.04, 95%CI, 1.59, 4.48), relative to living alone).

https://doi.org/10.1371/journal.pone.0244809.t005

The level of wellbeing reported on average within countries was similar for most countries with the exception of three countries with higher levels with large effect sizes (Austria (4.95, 95%CI, 3.55, 6.34), Finland (5.24, 95%CI, 3.10, 7.38), & Portugal (4.59, 95%CI, 3.12, 6.05)) and two countries with lower levels of wellbeing than average with large (Italy (-4.36, 95%CI, -11.06, 2.35)) and very large effect sizes (Hong Kong (-6.84, 95%CI, -8.02, -5.66)). See supporting information for information on each country ( S2 – S6 Tables).

The COVID-19 is the largest pandemic in modern history. This study assessed nearly 10,000 participants across many countries to examine the impact of the pandemic and resultant governmental lockdown measures on mental health. During the height of the lockdown, the pandemic was experienced as at least moderately stressful for most people, and 11% reported the highest levels of stress. Symptoms of depression were also high, including 25% of the sample indicating that the things they did were not reinforcing, 33% reporting high levels of boredom, and nearly 50% indicating they wasted a lot of time. Consistent with symptoms of stress and depression, 10% of participants were psychologically languishing. These results suggest that there is a subgroup of people who are especially suffering and that in about 50% of the respondents’ levels of mental health was only moderate. Previous studies have found that along with low levels, even moderate levels of mental health (which consists of only moderate levels of emotional, psychological, and social well-being) are associated with increased subsequent disability, productivity loss, and healthcare use [ 35 – 37 ]. Not everyone was suffering, however, as evidenced by the nearly 40% of participants who reported levels of mental health consistent with flourishing. The present results, while serious, do not point to more severe reactions observed in previous samples of selective quarantined individuals or groups [ 2 ]. Perhaps the previously reported distress in these groups is prevented when an entire country or world is in lockdown so that the feeling emerges that “everyone is in it together”.

Importantly, a handful of predictors emerged that consistently predicted all outcomes: Social support, education level, finances, access to basic needs, and the ability to respond psychologically flexible. The consistency of results examining predictors is noteworthy, both in terms of the consistently strong predictors (e.g., social support, education, psychological flexibly, as well as loss of income and lack of access to necessities) and in terms of the other predictors that were either not predictive or only weakly so. All predictors were chosen based on theoretical ties to the outcomes, previous findings, and studies on quarantines [ 2 ].

A novel finding was that people who left their house three or more times per week reported more positive affect than those that left their house less often. It is possible that these people experienced more variation, which contributed to positive affect. It is also possible they experienced a greater sense of normality. Future studies are encouraged to further investigate possible mechanisms through which this result unfolds.

Overall, these patterns did not differ substantially between countries. Although some differences did emerge, they were mostly inconsistent across outcomes. Three countries fared worse on two outcomes each: Hong Kong (stress & wellbeing); Turkey (stress & negative affect); and Finland (lower positive affect and higher negative affect)–though participants in Finland also reported higher levels of wellbeing than average. Two countries had more favorable outcomes than the average levels across all countries: Portugal (lower stress and higher wellbeing) and Austria (lower depression and higher wellbeing). The differences observed are likely due to a combination of chance, sampling, nation specific responses to the COVID-19 pandemic, cultural differences, and other factors playing out in the countries (e.g., political unrest [ 38 ]). If replicated, future studies are encouraged to examine possible mechanisms of these outcomes.

This study provides valuable insights on several levels. First, it documents the mental health outcomes across a broad sample during the COVID-19 global pandemic. Second, it informs about the conditions and resilience factors (social support, education, and psychological flexibility) and risk factors (loss of income and inability to get basic supplies) that affect mental health outcomes. Third, these factors can be used in future public health responses are being made, including those that require large scale lockdowns or quarantines. That is, public health officials should direct resources to identifying and supporting people with poor social support, income loss, and potentially lower levels of education and provide a strategy to mitigate special risks in these subpopulations. The importance of social support needs to be made clear to the public and to the degree possible mechanisms that can contribute to social support should be supported. Further, psychological flexibility is a trainable set of skills that has repeatedly been shown to ameliorate suffering [ 22 , 39 ]; and can be widely distributed with modern technological intervention tools such as digital, internet, or virtual means [ 40 ]. We do not claim, however, that psychological flexibility is the only factor that can be used for interventions. Instead, it is a recognized transdiagnostic factor assessed in this study and one that is feasible to be targeted and modified by interventions and prevention [ 41 – 43 ].

This study is limited by several important factors. First, the results are based on cross sectional analysis and correlations. As such, causation cannot be inferred and any delayed impact of the pandemic and lockdown on peoples’ mental health was not captured. Second, all results of this survey were obtained via self-report questionnaires, which can be subject to retrospective response bias. Third, although the sample was large and based on varied recruitment sources, it was not representative of the population and undersampled people who suffered most from the pandemic (i.e., front line health care professionals, people in intensive care, etc.) or people without internet access, etc. Finally, the country-specific incidence rates and lockdown measures differed across countries. These were not assessed, but future studies are encouraged to investigate how such factors impact mental health outcomes.

These limitations notwithstanding, based on nearly 10,000 international participants, this study found that approximately 10% of the population was languishing during or shortly after the lockdown period. These finding have implications for public health initiatives. First, officials are urged to attend to, find, and target people who have little social support and/ or whose finances have worsened as a result of the measures. Second, public health interventions are further urged to target psychological processes such as psychological flexibility in general to potentially help buffer other risk factors for mental health. Likewise, availability of social support and information about where to get support and remain connected are needed. These recommendations should become part of public health initiatives designed to promote mental health in general, and should equally be considered when lockdowns or physical distancing are prescribed during a pandemic.

Supporting information

S1 table. list of all countries included in the data set..

https://doi.org/10.1371/journal.pone.0244809.s001

S2 Table. Geodemographic predictors for Perceived Stress Scale.

https://doi.org/10.1371/journal.pone.0244809.s002

S3 Table. Geodemographic predictors for MSBS–depression.

https://doi.org/10.1371/journal.pone.0244809.s003

S4 Table. Geodemographic predictors for PANAS positive.

https://doi.org/10.1371/journal.pone.0244809.s004

S5 Table. Geodemographic predictors for PANAS negative.

https://doi.org/10.1371/journal.pone.0244809.s005

S6 Table. Geodemographic predictors for MHCSF—mental health continuum.

https://doi.org/10.1371/journal.pone.0244809.s006

S1 Appendix. Participation flowchart.

https://doi.org/10.1371/journal.pone.0244809.s007

Acknowledgments

We wish to thank the following people for their work in helping to implement the study: Spyros Demosthenous, Christiana Karashali, Diamanto Rovania (University of Cyprus); Maria Antoniade (European University of Cyprus); Ioanna Menoikou (Cyprus University of Technology); Elias Ioannou (University of Nicosia); Sonja Borner, Victoria Firsching-Block, Alexander Fenn (University of Basel); Cristīne Šneidere, Ingrīda Trups-Kalne, Lolita Vansovica, Sandra Feldmane, (Riga Stradiņš University); David Nilsson (Lund University); Miguel A. Segura-Vargas (Fundación Universitaria Konrad Lorenz); Claudia Lenuţa Rus, Catalina Otoiu, Cristina Vajaean (Babes-Bolyai University). We further wish to thank Fabio Coviello and Sonja Borner (University of Basel) for their help in preparing the manuscript.

• View Article
• Google Scholar
• 2. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Vol. 395, The Lancet. Lancet Publishing Group; 2020. p. 912–20.
• 3. Kristensen P, Weisaeth L, Heir T. Bereavement and mental health after sudden and violent losses: A Review. Vol. 75, Psychiatry. Guilford Publications Inc; 2012. p. 76–97. https://doi.org/10.1521/psyc.2012.75.1.76 pmid:22397543
• PubMed/NCBI
• 6. Alfano CA, Bower JL, Cowie J, Lau S, Simpson RJ. Long-duration space exploration and emotional health: Recommendations for conceptualizing and evaluating risk. Vol. 142, Acta Astronautica. Elsevier Ltd; 2018. p. 289–99.
• 9. Kanter JW, Busch AM, Weeks CE, Landes SJ. The nature of clinical depression: Symptoms, syndromes, and behavior analysis. Vol. 31, Behavior Analyst. Association for Behavior Analysis; 2008. p. 1–21.
• 12. Koenig HG. Research on religion, spirituality, and mental health: A review. Vol. 54, Canadian Journal of Psychiatry. Canadian Psychiatric Association; 2009. p. 283–91. https://doi.org/10.1177/070674370905400502 pmid:19497160
• 23. Gu J, Strauss C, Bond R, Cavanagh K. How do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve mental health and wellbeing? A systematic review and meta-analysis of mediation studies. Vol. 37, Clinical Psychology Review. Elsevier Inc.; 2015. p. 1–12. https://doi.org/10.1016/j.cpr.2015.01.006 pmid:25689576
• 29. Cohen S. Perceived stress in a probability sample of the United States. In: The social psychology of health. Thousand Oaks, CA, US: Sage Publications, Inc; 1988. p. 31–67. (The Claremont Symposium on Applied Social Psychology.).
• 43. Dindo L, Van Liew JR, Arch JJ. Acceptance and Commitment Therapy: A Transdiagnostic Behavioral Intervention for Mental Health and Medical Conditions. Vol. 14, Neurotherapeutics. Springer New York LLC; 2017. p. 546–53. https://doi.org/10.1007/s13311-017-0521-3 pmid:28271287

Mental Health Research Paper Topics

Exploring the wide array of mental health research paper topics can be an enriching experience for students studying health sciences. This subject matter is not only relevant but is also critically important in today’s context, given the rising prevalence of mental health issues in society. In this guide, we will navigate through a comprehensive list of potential topics, categorized into ten major areas of mental health. Additionally, this page provides expert advice on how to choose and delve into these topics effectively, as well as guidance on constructing a well-written mental health research paper. As a supplementary service, we also present iResearchNet’s professional writing offerings. iResearchNet specializes in providing students with high-quality, custom-written research papers on any topic of their choice. With a potent combination of expert degree-holding writers, meticulous research, and adherence to the highest standards of academic integrity, iResearchNet offers unparalleled support to students aiming to excel in their academic endeavors.

100 Mental Health Research Paper Topics

Embarking on the exploration of mental health research paper topics presents an incredible opportunity to delve into diverse areas of study and reveal intriguing insights. From understanding the human psyche to unraveling the intricate workings of various mental disorders, this domain offers a wide array of research avenues. In this section, we present a comprehensive list of 100 mental health research paper topics, neatly organized into ten major categories. This catalog is designed to cater to different interests, offer fresh perspectives, and stimulate thought-provoking discussions.

Academic Writing, Editing, Proofreading, And Problem Solving Services

Get 10% off with 24start discount code.

• The impact of social media on mental health
• The psychological effects of bullying
• Role of personality traits in mental health
• Nature vs. nurture debate in psychology
• Psychological effects of long-term stress
• The role of psychology in pain management
• The impact of sleep disorders on mental health
• Effects of meditation on mental health
• The psychology of decision-making
• Understanding cognitive biases
• Impact of parenting styles on children’s mental health
• Childhood trauma and its long-term effects
• Understanding Attention Deficit Hyperactivity Disorder (ADHD)
• The role of school environments in child mental health
• Adolescent depression: Causes and effects
• The impact of divorce on children
• Childhood Autism Spectrum Disorders
• Eating disorders in adolescents
• Impact of physical activity on children’s mental health
• Childhood anxiety disorders
• Impacts of work stress on mental health
• Understanding Bipolar Disorder
• Adult PTSD and its management
• Role of exercise in mental health maintenance
• The link between adult obesity and mental health
• Alcoholism and its mental health implications
• Understanding Schizophrenia
• Mental health impacts of sexual assault
• The effect of childlessness on mental health
• The role of religion and spirituality in mental health
• Mental health issues in aging population
• Understanding Alzheimer’s Disease
• Role of family in elder mental health
• Depression in the elderly
• Cognitive decline in aging: Prevention and management
• The impact of retirement on mental health
• Mental health effects of elder abuse
• The role of social interactions in elder mental health
• Understanding Parkinson’s Disease
• Dementia and mental health
• Global mental health policies: A comparative analysis
• 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.
• Money Back Guarantee : We are confident in the quality of our services. In the rare event that you are not satisfied with the final product, we offer a money-back guarantee to ensure your complete satisfaction and peace of mind.

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

Are you a health sciences student working on a mental health research paper and seeking professional assistance to elevate your work? Look no further. iResearchNet is your trusted partner in achieving success in your academic journey. We understand the complexities and challenges you face in conducting rigorous research and producing a compelling paper. Our comprehensive writing services are tailored specifically to your needs, offering you the expertise and support required to excel in your mental health research.

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.

ORDER HIGH QUALITY CUSTOM PAPER

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

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

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

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

26k Accesses

56 Citations

11 Altmetric

Metrics details

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

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

Article   Google Scholar  

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

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

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

Article   PubMed   Google Scholar  

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

PubMed   PubMed Central   Google Scholar  

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

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

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

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

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

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

PubMed   Google Scholar  

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

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

Article   CAS   Google Scholar  

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

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

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

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

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

Google Scholar  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Download references

Acknowledgements

Not Applicable.

Not Applicable

Author information

Authors and affiliations.

Telfer School of Management, University of Ottawa, 55 Laurier Ave E, Ottawa, ON, K1N 6N5, Canada

Mara Mihailescu

School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada

Elena Neiterman

You can also search for this author in PubMed   Google Scholar

Contributions

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.

Corresponding author

Correspondence to Mara Mihailescu .

Ethics declarations

Ethics approval and consent to participate, consent for publication, competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

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

Download citation

Received : 29 April 2019

Accepted : 20 September 2019

Published : 24 October 2019

DOI : https://doi.org/10.1186/s12889-019-7661-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Mental health
• Mental illness
• Medical students
• Scoping review
• Interventions
• North America

BMC Public Health

ISSN: 1471-2458

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Published: 10 May 2023

Mental health awareness: uniting advocacy and research

Nature Mental Health volume  1 ,  pages 295–296 ( 2023 ) Cite this article

3242 Accesses

6 Altmetric

Metrics details

Mental Health Month has been observed to reduce the stigma that is associated with mental illness and to educate the public and encourage individuals to make their mental health and wellbeing a priority. It is an important moment to bring the strengths of advocacy groups and researchers together to promote mental health awareness and to improve equity.

Observances have become a popular tool to garner media and notice for topics deserving attention, from medical conditions to public health concerns, commemoration of notable events, or celebration of cultural groups. Codifying the scope and needs connected to an issue or illness through awareness campaigns can provide opportunities for imparting useful information, reducing stigma and marshalling support for policy change. The impact of awareness campaigns can be difficult to measure beyond tallying social media mentions or news stories. Effective advocacy, however, extends beyond traffic and paves the way for the creation of knowledge and partnerships among allies and with those whose interests are being represented. When the magnitude of an issue and the potential for improvement are great and are matched by broad involvement and recognition by stakeholders, the possibility for impact is also great.

Held annually in May, Mental Health Month , also called Mental Health Awareness Month, is an observance with such reach, resonating with many people. Nearly everyone has experience with the challenges that are associated with mental health, either first-hand or through loved ones or in their community. There is a need for education, support and initiative to improve our understanding of the causes of mental health disorders and to increase the availability of resources for prevention and treatment. Mental Health Month also offers the possibility of bringing together groups who often work in parallel, such as mental health advocates and mental health research organizations, that can mutually benefit from each other’s functions and expertise.

Mental Health Month was first established in the US in 1949 by the National Mental Health Association, now known as Mental Health America . At a time more often associated with the outset of the Cold War and Marshall Plan than setting an agenda for domestic mental health and wellbeing advocacy, in the more than 70 years since, Mental Health Month has grown into an international event designed to reduce exclusion, stigma and discrimination against people with mental health conditions or disorders. Mental Health America are joined by other prominent mental health advocacy groups to sponsor related observances: Mental Health Awareness Week Canada (1–7 May, 2023) and Europe (22–28 May, 2023); and federal agencies such as the Substance Use Abuse and Mental Health Services Administration ( SAMSHA ) in the US, promoting related public education platforms, including National Prevention Week (7–13 May, 2023).

Observances and awareness campaigns also provide occasions to put mental health in context. Increasing acknowledgment of the role of social determinants, for example, as mechanisms that can increase vulnerability for developing disorders and that drive disparities in mental health are an important framework to underscore as part of promoting mental health awareness. Given the complex and broad scope of people, disorders, conditions and issues under the umbrella of mental health, observances also give us the chance to focus more closely on specific problems or experiences. The theme for Mental Health Month in 2023 is ‘Look Around, Look Within’, which emphasizes the interdependence of mental health and wellness with an individual’s internal and external experiences and environments.

“The ‘Look Around, Look Within’ theme builds on the growing recognition that all humans have mental health needs and that our available resources to build resilience and heal come in many forms — including in the natural world,” explains Jennifer Bright, Mental Health America Board Chair and President of Momentum Health Strategies. “Mental Health America’s strategic plan, focused on NextGen Prevention, carries a similar theme — that the social factors supporting mental health are essential building blocks. These encompass basic needs like healthy food, stable housing, and access to treatment and supports, but they also include spirituality, connection with peers with lived experience, and safe and natural spaces.”

Overlapping with Mental Health Month, Mental Health Foundation sponsors Mental Health Week in the UK (15–21 May, 2023), dedicating this year to raising awareness around anxiety. It shares an individual-centered approach to advocacy. In addition to providing toolkits and resources that point to how prevalent stress and anxiety can be to reduce stigma, it also promotes the accessibility of coping strategies for managing anxiety. As part of the Mental Health Awareness Week campaign, Mental Health Foundation and others use the international symbol of wearing a green ribbon or clothing to physically raise awareness around mental health. Nature Mental Health also incorporates the symbol of the green ribbon on the cover of this month’s issue and as our journal theme color. Green evokes the ideas of vitality, growth, new beginnings and hope — powerful imagery in mental health awareness.

Alongside stories, sponsorships and social media resources, mental health advocacy toolkits and strategy documents include fact sheets and messaging that are shaped and informed by research. Yet, there is often a perception that a divide exists between the mental health advocacy and research spaces, but observances such as Mental Health Month can bridge the two.

According to Lea Milligan, Chief Executive Officer of MQ: Transforming Mental Health , an international mental health research organization, there are complementary approaches and priorities in advocacy and research: “Mental health research can be used to bolster awareness by providing evidence-based information and resources that can help individuals and communities better understand mental health and the factors that contribute to mental health problems. This can include information on risk factors, prevention strategies, and available treatments.”

In addition, increased efforts to involve people with lived experience of mental illness in the research enterprise is a goal that is well-served through connection with advocacy. “While MQ is primarily focused on promoting mental health research, it also recognizes the importance of advocacy in advancing the mental health agenda” suggests Milligan. “MQ advocates for increased funding and support for mental health research, as well as policies that promote mental health and wellbeing. Additionally, MQ seeks to empower individuals with lived experience of mental health conditions to be involved in research and advocacy efforts, and to have their voices heard in the development of policies and programs that affect their lives. MQ provides resources and support for individuals with lived experience who wish to be involved in research or advocacy efforts, including training programs, research grants, and opportunities to participate in research studies.”

Involvement or engagement is certainly one of the most important metrics of advocacy. By strengthening collaboration between advocacy and research organizations and identifying the mutual areas of benefit, such as engagement and increased funding, we may find new ways to green light mental health awareness and action toward mental health equity.

Rights and permissions

Reprints and permissions

About this article

Cite this article.

Mental health awareness: uniting advocacy and research. Nat. Mental Health 1 , 295–296 (2023). https://doi.org/10.1038/s44220-023-00072-6

Download citation

Published : 10 May 2023

Issue Date : May 2023

DOI : https://doi.org/10.1038/s44220-023-00072-6

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

55 research questions about mental health

Last updated

11 March 2024

Reviewed by

Brittany Ferri, PhD, OTR/L

Research in the mental health space helps fill knowledge gaps and create a fuller picture for patients, healthcare professionals, and policymakers. Over time, these efforts result in better quality care and more accessible treatment options for those who need them.

Use this list of mental health research questions to kickstart your next project or assignment and give yourself the best chance of producing successful and fulfilling research.

• Why does mental health research matter?

Mental health research is an essential area of study. It includes any research that focuses on topics related to people’s mental and emotional well-being.

As a complex health topic that, despite the prevalence of mental health conditions, still has an unending number of unanswered questions, the need for thorough research into causes, triggers, and treatment options is clear.

Research into this heavily stigmatized and often misunderstood topic is needed to find better ways to support people struggling with mental health conditions. Understanding what causes them is another crucial area of study, as it enables individuals, companies, and policymakers to make well-informed choices that can help prevent illnesses like anxiety and depression.

• How to choose a strong mental health research topic

As one of the most important parts of beginning a new research project, picking a topic that is intriguing, unique, and in demand is a great way to get the best results from your efforts.

Mental health is a blanket term with many niches and specific areas to explore. But, no matter which direction you choose, follow the tips below to ensure you pick the right topic.

Prioritize your interests and skills

While a big part of research is exploring a new and exciting topic, this exploration is best done within a topic or niche in which you are interested and experienced.

Research is tough, even at the best of times. To combat fatigue and increase your chances of pushing through to the finish line, we recommend choosing a topic that aligns with your personal interests, training, or skill set.

Consider emerging trends

Topical and current research questions are hot commodities because they offer solutions and insights into culturally and socially relevant problems.

Depending on the scope and level of freedom you have with your upcoming research project, choosing a topic that’s trending in your area of study is one way to get support and funding (if you need it).

Not every study can be based on a cutting-edge topic, but this can be a great way to explore a new space and create baseline research data for future studies.

Assess your resources and timeline

Before choosing a super ambitious and exciting research topic, consider your project restrictions.

You’ll need to think about things like your research timeline, access to resources and funding, and expected project scope when deciding how broad your research topic will be. In most cases, it’s better to start small and focus on a specific area of study.

Broad research projects are expensive and labor and resource-intensive. They can take years or even decades to complete. Before biting off more than you can chew, consider your scope and find a research question that fits within it.

Read up on the latest research

Finally, once you have narrowed in on a specific topic, you need to read up on the latest studies and published research. A thorough research assessment is a great way to gain some background context on your chosen topic and stops you from repeating a study design. Using the existing work as your guide, you can explore more specific and niche questions to provide highly beneficial answers and insights.

• Trending research questions for post-secondary students

As a post-secondary student, finding interesting research questions that fit within the scope of your classes or resources can be challenging. But, with a little bit of effort and pre-planning, you can find unique mental health research topics that will meet your class or project requirements.

Examples of research topics for post-secondary students include the following:

How does school-related stress impact a person’s mental health?

To what extent does burnout impact mental health in medical students?

How does chronic school stress impact a student’s physical health?

How does exam season affect the severity of mental health symptoms?

Is mental health counseling effective for students in an acute mental crisis?

• Research questions about anxiety and depression

Anxiety and depression are two of the most commonly spoken about mental health conditions. You might assume that research about these conditions has already been exhausted or that it’s no longer in demand. That’s not the case at all.

According to a 2022 survey by Centers for Disease Control and Prevention (CDC), 12.5% of American adults struggle with regular feelings of worry, nervousness, and anxiety, and 5% struggle with regular feelings of depression. These percentages amount to millions of lives affected, meaning new research into these conditions is essential.

If either of these topics interests you, here are a few trending research questions you could consider:

Does gender play a role in the early diagnosis of anxiety?

How does untreated anxiety impact quality of life?

What are the most common symptoms of anxiety in working professionals aged 20–29?

To what extent do treatment delays impact quality of life in patients with undiagnosed anxiety?

To what extent does stigma affect the quality of care received by people with anxiety?

Here are some examples of research questions about depression:

Does diet play a role in the severity of depression symptoms?

Can people have a genetic predisposition to developing depression?

How common is depression in work-from-home employees?

Does mood journaling help manage depression symptoms?

What role does exercise play in the management of depression symptoms?

• Research questions about personality disorders

Personality disorders are complex mental health conditions tied to a person’s behaviors, sense of self, and how they interact with the world around them. Without a diagnosis and treatment, people with personality disorders are more likely to develop negative coping strategies during periods of stress and adversity, which can impact their quality of life and relationships.

There’s no shortage of specific research questions in this category. Here are some examples of research questions about personality disorders that you could explore:

What environments are more likely to trigger the development of a personality disorder?

What barriers impact access to care for people with personality disorders?

To what extent does undiagnosed borderline personality disorder impact a person’s ability to build relationships?

How does group therapy impact symptom severity in people with schizotypal personality disorder?

What is the treatment compliance rate of people with paranoid personality disorder?

• Research questions about substance use disorders

“Substance use disorders” is a blanket term for treatable behaviors and patterns within a person’s brain that lead them to become dependent on illicit drugs, alcohol, or prescription medications. It’s one of the most stigmatized mental health categories.

The severity of a person’s symptoms and how they impact their ability to participate in their regular daily life can vary significantly from person to person. But, even in less severe cases, people with a substance use disorder display some level of loss of control due to their need to use the substance they are dependent on.

This is an ever-evolving topic where research is in hot demand. Here are some example research questions:

To what extent do meditation practices help with craving management?

How effective are detox centers in treating acute substance use disorder?

Are there genetic factors that increase a person’s chances of developing a substance use disorder?

How prevalent are substance use disorders in immigrant populations?

To what extent do prescription medications play a role in developing substance use disorders?

• Research questions about mental health treatments

Treatments for mental health, pharmaceutical therapies in particular, are a common topic for research and exploration in this space.

Besides the clinical trials required for a drug to receive FDA approval, studies into the efficacy, risks, and patient experiences are essential to better understand mental health therapies.

These types of studies can easily become large in scope, but it’s possible to conduct small cohort research on mental health therapies that can provide helpful insights into the actual experiences of the people receiving these treatments.

Here are some questions you might consider:

What are the long-term effects of electroconvulsive therapy (ECT) for patients with severe depression?

How common is insomnia as a side effect of oral mental health medications?

What are the most common causes of non-compliance for mental health treatments?

How long does it take for patients to report noticeable changes in symptom severity after starting injectable mental health medications?

What issues are most common when weaning a patient off of an anxiety medication?

• Controversial mental health research questions

If you’re interested in exploring more cutting-edge research topics, you might consider one that’s “controversial.”

Depending on your own personal values, you might not think many of these topics are controversial. In the context of the research environment, this depends on the perspectives of your project lead and the desires of your sponsors. These topics may not align with the preferred subject matter.

That being said, that doesn’t make them any less worth exploring. In many cases, it makes them more worthwhile, as they encourage people to ask questions and think critically.

Here are just a few examples of “controversial” mental health research questions:

To what extent do financial crises impact mental health in young adults?

How have climate concerns impacted anxiety levels in young adults?

To what extent do psychotropic drugs help patients struggling with anxiety and depression?

To what extent does political reform impact the mental health of LGBTQ+ people?

What mental health supports should be available for the families of people who opt for medically assisted dying?

• Research questions about socioeconomic factors & mental health

Socioeconomic factors—like where a person grew up, their annual income, the communities they are exposed to, and the amount, type, and quality of mental health resources they have access to—significantly impact overall health.

This is a complex and multifaceted issue. Choosing a research question that addresses these topics can help researchers, experts, and policymakers provide more equitable and accessible care over time.

Examples of questions that tackle socioeconomic factors and mental health include the following:

How does sliding scale pricing for therapy increase retention rates?

What is the average cost to access acute mental health crisis care in [a specific region]?

To what extent does a person’s environment impact their risk of developing a mental health condition?

How does mental health stigma impact early detection of mental health conditions?

To what extent does discrimination affect the mental health of LGBTQ+ people?

• Research questions about the benefits of therapy

Therapy, whether that’s in groups or one-to-one sessions, is one of the most commonly utilized resources for managing mental health conditions. It can help support long-term healing and the development of coping mechanisms.

Yet, despite its popularity, more research is needed to properly understand its benefits and limitations.

Here are some therapy-based questions you could consider to inspire your own research:

In what instances does group therapy benefit people more than solo sessions?

How effective is cognitive behavioral therapy for patients with severe anxiety?

After how many therapy sessions do people report feeling a better sense of self?

Does including meditation reminders during therapy improve patient outcomes?

To what extent has virtual therapy improved access to mental health resources in rural areas?

• Research questions about mental health trends in teens

Adolescents are a particularly interesting group for mental health research due to the prevalence of early-onset mental health symptoms in this age group.

As a time of self-discovery and change, puberty brings plenty of stress, anxiety, and hardships, all of which can contribute to worsening mental health symptoms.

If you’re looking to learn more about how to support this age group with mental health, here are some examples of questions you could explore:

Does parenting style impact anxiety rates in teens?

How early should teenagers receive mental health treatment?

To what extent does cyberbullying impact adolescent mental health?

What are the most common harmful coping mechanisms explored by teens?

How have smartphones affected teenagers’ self-worth and sense of self?

• Research questions about social media and mental health

Social media platforms like TikTok, Instagram, YouTube, Facebook, and X (formerly Twitter) have significantly impacted day-to-day communication. However, despite their numerous benefits and uses, they have also become a significant source of stress, anxiety, and self-worth issues for those who use them.

These platforms have been around for a while now, but research on their impact is still in its infancy. Are you interested in building knowledge about this ever-changing topic? Here are some examples of social media research questions you could consider:

To what extent does TikTok’s mental health content impact people’s perception of their health?

How much non-professional mental health content is created on social media platforms?

How has social media content increased the likelihood of a teen self-identifying themselves with ADHD or autism?

To what extent do social media photoshopped images impact body image and self-worth?

Has social media access increased feelings of anxiety and dread in young adults?

• Mental health research is incredibly important

As you have seen, there are so many unique mental health research questions worth exploring. Which options are piquing your interest?

Whether you are a university student considering your next paper topic or a professional looking to explore a new area of study, mental health is an exciting and ever-changing area of research to get involved with.

Your research will be valuable, no matter how big or small. As a niche area of healthcare still shrouded in stigma, any insights you gain into new ways to support, treat, or identify mental health triggers and trends are a net positive for millions of people worldwide.

Get started today

Go from raw data to valuable insights with a flexible research platform

Editor’s picks

Last updated: 21 December 2023

Last updated: 16 December 2023

Last updated: 6 October 2023

Last updated: 5 March 2024

Last updated: 25 November 2023

Last updated: 15 February 2024

Last updated: 11 March 2024

Last updated: 12 December 2023

Last updated: 6 March 2024

Last updated: 10 April 2023

Last updated: 20 December 2023

Latest articles

Related topics, log in or sign up.

Get started for free

• Alzheimer's disease & dementia
• Arthritis & Rheumatism
• Attention deficit disorders
• Autism spectrum disorders
• Biomedical technology
• Diseases, Conditions, Syndromes
• Endocrinology & Metabolism
• Gastroenterology
• Gerontology & Geriatrics
• Health informatics
• Inflammatory disorders
• Medical economics
• Medical research
• Medications
• Neuroscience
• Obstetrics & gynaecology
• Oncology & Cancer
• Ophthalmology
• Overweight & Obesity
• Parkinson's & Movement disorders
• Psychology & Psychiatry
• Radiology & Imaging
• Sleep disorders
• Sports medicine & Kinesiology
• Vaccination
• Breast cancer
• Cardiovascular disease
• Chronic obstructive pulmonary disease
• Colon cancer
• Coronary artery disease
• Heart attack
• Heart disease
• High blood pressure
• Kidney disease
• Lung cancer
• Multiple sclerosis
• Myocardial infarction
• Ovarian cancer
• Post traumatic stress disorder
• Rheumatoid arthritis
• Schizophrenia
• Skin cancer
• Type 2 diabetes
• Full List »

share this!

April 8, 2024

This article has been reviewed according to Science X's editorial process and policies . Editors have highlighted the following attributes while ensuring the content's credibility:

fact-checked

peer-reviewed publication

New study highlights the benefit of touch on mental and physical health

by Netherlands Institute for Neuroscience - KNAW

Through a large-scale analysis, researchers at the Netherlands Institute for Neuroscience have uncovered the ways in which consensual touch can benefit a person's physical and mental well-being.

You might recognize the comforting feeling when someone offers you a hug at the end of a stressful day or strokes your shoulder when you're feeling down. But the question remains: can touch really help you feel better, and does it matter who it's from or how they touch you?

To explore these questions, researchers from the Social Brain Lab at the Netherlands Institute for Neuroscience and the University Hospital Essen conducted a large-scale analysis of studies exploring touch interventions.

The benefits of touch on mental and physical health

Does touch truly improve someone's well-being? It is an easy question to ask but more complicated to answer. Individual studies often only focus on specific instances and may contradict each other. Combining all these studies together for a large-scale analysis offers a clearer answer: yes, touch substantially improves both physical and mental well-being, for example, via reduction of pain, anxiety, depression, and stress in adults.

But in fact, those with physical or mental health problems (and therefore most in need of support) benefit even more from touch than healthy adults. "This is especially relevant considering how often touch interventions are overlooked," Packheiser, the first author, adds.

"A key question of our study is to leverage the hundreds of individual studies out there to identify what type of touch works best," adds Professor Keysers, director of the Social Brain Lab. "What if you don't have a friend or partner close by to hug you? Would touch from a stranger or even a machine also help? And how often? The study clearly shows that touch can indeed be optimized, but the most important factors are not necessarily those we suspect."

Interestingly, the person touching you, how they touch you, and the duration of their touch doesn't make a difference in terms of impact. A long-lasting massage by a therapist could, therefore, be just as effective as a quick hug offered by a friend. That is until the frequency of the intervention is considered. The more often a touch intervention is offered the greater the impact. A quick hug could, therefore, be even more impactful than a massage if it is offered more frequently.

Human or non-human touch?

The next question was whether touch intervention needs to be human at all. As it turns out, object or robot interventions can be equally effective at improving physical well-being. "There are lots of people in need of well-being improvements, perhaps because they're lonely but also because clinical conditions may inflict them. These results indicate that a touch-robot or even a simple weighted blanket has the potential to help those people," last author Frédéric Michon explains.

However, the benefits of robot and object interventions are less effective for mental well-being. Mental health disorders like anxiety or depression might, therefore, require human touch after all, "perhaps suggestive of the importance for an emotional component associated with the touch," Michon points out.

While the researchers were equally curious about human-to-animal contact, studies exploring this question are still lacking. "It would be useful to see whether an animal's or pet's touch could improve well-being, and inversely if they also benefit from it, but unfortunately, there simply aren't enough studies, or properly controlled ones, for us to draw any general conclusions on these topics," Michon clarifies.

Touch interventions across ages

When the team looked into the impact of touch on newborns, they found out that newborns also benefited significantly from touch. However, the person conducting the touch intervention was more important: the benefits of touch are higher when done by a parent instead of a health care worker.

"This finding could be impactful," Packheiser adds. "Death rates due to premature births are high in some countries, and the knowledge that a baby benefits more from the touch of their own parent offers another easily implementable form of support for the baby's health".

Due to a lack of studies, it proved difficult to draw conclusions about children and teenagers. "Large-scale studies like this help us draw more general conclusions, but they also help us identify where research is lacking," Michon explains.

"We hope that our findings can steer future research to explore lesser-known questions. This includes animal touch, but also touch across ages, and in specific clinical settings like autistic patients, another category that has not been explored extensively."

The study is published in the journal Nature Human Behaviour .

Explore further

Feedback to editors

New study says obese and overweight children at risk of iron deficiency

35 minutes ago

How the body switches out of 'fight' mode: Study shows hormones reprogram metabolism of immune cells

Sepsis signature shifts speed of diagnosis

Psychiatric research uses linguistics models to analyze game play and listen in on ways environment shapes interaction

AI-assisted breast-cancer screening may reduce unnecessary testing

Study finds weak link between adolescent media use and psychotic experiences in adulthood

Performance on some cognitive tasks is better predicted by gender identity than by sex assigned at birth, finds study

Researchers advance understanding of Parkinson's disease

2 hours ago

Revascularization may enhance quality of life for patients with chronic limb threatening ischemia

Newly found genetic variant defends against Alzheimer's disease

Related stories.

Touchibo, a robot that fosters inclusion in education through touch

Apr 5, 2024

Study examines how nurses view touch as a form of care

Apr 26, 2021

Mothers' mental health may affect twins' and singletons' touch and movement during pregnancy

Jun 9, 2021

Parental touch may reduce social anxiety in children

May 23, 2018

Affectionate touch contributes to stress and conflict management

Feb 11, 2019

A touch from a conversing robot is linked to positive emotional state

May 5, 2021

Recommended for you

'Deaths of despair' among Black Americans surpassed those of white Americans in 2022

3 hours ago

Living near green space associated with fewer emotional problems in preschool-age kids, study finds

Researchers identify neurons responsible for key activity transition in brain development

Let us know if there is a problem with our content.

Use this form if you have come across a typo, inaccuracy or would like to send an edit request for the content on this page. For general inquiries, please use our contact form . For general feedback, use the public comments section below (please adhere to guidelines ).

Please select the most appropriate category to facilitate processing of your request

Thank you for taking time to provide your feedback to the editors.

Your feedback is important to us. However, we do not guarantee individual replies due to the high volume of messages.

E-mail the story

Your email address is used only to let the recipient know who sent the email. Neither your address nor the recipient's address will be used for any other purpose. The information you enter will appear in your e-mail message and is not retained by Medical Xpress in any form.

Newsletter sign up

Get weekly and/or daily updates delivered to your inbox. You can unsubscribe at any time and we'll never share your details to third parties.

More information Privacy policy

Donate and enjoy an ad-free experience

We keep our content available to everyone. Consider supporting Science X's mission by getting a premium account.

E-mail newsletter

This paper is in the following e-collection/theme issue:

Published on 8.4.2024 in Vol 12 (2024)

Effects of Telemedicine on Informal Caregivers of Patients in Palliative Care: Systematic Review and Meta-Analysis

Authors of this article:

• Xiaoyu Yang 1 , BSN ; 
• Xueting Li 2 , BSN ; 
• Shanshan Jiang 2 , BSN ; 
• Xinying Yu 3 , MSN

1 Department of Oncology, Shengjing Hospital of China Medical University, , Shenyang, , China

2 College of Nursing, China Medical University, , Shenyang, , China

3 Department of Pediatrics, Shengjing Hospital of China Medical University, , Shenyang, , China

Corresponding Author:

Xinying Yu, MSN

Background: Telemedicine technology is a rapidly developing field that shows immense potential for improving medical services. In palliative care, informal caregivers assume the primary responsibility in patient care and often face challenges such as increased physical and mental stress and declining health. In such cases, telemedicine interventions can provide support and improve their health outcomes. However, research findings regarding the use of telemedicine among informal caregivers are controversial, and the efficacy of telemedicine remains unclear.

Objective: This study aimed to evaluate the impacts of telemedicine on the burden, anxiety, depression, and quality of life of informal caregivers of patients in palliative care.

Methods: A systematic literature search was conducted using the PubMed, Embase, Web of Science, CENTRAL, PsycINFO, CINAHL Plus with Full Text, CBM, CNKI, WanFang, and VIP databases to identify relevant randomized controlled trials published from inception to March 2023. Two authors independently screened the studies and extracted the relevant information. The methodological quality of the included studies was assessed using the Cochrane risk-of-bias tool. Intervention effects were estimated and sensitivity analysis was conducted using Review Manager 5.4, whereas 95% prediction intervals (PIs) were calculated using R (version 4.3.2) and RStudio.

Results: A total of 9 randomized controlled trials were included in this study. The meta-analysis indicated that telemedicine has reduced the caregiving burden (standardized mean differences [SMD] −0.49, 95% CI −0.72 to −0.27; P <.001; 95% PI −0.86 to −0.13) and anxiety (SMD −0.23, 95% CI −0.40 to −0.06; P =.009; 95% PI −0.98 to 0.39) of informal caregivers; however, it did not affect depression (SMD −0.21, 95% CI −0.47 to 0.05; P =.11; 95% PI −0.94 to 0.51) or quality of life (SMD 0.35, 95% CI −0.20 to 0.89; P =.21; 95% PI −2.15 to 2.85).

Conclusions: Although telemedicine can alleviate the caregiving burden and anxiety of informal caregivers, it does not significantly reduce depression or improve their quality of life. Further high-quality, large-sample studies are needed to validate the effects of telemedicine. Furthermore, personalized intervention programs based on theoretical foundations are required to support caregivers.

Trial Registration: PROSPERO CRD42023415688; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=415688

Introduction

With the continued increase in the number of individuals with multiple and severe diseases, the global demand for palliative care services is also growing [ 1 ]. Given that most patients who require palliative care prefer to spend time at home and receive the necessary care [ 2 - 4 ], informal caregivers play a crucial role in caring for patients. However, the cumbersome and complex care tasks may have negative impacts on their physical, psychological, and social well-being [ 5 - 7 ]. In recent years, telemedicine, as an emerging technology, has been increasingly used in home care [ 2 ], benefiting informal caregivers [ 8 , 9 ]. It may serve as a pathway to support informal caregivers of patients in palliative care, improve their health outcomes, and thus enhance the quality of palliative care [ 10 ].

The World Health Organization estimates that 56.8 million people require palliative care yearly [ 11 ]. However, there is a prevailing shortage of professional palliative care personnel, and the majority of patients prefer to receive such care at home [ 2 - 4 ]. Hence, informal caregivers, usually family members or friends, assume the primary responsibility for patient care. In doing so, they adapt to changes in their role, family, and social life to provide long-term, unpaid care for patients [ 12 , 13 ]. Informal caregivers frequently lack professional training [ 4 ]. Thus, they face unmet supportive care needs, such as symptom management, psychological counseling, and social support [ 4 , 13 ], and experience anxiety, depression, physical overload, and a decline in the quality of life (QOL) [ 5 - 7 ]. Studies reveal that the state of informal caregivers and the condition of the patients mutually affect each other. The quality of care provided by caregivers in poor condition can be diminished, exacerbating the patient’s condition. In turn, the patient’s worsening condition can negatively affect informal caregivers [ 7 , 14 , 15 ]. Therefore, the demand to assist informal caregivers and address their physiological, psychological, and social health needs is urgent.

With the development of the information age, telemedicine has demonstrated tremendous potential in providing health care. Telemedicine refers to the use of information and communication technologies to facilitate communication between patients and health care workers for the assessment, diagnosis, treatment, and prevention of diseases, thereby improving patient health [ 16 ]. As a personalized medical approach, telemedicine overcomes the conventional care constraints of time and space; facilitates remote treatment, supervision, education, and care services; and promotes the rational distribution and refinement of medical resources [ 17 ]. Telemedicine has been widely applied in medical fields such as diabetes, chronic wounds, and cardiovascular diseases [ 18 , 19 ], benefiting patients and improving the health outcomes of informal caregivers [ 8 , 9 ].

In recent years, telemedicine has also provided novel ideas to guide palliative care [ 20 ]. In the field of palliative care, an increasing number of informal caregivers are opting to provide home care for patients who require palliative care [ 21 ]. Telemedicine facilitates real-time communication between professionals and family caregivers. This promotes information sharing; assists in the patient’s symptom management; and helps in providing health education, psychological counseling, and social support [ 22 ]. However, the outcomes of using telemedicine with informal caregivers are controversial. For example, a randomized controlled trial (RCT) by Chen et al [ 23 ] indicated that telemedicine could alleviate caregiving burden and enhance the QOL of informal caregivers. However, Dionne-Odom et al [ 24 ] found no significant difference between the telemedicine and control groups in terms of improvements in informal caregivers’ QOL, burden, or emotional state. Of the few available systematic reviews, most provide a descriptive summary of results without performing a meta-analysis to quantify the outcomes of the studies [ 25 - 27 ]. Thus, the intervention effects of telemedicine remain unclear.

Given the limitations of previous reviews, we conducted a systematic review and meta-analysis. We summarized articles on the intervention effects of telemedicine among the informal caregivers of patients in palliative care, focusing on 4 health outcomes: caregiver burden, anxiety, depression, and QOL. This provides a reference for the clinical practice of telemedicine. This is the first systematic review and meta-analysis to verify the effects of telemedicine on the outcomes for informal caregivers of patients in palliative care.

This systematic review adhered to the guidelines in the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist [ 28 ] ( Checklist 1 ). In addition, it was registered on PROSPERO (CRD42023415688).

Ethical Considerations

As all data used were obtained from previously published articles, this research did not require ethical approval from an institutional review board or informed consent from participants.

Search Strategy

A literature search was conducted in 10 electronic databases (PubMed, Embase, Web of Science, CENTRAL, PsycINFO, CINAHL Plus with Full Text, CBM, CNKI, WanFang, and VIP) for publications dating from the establishment of each database until March 31, 2023. Following the Population, Intervention, Comparison, Outcome, and Study design principles, the searches in this systematic review were performed using Medical Subject Headings, the title or abstract, and keywords, as well as Boolean logical operations. Multimedia Appendix 1 describes the search strategy for all databases. In addition, relevant systematic reviews and references were manually screened to identify additional eligible studies.

Study Eligibility Criteria

The inclusion criteria were as follows. (1) The study population was informal adult caregivers (aged ≥18 y) caring for patients receiving palliative care for severe diseases (eg, advanced stage, incurable “stage 4” diseases). (2) Intervention measures were being provided through the internet, applications, telephone, video, or other telemedicine technologies. (3) The control group received usual care or enhanced usual care or was on a waiting list. (4) The study reported outcomes for informal caregivers focusing on 1 or more of the following aspects: caregiver burden, anxiety, depression, or QOL. (5) The study was designed as an RCT. (6) The article was published in English or Chinese.

The exclusion criteria were as follows. (1) The publications were qualitative research, conference abstracts, letters, comments, reviews, or protocols. (2) Patients were underage (aged <18 y), or palliative care indications were unrelated to life-limiting diseases (eg, chronic diseases or nonmalignant pain). (3) Interventions were not being targeted at informal caregivers. (4) The full-text article or relevant data were not accessible.

Study Selection and Data Extraction

The titles and abstracts of the retrieved literature were first downloaded and imported into Endnote X9 (Clarivate; a reference management program) to remove duplicates. Two evaluators then independently screened the studies based on the inclusion and exclusion criteria. Any disagreements were resolved through consultation or discussion with a third researcher. Data were extracted through a predesigned table, including the name of the first author, year of publication, country, age of the caregiver, sample size, type of disease diagnosed in the patient, type and content of intervention measures, study duration, and time of the outcome assessment.

Quality Assessment

Two evaluators independently assessed the methodological quality of the included studies using the Cochrane Collaboration’s tool for assessing the risk of bias [ 29 ]. Seven aspects were evaluated: (1) random sequence generation, (2) allocation concealment, (3) blinding of participants and personnel, (4) blinding of outcome assessment, (5) incomplete outcome data, (6) selective reporting, and (7) other biases. Each study was categorized as “low risk,” “uncertain risk,” or “high risk,” with disagreements resolved through consultation or discussion with a third researcher.

Data Analysis

For studies with multiple measurements, only data from the last measurement were extracted for analysis. SDs were calculated according to the Cochrane Handbook for Systematic Reviews of Interventions if not reported [ 29 ]. If required data were not reported, we contacted the first authors of the relevant publication. Heterogeneity testing and the meta-analysis were conducted using Review Manager 5.4 (The Cochrane Collaboration). Intervention effects were estimated through standardized mean differences (SMDs) and 95% CIs, and forest plots were generated. A 2-sided P value <.05 was considered statistically significant. Heterogeneity was evaluated using the χ 2 test (with P <.10 indicating heterogeneity) and I 2 test (with I 2 >50% indicating moderate heterogeneity and I 2 >75% indicating high heterogeneity). If I 2 ≤50% and P >.10, a fixed-effect model was adopted for data merging and analysis; otherwise, a random-effects model was used. A sensitivity analysis was conducted using a one-study-out method to evaluate the robustness of the combined results. In addition, 95% prediction intervals (PIs) were calculated using R (version 4.3.2; R Foundation for Statistical Computing) and RStudio (Posit) to explain the heterogeneity across studies and estimate the true effects in similar future studies [ 30 ].

Search Results and Selection

A preliminary search of the electronic databases yielded 5456 articles: 254 in Chinese and 5202 in English. After removing 1733 duplicated articles, an additional 3669 unrelated articles were excluded after evaluating their titles and abstracts, leaving 54 articles for the full-text review. From these, 8 articles were included, and with the addition of 1 more article, 9 studies were ultimately included in the meta-analysis. The screening process is detailed in Figure 1 [ 28 ].

Characteristics of the Included Studies

Study characteristics.

Multimedia Appendix 2 [ 23 , 24 , 31 - 37 ] summarizes the main characteristics of the included studies. These studies were all RCTs published in 3 countries between 2015 and 2023: a total of 6 from the United States, 1 from the Netherlands, and 2 from China. Four studies mentioned the theoretical or conceptual framework of the intervention, including Erikson’s psychosocial development theory and Bowen’s family system theory [ 23 ], self-determination theory [ 31 ], shared decision-making [ 33 ], and cognitive behavioral stress management [ 35 ].

Characteristics of Informal Caregivers

The studies involved 1215 informal caregivers, with the number of participants in each study ranging from 35 to 334. The average age of the informal caregivers ranged from 45.71 (SD 11.85) to 60.1 (SD 12.5) years, and they were predominantly patients’ parents, spouses or partners, and children. The types of diseases of the patient included advanced cancer, advanced heart failure, and advanced dementia.

Characteristics of Telemedicine Interventions

Telemedicine was practiced via websites, web conferences, applications, or the telephone, but primarily through websites and the telephone. A total of 4 studies provided interventions through a website. Oliver et al [ 33 ] performed a 3-arm clinical trial, where 1 group received an intervention via Facebook, which offered education and social support to informal caregivers, whereas a separate group received the ACCESS intervention. Here, in addition to the Facebook-based intervention, web conferences were incorporated to facilitate the engagement of informal caregivers in joint decision-making in palliative care. The project aimed to alleviate informal family caregivers’ anxiety and depression. Pensak et al [ 35 ] implemented a 12-week intervention named Pep-Pal, which provided stress management support to informal caregivers of patients with advanced cancer via a website. The intervention program of Parker Oliver et al [ 34 ], ACTIVE, used web conferences or telephone calls to link informal caregivers to end-of-life care teams to improve caregivers’ perceptions of pain management. Similarly, Fu et al [ 37 ] established real-time communication between medical staff and family caregivers of patients with advanced cancer via an internet platform to provide relevant health guidance. Furthermore, 2 studies provided intervention through an application. Schuit et al [ 36 ] developed a program called Oncokompas to provide personalized information, suggestions, and supportive care solutions tailored to the caregiver’s situation. Chen et al [ 23 ] created a dyadic life review program for patients with advanced cancer and their caregivers using WeChat software to promote their QOL. In addition, 3 studies offered interventions via the telephone. Dionne-Odom et al [ 24 ] implemented a telephone intervention program named ENABLE CHF-PC, which offered psychological and problem-solving support for patients with heart failure in palliative care and their caregivers to improve their emotions, burden, and QOL. Two years later, Dionne-Odom et al [ 32 ] performed a similar intervention for patients with advanced cancer and their caregivers. Finally, Badr et al [ 31 ] provided a telephonic psychosocial intervention to enhance the QOL of patients with advanced cancer and their caregivers.

Characteristics of Controls

The control group in 1 study received enhanced usual care [ 33 ], whereas those in the remaining studies received usual care. Furthermore, in the study by Schuit et al [ 36 ], informal caregivers in the control group were allowed to use telemedicine equipment after the research ended.

Risk of Bias

A quality assessment of the included studies was conducted using the Cochrane risk-of-bias tool. Although most studies (6/9, 67%) reported using randomization, some did not detail allocation concealment, potentially leading to selection bias. Only 2 studies were determined as having a low risk of implementation bias owing to the challenge of blinding researchers and participants in telemedicine intervention trials [ 24 , 32 ]. Approximately half (4/9, 45%) the studies blinded the outcome assessors, and thus, their risk of measurement bias was classified as low. Three studies were determined to have a high risk of attrition bias due to elevated loss to follow-up rates or a lack of appropriate data processing methods [ 32 , 35 , 37 ]. However, no selective reporting bias was detected in the included studies. Four studies were categorized as having a high risk of other biases due to baseline differences [ 24 , 34 ] and small sample sizes [ 31 , 32 ]. The results are shown in Figure 2 .

Meta-Analysis

Caregiver burden.

A total of 5 studies that evaluated caregiver burden were included in the meta-analysis [ 23 , 31 , 35 - 37 ]. Since no significant heterogeneity was observed among the included studies ( I 2 =0%; P =.64), a fixed-effect model was used for merging the data. The results revealed that telemedicine intervention could mitigate the burden on informal caregivers (SMD −0.49, 95% CI −0.72 to −0.27; P <.001; 95% PI −0.86 to −0.13), as shown in Figure 3A . The sensitivity analysis showed that the results were stable, as shown in Figure 4A . The results remained unchanged when studies were merged using a random-effects model.

A total of 5 studies assessed the anxiety level of informal caregivers [ 24 , 31 , 32 , 34 , 35 ]. Due to mild heterogeneity among the included studies ( I 2 =43%; P =.14), a fixed-effect model was adopted to pool the data for analysis. The results demonstrated that telemedicine intervention could reduce informal caregivers’ level of anxiety (SMD −0.23, 95% CI −0.40 to −0.06; P =.009; 95% PI −0.98 to 0.39), as shown in Figure 3B . The sensitivity analysis showed that after excluding Badr et al [ 31 ], the pooled results were the opposite, with I 2 decreasing to 0%, as shown in Figure 4B . This could be attributed to a higher risk of bias in this study. However, when merging studies using a random-effects model, the results still retained statistical significance (SMD −0.30, 95% CI −0.57 to −0.03; P =.03).

A total of 5 studies assessed the depression level of informal caregivers [ 24 , 31 - 33 , 35 ]. In the study by Oliver et al [ 33 ], “a” represents the ACCESS intervention and “b” represents the Facebook intervention. Due to moderate heterogeneity among the included studies ( I 2 =51%; P =.07), a random-effects model was used for merging the data. The analysis indicated that the telemedicine intervention did not result in a statistically significant difference in reducing depression among informal caregivers (SMD −0.21, 95% CI −0.47 to 0.05; P =.11; 95% PI −0.94 to 0.51), as shown in Figure 3C . Furthermore, the sensitivity analysis showed that no individual trial could change the results. However, after excluding Badr et al [ 31 ], the I 2 decreased to 0%, as shown in Figure 4C .

QOL of Caregivers

A total of 4 studies that assessed QOL were included in the meta-analysis [ 23 , 24 , 32 , 36 ]. Due to moderate heterogeneity among the studies ( I 2 =73%; P =.01), a random-effects model was used. The results indicated that the telemedicine intervention did not result in a statistically significant difference in improving the overall QOL of informal caregivers (SMD 0.35, 95% CI −0.20 to 0.89; P =.21; 95% PI −2.15 to 2.85), as shown in Figure 3D . Furthermore, the sensitivity analysis indicated that no individual trial could change the results. However, after excluding Chen et al [ 23 ], the I 2 decreased to 0%, as shown in Figure 4D .

Principal Findings

The results of this review indicate that compared to conventional care, telemedicine interventions can alleviate the caregiving burden and anxiety of informal caregivers; however, they do not significantly alleviate depression or improve their QOL. The 95% PIs indicate considerable heterogeneity among the studies, and the effects of future telemedicine interventions on these outcomes remain uncertain, except for reducing caregiver burden.

The results of the study demonstrated that telemedicine interventions could relieve the caregiving burden of informal caregivers, which is consistent with previous research [ 9 , 12 , 31 ]. The systematic review by Hu et al [ 9 ] demonstrates that internet-based interventions can effectively alleviate the stress of informal caregivers of patients with chronic diseases and improve their well-being. Chih et al [ 38 ] developed the Comprehensive Health Enhancement Support System for informal caregivers of patients with advanced cancer. The tool reduced the negative emotions of family caregivers and subsequently decreased their caregiving burden. Caregiver burden consists of both subjective and objective levels. Subjective burden includes the perceived physical, emotional, social, and economic difficulties caused by caring for individuals with serious diseases, whereas objective burden refers to the time and number of tasks devoted to patient care [ 39 ]. Telemedicine facilitates health education, assists in decision-making, helps develop problem-solving skills, and provides social support. It also improves and conserves the resources and time of informal caregivers. Thus, it is conducive to alleviating the caregiving burden at both the subjective and objective levels.

The results revealed that telemedicine interventions can alleviate anxiety in informal caregivers, which is consistent with the findings of previous research [ 8 , 27 ]. Research indicates that the likelihood of anxiety occurring in caregivers of patients with advanced cancer is 3 times that of the general population [ 40 ]. Here, factors such as overwhelming nursing pressure, inadequate self-care, and the lack of supportive care can lead to anxiety [ 41 , 42 ]. Currently, the proposed interventions to reduce the anxiety of informal caregivers focus on psychological education, skill training, and treatment counseling [ 43 ]. In this case, telemedicine enables monitoring, assessing, and managing patient symptoms, which can enhance informal caregivers’ symptom management skills [ 1 , 37 ]. Moreover, it allows them to join discussions on the disease and participate in clinical decisions [ 20 , 33 , 44 ]. This can help satisfy informal caregivers’ information needs and enhance their caregiving confidence and ability. In addition, telemedicine can provide psychological interventions, improve interpersonal relationships, and offer training in stress management skills [ 31 , 32 ], thereby alleviating symptoms of anxiety. However, the sensitivity analysis indicated that the result was unstable. To ensure greater stability, it will be necessary to gather additional data for further investigation.

The results of our research indicate that telemedicine does not have a statistically significant effect on alleviating depression among caregivers, which is consistent with the findings of previous research [ 45 ]. In addition to influencing factors such as the high nursing stress and insufficient social support observed for anxiety, an increased economic burden may also contribute to the onset of depression [ 42 , 46 ]. Despite its potential advantages, telemedicine requires a stable internet connection and available electronic devices. The initial investment cost of such equipment may negatively affect informal caregivers [ 47 ]. Furthermore, researchers only offered counseling on disease knowledge and mental and emotional well-being, but not economic and welfare support. Subsequently, factors including a lower baseline depression level in the study population [ 24 ], small sample size, and significant differences in intervention measures in various studies may negatively impact the combined results. These findings differ from those of Northouse et al [ 48 ], possibly due to variations in the target population. The study by Northouse et al [ 48 ] focused on informal caregivers of patients with cancer. In contrast, our research noted higher loss to follow-up rates in the population with advanced diseases, potentially impeding the discovery of beneficial outcomes. Moreover, Northouse et al [ 48 ] conducted a self-controlled study, whereas we included RCTs in which conventional palliative care can alleviate depression in informal caregivers [ 46 ]. Consequently, the extent to which telemedicine can improve depression is limited.

Quality of Life

This study found that telemedicine does not significantly improve the QOL of informal caregivers of patients in palliative care, which is consistent with the findings of earlier research [ 25 , 49 ]. Most informal caregivers consistently place the needs of patients above their own [ 50 ], leading to various unmet supportive care needs, such as physical, psychological, and social needs [ 6 , 51 ], and a subsequent decline in QOL. As QOL is a multidimensional construct, a multidisciplinary intervention is often more effective than single-faceted approaches. However, the majority of studies (3/4, 75%) in this review targeted interventions at the social-psychological level, and the results might not be ideal. Furthermore, the small sample sizes in the included studies and variations in intervention measures may have limited the possibility of revealing meaningful results. Finally, the effectiveness of intervention measures may further be moderated by other factors such as the characteristics of informal caregivers, preexisting mental health issues, and the caregiver-patient relationship. Therefore, future efforts should aim to devise personalized interventions for specific informal caregiver populations to ensure the best possible support.

Strengths and Limitations

This study meticulously adhered to the systematic review writing process, developed a comprehensive search strategy, and selected appropriate methods for meta-analysis. To enhance the reliability of the results, only RCT studies were included. However, this review also had limitations. First, we only included available data for the analysis. Missing data may impact the combined results of the meta-analysis. Second, some included studies, especially pilot studies, have small sample sizes, which requires a cautious approach to generalizing the results. Third, the inclusion of only English- and Chinese-language articles may lead to publication bias. Last, the included studies all measured the results immediately after intervention, without evaluating the persistence of the intervention effect. Therefore, in the future, large samples and high-quality research are required to further validate the intervention effects of telemedicine and explore the most suitable intervention duration for informal caregivers.

Implications for Practice and Future Research

The findings indicated that telemedicine interventions have beneficial effects on the informal caregivers of patients in palliative care. We recommend that professional palliative care personnel consider the needs of informal caregivers, incorporating telemedicine into care plans to optimize and complement existing health care measures. When implementing such interventions, several considerations arise. First, the needs of informal caregivers are diverse and require multidisciplinary team collaboration. Second, personalized interventions should be tailored based on the demographic characteristics of informal caregivers. Finally, cost-effectiveness should be considered. In this regard, we suggest that relevant organizations establish regulations to minimize health care costs as much as possible.

Moreover, a theoretical or conceptual framework can provide the foundation of interventions, drive their development, and facilitate the prediction and explanation of their mechanism to achieve the desired effect [ 22 ]. For example, in the included studies, Badr et al [ 31 ] conducted a study based on self-determination theory. The authors hypothesized that telephone-based psychosocial interventions could improve the mental state and burden of patients and informal caregivers. Those results were statistically significant. The study by Pensak et al [ 35 ] was based on cognitive behavioral stress management theory and provided stress management training to alleviate informal caregivers’ burden. In contrast, studies lacking theoretical support failed to improve patient and informal caregiver outcomes. Therefore, it is recommended that researchers have a relevant theoretical foundation when devising intervention measures to enhance the intervention effect, which will be more likely to benefit informal caregivers.

In summary, telemedicine can alleviate caregiving burden and anxiety in informal caregivers but does not significantly impact their depression and QOL. Despite certain outcomes lacking statistical significance, they retain clinical relevance for those engaged in family palliative care. We believe that support provided through telemedicine represents a viable means to ensure the continuity of care, address the needs of informal caregivers, and foster favorable outcomes. Future studies that involve large samples and high-quality research are still required to further validate the effects of telemedicine. Furthermore, intervention measures should be designed with a solid theoretical basis to the fullest extent.

Acknowledgments

This study was supported by the scientific research project of the Chinese Nursing Association (ZHKY202101). The funder had no role in the study design, data extraction process, data analysis, results interpretation, or manuscript preparation.

Authors' Contributions

X Yang and X Yu were responsible for the topic and design of this review. X Yu obtained funding, and X Yang drafted the manuscript. X Yang, XL, and SJ performed the study selection and data extraction. X Yu supervised the project. All authors were responsible for the analysis and interpretation. All authors reviewed and approved the final manuscript.

Conflicts of Interest

None declared.

Search strategy.

Characteristics of the included studies.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist.

• Bauer EH, Schultz A, Brandt F, Smith AC, Bollig G, Dieperink KB. Protocol for an integrative review: patient and families’ perspectives on telehealth in palliative care. BMJ Open. Sep 7, 2022;12(9):e062723. [ CrossRef ] [ Medline ]
• Steindal SA, Nes AAG, Godskesen TE, et al. Patients' experiences of telehealth in palliative home care: scoping review. J Med Internet Res. May 5, 2020;22(5):e16218. [ CrossRef ] [ Medline ]
• Gomes B, Calanzani N, Curiale V, McCrone P, Higginson IJ. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Cochrane Database Syst Rev. Jun 6, 2013;2013(6):CD007760. [ CrossRef ] [ Medline ]
• Michaels J, Chen C, Ann Meeker M. Navigating the caregiving abyss: a metasynthesis of how family caregivers manage end-of-life care for older adults at home. Palliat Med. Jan 2022;36(1):81-94. [ CrossRef ] [ Medline ]
• Candy B, Jones L, Drake R, Leurent B, King M. Interventions for supporting informal Caregivers of patients in the terminal phase of a disease. Cochrane Database Syst Rev. Jun 15, 2011;(6):CD007617. [ CrossRef ] [ Medline ]
• Williams AM, Wang L, Kitchen P. Impacts of care-giving and sources of support: a comparison of end-of-life and non-end-of-life caregivers in Canada. Health Soc Care Community. Mar 2016;24(2):214-224. [ CrossRef ] [ Medline ]
• Valero-Cantero I, Casals C, Carrión-Velasco Y, Barón-López FJ, Martínez-Valero FJ, Vázquez-Sánchez MÁ. The influence of symptom severity of palliative care patients on their family Caregivers. BMC Palliat Care. Feb 28, 2022;21(1):27. [ CrossRef ] [ Medline ]
• Sherifali D, Ali MU, Ploeg J, et al. Impact of internet-based interventions on caregiver mental health: systematic review and meta-analysis. J Med Internet Res. Jul 3, 2018;20(7):e10668. [ CrossRef ] [ Medline ]
• Hu C, Kung S, Rummans TA, Clark MM, Lapid MI. Reducing caregiver stress with Internet-based interventions: a systematic review of open-label and randomized controlled trials. J Am Med Inform Assoc. Apr 2015;22(e1):e194-e209. [ CrossRef ] [ Medline ]
• Payne S, Tanner M, Hughes S. Digitisation and the patient-professional relationship in palliative care. Palliat Med. Apr 2020;34(4):441-443. [ CrossRef ] [ Medline ]
• Palliative care. World Health Organization. Aug 5, 2020. URL: https://www.who.int/news-room/fact-sheets/detail/palliative-care [Accessed 2024-02-07]
• Pop RS, Puia A, Mosoiu D. Factors influencing the quality of life of the primary caregiver of a palliative patient: narrative review. J Palliat Med. May 2022;25(5):813-829. [ CrossRef ] [ Medline ]
• Ullrich A, Ascherfeld L, Marx G, Bokemeyer C, Bergelt C, Oechsle K. Quality of life, psychological burden, needs, and satisfaction during specialized inpatient palliative care in family caregivers of advanced cancer patients. BMC Palliat Care. May 10, 2017;16(1):31. [ CrossRef ] [ Medline ]
• Kershaw T, Ellis KR, Yoon H, Schafenacker A, Katapodi M, Northouse L. The interdependence of advanced cancer patients' and their family caregivers' mental health, physical health, and self-efficacy over time. Ann Behav Med. Dec 2015;49(6):901-911. [ CrossRef ] [ Medline ]
• Dionne-Odom JN, Hull JG, Martin MY, et al. Associations between advanced cancer patients' survival and family caregiver presence and burden. Cancer Med. May 2016;5(5):853-862. [ CrossRef ] [ Medline ]
• Huang Z, Wu S, Yu T, Hu A. Efficacy of telemedicine for patients with chronic wounds: a meta-analysis of randomized controlled trials. Adv Wound Care (New Rochelle). Feb 2021;10(2):103-112. [ CrossRef ] [ Medline ]
• Pengput A, Schwartz DG. Telemedicine in Southeast Asia: a systematic review. Telemed J E Health. Dec 2022;28(12):1711-1733. [ CrossRef ] [ Medline ]
• Chen L, Cheng L, Gao W, Chen D, Wang C, Ran X. Telemedicine in chronic wound management: systematic review and meta-analysis. JMIR Mhealth Uhealth. Jun 25, 2020;8(6):e15574. [ CrossRef ] [ Medline ]
• Timpel P, Oswald S, Schwarz PEH, Harst L. Mapping the evidence on the effectiveness of telemedicine interventions in diabetes, dyslipidemia, and hypertension: an umbrella review of systematic reviews and meta-analyses. J Med Internet Res. Mar 18, 2020;22(3):e16791. [ CrossRef ] [ Medline ]
• Finucane AM, O’Donnell H, Lugton J, Gibson-Watt T, Swenson C, Pagliari C. Digital health interventions in palliative care: a systematic meta-review. NPJ Digit Med. Apr 6, 2021;4(1):64. [ CrossRef ] [ Medline ]
• Starr LT, Washington KT, McPhillips MV, Pitzer K, Demiris G, Oliver DP. “It was terrible, I didn’t sleep for two years”: a mixed methods exploration of sleep and its effects among family caregivers of in-home hospice patients at end-of-life. Palliat Med. Dec 2022;36(10):1504-1521. [ CrossRef ] [ Medline ]
• Zhai S, Chu F, Tan M, Chi NC, Ward T, Yuwen W. Digital health interventions to support family caregivers: an updated systematic review. Digit Health. 2023;9:20552076231171967. [ CrossRef ] [ Medline ]
• Chen Y, Sun L, Xiao H, Zheng J, Lin X. Evaluation of a WeChat-based dyadic life review program for people with advanced cancer and family caregivers: a mixed-method feasibility study. Palliat Med. Mar 2022;36(3):498-509. [ CrossRef ] [ Medline ]
• Dionne-Odom JN, Ejem DB, Wells R, et al. Effects of a telehealth early palliative care intervention for family caregivers of persons with advanced heart failure: the ENABLE CHF-PC randomized clinical trial. JAMA Netw Open. Apr 1, 2020;3(4):e202583. [ CrossRef ] [ Medline ]
• Zheng Y, Head BA, Schapmire TJ. A systematic review of telehealth in palliative care: caregiver outcomes. Telemed J E Health. Apr 2016;22(4):288-294. [ CrossRef ] [ Medline ]
• Cameron P, Munyan K. Systematic review of telehospice telemedicine and e-health. Telemed J E Health. Nov 2021;27(11):1203-1214. [ CrossRef ] [ Medline ]
• Chen Y, Qiao C, Zhang X, Li W, Yang H. The effect of TELE-palliative care on patient and caregiver outcomes: a systematic review. Am J Hosp Palliat Care. Aug 2023;40(8):907-925. [ CrossRef ] [ Medline ]
• Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. Mar 29, 2021;372:71. [ CrossRef ] [ Medline ]
• Higgins JPT, Thomas J, Chandler J, et al. Cochrane Handbook for Systematic Reviews of Interventions (Version 64). The Cochrane Collaboration; 2023. URL: https://training.cochrane.org/handbook/current [Accessed 2023-08-27]
• IntHout J, Ioannidis JPA, Rovers MM, Goeman JJ. Plea for routinely presenting prediction intervals in meta-analysis. BMJ Open. Jul 12, 2016;6(7):e010247. [ CrossRef ] [ Medline ]
• Badr H, Smith CB, Goldstein NE, Gomez JE, Redd WH. Dyadic psychosocial intervention for advanced lung cancer patients and their family caregivers: results of a randomized pilot trial. Cancer. Jan 1, 2015;121(1):150-158. [ CrossRef ] [ Medline ]
• Dionne-Odom JN, Azuero A, Taylor RA, et al. A lay navigator-led, early palliative care intervention for African American and rural family caregivers of individuals with advanced cancer (Project Cornerstone): results of a pilot randomized trial. Cancer. Mar 15, 2022;128(6):1321-1330. [ CrossRef ] [ Medline ]
• Oliver DP, Washington K, Benson J, et al. Access for cancer caregivers to education and support for shared decision making (ACCESS) intervention: a cluster cross-over randomised clinical trial. BMJ Support Palliat Care. Mar 2, 2023.:spcare-2022-004100. [ CrossRef ] [ Medline ]
• Parker Oliver D, Demiris G, Washington K, Kruse RL, Petroski G. Hospice family caregiver involvement in care plan meetings: a mixed-methods randomized controlled trial. Am J Hosp Palliat Care. Nov 2017;34(9):849-859. [ CrossRef ] [ Medline ]
• Pensak NA, Carr AL, Jones J, et al. A pilot study of mobilized intervention to help caregivers of oncology patients manage distress. Psychooncology. Apr 2021;30(4):520-528. [ CrossRef ] [ Medline ]
• Schuit AS, Rienks MM, Hooghiemstra N, et al. Reach and efficacy of the eHealth application Oncokompas, facilitating partners of incurably ill cancer patients to self-manage their caregiver needs: a randomized controlled trial. Support Care Cancer. Dec 2022;30(12):10191-10201. [ CrossRef ] [ Medline ]
• Fu YZ, Wang JX, Huang L. Application of “Internet+” extension model in family caregivers of advanced cancer [Article in Chinese]. Bachu Medical Journal. 2021;4(4):44-49. [ CrossRef ]
• Chih MY, DuBenske LL, Hawkins RP, et al. Communicating advanced cancer patients’ symptoms via the internet: a pooled analysis of two randomized trials examining caregiver preparedness, physical burden, and negative mood. Palliat Med. Jun 2013;27(6):533-543. [ CrossRef ] [ Medline ]
• Soto-Guerrero S, Palacios J, Langer P, et al. Objective burden, caregiver psychological distress, and patient religion and quality of life are associated with high-intensity burden of care among caregivers of advanced cancer patients in a Latino population. Palliat Support Care. Jun 26, 2023.:1-9. [ CrossRef ] [ Medline ]
• Trevino KM, Prigerson HG, Maciejewski PK. Advanced cancer caregiving as a risk for major depressive episodes and generalized anxiety disorder. Psychooncology. Jan 2018;27(1):243-249. [ CrossRef ] [ Medline ]
• Moss KO, Kurzawa C, Daly B, Prince-Paul M. Identifying and addressing family caregiver anxiety. J Hosp Palliat Nurs. Feb 2019;21(1):14-20. [ CrossRef ] [ Medline ]
• Tay DL, Iacob E, Reblin M, et al. What contextual factors account for anxiety and depressed mood in hospice family caregivers? Psychooncology. Feb 2022;31(2):316-325. [ CrossRef ] [ Medline ]
• Northouse LL, Katapodi MC, Song L, Zhang L, Mood DW. Interventions with family caregivers of cancer patients: meta-analysis of randomized trials. CA Cancer J Clin. 2010;60(5):317-339. [ CrossRef ] [ Medline ]
• Rogante M, Giacomozzi C, Grigioni M, Kairy D. Telemedicine in palliative care: a review of systematic reviews. Ann Ist Super Sanita. 2016;52(3):434-442. [ CrossRef ] [ Medline ]
• Bauernschmidt D, Hirt J, Langer G, et al. Technology-based counselling for people with dementia and their informal carers: a systematic review and meta-analysis. J Alzheimers Dis. 2023;93(3):891-906. [ CrossRef ] [ Medline ]
• Alam S, Hannon B, Zimmermann C. Palliative care for family caregivers. J Clin Oncol. Mar 20, 2020;38(9):926-936. [ CrossRef ] [ Medline ]
• Walton L, Courtright K, Demiris G, Gorman EF, Jackson A, Carpenter JG. Telehealth palliative care in nursing homes: a scoping review. J Am Med Dir Assoc. Mar 2023;24(3):356-367. [ CrossRef ] [ Medline ]
• Northouse L, Schafenacker A, Barr KLC, et al. A tailored web-based psychoeducational intervention for cancer patients and their family caregivers. Cancer Nurs. 2014;37(5):321-330. [ CrossRef ] [ Medline ]
• Söylemez BA, Özgül E, Küçükgüçlü Ö, Yener G. Telehealth applications used for self-efficacy levels of family caregivers for individuals with dementia: a systematic review and meta-analysis. Geriatr Nurs. 2023;49:178-192. [ CrossRef ] [ Medline ]
• Norinder M, Årestedt K, Lind S, et al. Higher levels of unmet support needs in spouses are associated with poorer quality of life - a descriptive cross-sectional study in the context of palliative home care. BMC Palliat Care. Aug 28, 2021;20(1):132. [ CrossRef ] [ Medline ]
• Cheng HL, Leung DYP, Ko PS, et al. Mediating role of self-efficacy between unmet needs and quality of life in palliative cancer caregivers. Psychooncology. Mar 2023;32(3):457-464. [ CrossRef ] [ Medline ]

Abbreviations

Edited by Lorraine Buis; submitted 03.11.23; peer-reviewed by Carlos Laranjeira, Shumenghui Zhai; final revised version received 28.02.24; accepted 28.02.24; published 08.04.24.

© Xiaoyu Yang, Xueting Li, Shanshan Jiang, Xinying Yu. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 8.4.2024.

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

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Wiley - PMC COVID-19 Collection

The coronavirus ( COVID ‐19) pandemic's impact on mental health

Bilal javed.

1 Faculty of Sciences, PMAS Arid Agriculture University, Rawalpindi Pakistan

2 Roy & Diana Vagelos Laboratories, Department of Chemistry, University of Pennsylvania, Philadelphia Pennsylvania, USA

Abdullah Sarwer

3 Nawaz Sharif Medical College, University of Gujrat, Gujrat Pakistan

4 Department of General Medicine, Allama Iqbal Memorial Teaching Hospital, Sialkot Pakistan

Erik B. Soto

5 Graduate School of Public Health, University of Pittsburgh, Pittsburgh Pennsylvania, USA

Zia‐ur‐Rehman Mashwani

Throughout the world, the public is being informed about the physical effects of SARS‐CoV‐2 infection and steps to take to prevent exposure to the coronavirus and manage symptoms of COVID‐19 if they appear. However, the effects of this pandemic on one's mental health have not been studied at length and are still not known. As all efforts are focused on understanding the epidemiology, clinical features, transmission patterns, and management of the COVID‐19 outbreak, there has been very little concern expressed over the effects on one's mental health and on strategies to prevent stigmatization. People's behavior may greatly affect the pandemic's dynamic by altering the severity, transmission, disease flow, and repercussions. The present situation requires raising awareness in public, which can be helpful to deal with this calamity. This perspective article provides a detailed overview of the effects of the COVID‐19 outbreak on the mental health of people.

1. INTRODUCTION

A pandemic is not just a medical phenomenon; it affects individuals and society and causes disruption, anxiety, stress, stigma, and xenophobia. The behavior of an individual as a unit of society or a community has marked effects on the dynamics of a pandemic that involves the level of severity, degree of flow, and aftereffects. 1 Rapid human‐to‐human transmission of the SARS‐CoV‐2 resulted in the enforcement of regional lockdowns to stem the further spread of the disease. Isolation, social distancing, and closure of educational institutes, workplaces, and entertainment venues consigned people to stay in their homes to help break the chain of transmission. 2 However, the restrictive measures undoubtedly have affected the social and mental health of individuals from across the board. 3

As more and more people are forced to stay at home in self‐isolation to prevent the further flow of the pathogen at the societal level, governments must take the necessary measures to provide mental health support as prescribed by the experts. Professor Tiago Correia highlighted in his editorial as the health systems worldwide are assembling exclusively to fight the COVID‐19 outbreak, which can drastically affect the management of other diseases including mental health, which usually exacerbates during the pandemic. 4 The psychological state of an individual that contributes toward the community health varies from person‐to‐person and depends on his background and professional and social standings. 5

Quarantine and self‐isolation can most likely cause a negative impact on one's mental health. A review published in The Lancet said that the separation from loved ones, loss of freedom, boredom, and uncertainty can cause a deterioration in an individual's mental health status. 6 To overcome this, measures at the individual and societal levels are required. Under the current global situation, both children and adults are experiencing a mix of emotions. They can be placed in a situation or an environment that may be new and can be potentially damaging to their health. 7

2. CHILDREN AND TEENS AT RISK

Children, away from their school, friends, and colleagues, staying at home can have many questions about the outbreak and they look toward their parents or caregivers to get the answer. Not all children and parents respond to stress in the same way. Kids can experience anxiety, distress, social isolation, and an abusive environment that can have short‐ or long‐term effects on their mental health. Some common changes in children's behavior can be 8 :

• Excessive crying and annoying behavior
• Increased sadness, depression, or worry
• Difficulties with concentration and attention
• Changes in, or avoiding, activities that they enjoyed in the past
• Unexpected headaches and pain throughout their bodies
• Changes in eating habits

To help offset negative behaviors, requires parents to remain calm, deal with the situation wisely, and answer all of the child's questions to the best of their abilities. Parents can take some time to talk to their children about the COVID‐19 outbreak and share some positive facts, figures, and information. Parents can help to reassure them that they are safe at home and encourage them to engage in some healthy activities including indoor sports and some physical and mental exercises. Parents can also develop a home schedule that can help their children to keep up with their studies. Parents should show less stress or anxiety at their home as children perceive and feel negative energy from their parents. The involvement of parents in healthy activities with their children can help to reduce stress and anxiety and bring relief to the overall situation. 9

3. ELDERS AND PEOPLE WITH DISABILITIES AT RISK

Elderly people are more prone to the COVID‐19 outbreak due to both clinical and social reasons such as having a weaker immune system or other underlying health conditions and distancing from their families and friends due to their busy schedules. According to medical experts, people aged 60 or above are more likely to get the SARS‐CoV‐2 and can develop a serious and life‐threatening condition even if they are in good health. 10

Physical distancing due to the COVID‐19 outbreak can have drastic negative effects on the mental health of the elderly and disabled individuals. Physical isolation at home among family members can put the elderly and disabled person at serious mental health risk. It can cause anxiety, distress, and induce a traumatic situation for them. Elderly people depend on young ones for their daily needs, and self‐isolation can critically damage a family system. The elderly and disabled people living in nursing homes can face extreme mental health issues. However, something as simple as a phone call during the pandemic outbreak can help to console elderly people. COVID‐19 can also result in increased stress, anxiety, and depression among elderly people already dealing with mental health issues.

Family members may witness any of the following changes to the behavior of older relatives 11 ;

• Irritating and shouting behavior
• Change in their sleeping and eating habits
• Emotional outbursts

The World Health Organization suggests that family members should regularly check on older people living within their homes and at nursing facilities. Younger family members should take some time to talk to older members of the family and become involved in some of their daily routines if possible. 12

4. HEALTH WORKERS AT RISK

Doctors, nurses, and paramedics working as a front‐line force to fight the COVID‐19 outbreak may be more susceptible to develop mental health symptoms. Fear of catching a disease, long working hours, unavailability of protective gear and supplies, patient load, unavailability of effective COVID‐19 medication, death of their colleagues after exposure to COVID‐19, social distancing and isolation from their family and friends, and the dire situation of their patients may take a negative toll of the mental health of health workers. The working efficiency of health professionals may decrease gradually as the pandemic prevails. Health workers should take short breaks between their working hours and deal with the situation calmly and in a relaxed manner. 5

5. STIGMATIZATION

Generally, people recently released from quarantine can experience stigmatization and develop a mix of emotions. Everyone may feel differently and have a different welcome by society when they come out of quarantine. People who recently recovered may have to exercise social distancing from their family members, friends, and relatives to ensure their family's safety because of unprecedented viral nature. Different age groups respond to this social behavior differently, which can have both short‐ and long‐term effects. 1

Health workers trying to save lives and protect society may also experience social distancing, changes in the behavior of family members, and stigmatization for being suspected of carrying COVID‐19. 6 Previously infected individuals and health professionals (dealing pandemic) may develop sadness, anger, or frustration because friends or loved ones may have unfounded fears of contracting the disease from contact with them, even though they have been determined not to be contagious. 5

However, the current situation requires a clear understanding of the effects of the recent outbreak on the mental health of people of different age groups to prevent and avoid the COVID‐19 pandemic.

6. TAKE HOME MESSAGE

• Understanding the effects of the COVID‐19 outbreak on the mental health of various populations are as important as understanding its clinical features, transmission patterns, and management.
• Spending time with family members including children and elderly people, involvement in different healthy exercises and sports activities, following a schedule/routine, and taking a break from traditional and social media can all help to overcome mental health issues.
• Public awareness campaigns focusing on the maintenance of mental health in the prevailing situation are urgently needed.

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.

AUTHOR CONTRIBUTIONS

B.J. and A.S. devised the study. B.J. collected and analyzed the data and wrote the first draft. E.B.S. edited and revised the manuscript. A.S. and Z.M. provided useful information. All the authors contributed to the subsequent drafts. The authors reviewed and endorsed the final submission.

Javed B, Sarwer A, Soto EB, Mashwani Z‐R. The coronavirus (COVID‐19) pandemic's impact on mental health . Int J Health Plann Mgmt . 2020; 35 :993–996. 10.1002/hpm.3008 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]